U.S. GOVERNMENT PRINTING OFFICE

70–278 DTP WASHINGTON : 2001

VA HEALTHCARE IN THE NEXT MILLENNIUM

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY,

VETERANS AFFAIRS, AND INTERNATIONAL

RELATIONS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED SIXTH CONGRESS

SECOND SESSION

APRIL 10, 2000

Serial No. 106–190

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpo.gov/congress/house

http://www.house.gov/reform

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Internet: bookstore.gpo.gov Phone: (202) 512–1800 Fax: (202) 512–2250

Mail: Stop SSOP, Washington, DC 20402–0001

(II)

COMMITTEE ON GOVERNMENT REFORM

DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York

CONSTANCE A. MORELLA, Maryland

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEPHEN HORN, California

JOHN L. MICA, Florida

THOMAS M. DAVIS, Virginia

DAVID M. MCINTOSH, Indiana

MARK E. SOUDER, Indiana

JOE SCARBOROUGH, Florida

STEVEN C. LATOURETTE, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

BOB BARR, Georgia

DAN MILLER, Florida

ASA HUTCHINSON, Arkansas

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

GREG WALDEN, Oregon

DOUG OSE, California

PAUL RYAN, Wisconsin

HELEN CHENOWETH-HAGE, Idaho

DAVID VITTER, Louisiana

HENRY A. WAXMAN, California

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

PATSY T. MINK, Hawaii

CAROLYN B. MALONEY, New York

ELEANOR HOLMES NORTON, Washington,

DC

CHAKA FATTAH, Pennsylvania

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

THOMAS H. ALLEN, Maine

HAROLD E. FORD, JR., Tennessee

JANICE D. SCHAKOWSKY, Illinois

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

DAVID A. KASS, Deputy Counsel and Parliamentarian

LISA SMITH ARAFUNE, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS, AND INTERNATIONAL

RELATIONS

CHRISTOPHER SHAYS, Connecticut, Chairman

MARK E. SOUDER, Indiana

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

DAVID M. MCINTOSH, Indiana

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

HELEN CHENOWETH-HAGE, Idaho

ROD R. BLAGOJEVICH, Illinois

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

JOHN F. TIERNEY, Massachusetts

THOMAS H. ALLEN, Maine

EDOLPHUS TOWNS, New York

BERNARD SANDERS, Vermont

(Independent)

JANICE D. SCHAKOWSKY, Illinois

EX OFFICIO

DAN BURTON, Indiana HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel

KRISTINE MCELROY, Professional Staff Member

JASON CHUNG, Clerk

DAVID RAPALLO, Minority Counsel

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C O N T E N T S

Page

Hearing held on April 10, 2000 .............................................................................. 1

Statement of:

Martineau, Jean-Guy, director of Veterans Services, city of Salem; Donald

T. Welsh, director of Veterans Services, city of Gloucester; Michael

G. Ingham, director of Veterans Services, city of Haverhill; and Robert

C. Hogan, director of Veterans Services, town of Burlington .................... 45

Murphy, Dr. Frances M., Acting Deputy Under Secretary for Health

for Policy and Management, Department of Veterans’ Affairs; Dr.

Jeannette Chirico-Post, Director of Veterans’ Integrated Service Network 1; and William Conte, director, Edith Nourse Rogers Memorial

VA Medical Center ........................................................................................ 16

Restani, Neil F., director of Veterans Services, town of Lynnfield .............. 84

Letters, statements, etc., submitted for the record by:

Hogan, Robert C., director of Veterans Services, town of Burlington,

prepared statement of ................................................................................... 64

Ingham, Michael G., director of Veterans Services, city of Haverhill,

prepared statement of ................................................................................... 58

Martineau, Jean-Guy, director of Veterans Services, city of Salem, prepared statement of ........................................................................................ 47

Murphy, Dr. Frances M., Acting Deputy Under Secretary for Health

for Policy and Management, Department of Veterans’ Affairs, prepared

statement of ................................................................................................... 19

Restani, Neil F., director of Veterans Services, town of Lynnfield, prepared statement of ........................................................................................ 86

Shays, Hon. Christopher, a Representative in Congress from the State

of Connecticut, prepared statement of ........................................................ 3

Tierney, Hon. John, a Representative in Congress from the State of

Massachusetts, prepared statement of ........................................................ 7

Welsh, Donald T., director of Veterans Services, city of Gloucester, prepared statement of ........................................................................................ 53

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VA HEALTHCARE IN THE NEXT MILLENNIUM

MONDAY, APRIL 10, 2000

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS

AFFAIRS, AND INTERNATIONAL RELATIONS,

COMMITTEE ON GOVERNMENT REFORM,

Peabody, MA.

The subcommittee met, pursuant to notice, at 10 a.m., at the

Peabody Memorial Veterans High School, 485 Lowell Street, Peabody, MA, Hon. Christopher Shays (chairman of the subcommittee)

presiding.

Present: Representatives Shays and Tierney.

Staff present: Lawrence J. Halloran, staff director and counsel;

Kristine McElroy, professional staff member; Jason Chung, clerk;

and David Rapallo, minority counsel.

Mr. SHAYS. This hearing will come to order and welcome our witnesses and guests and ladies and gentlemen, I invite you to please

rise as the Peabody Air Force Junior ROTC Color Guard posts the

colors.

Today, we came here to listen and to learn from those with a direct stake in the future of veterans’ health care in New England.

This is our third hearing on the impact of reorganization and

funding shifts on the availability and the quality of care in Department of Veterans’ Affairs [VA] facilities. Earlier testimony described long waits for access to specialists, lapses in health care

standards and funding inequities within and between regional Veterans Integrated Service Networks (VSNS). VA officials said facility restructuring here in VISN–1 and refinements in the Veterans

Equitable Resource Allocation [VERA] system would, in time, bring

improvements.

But last July, Congress’ auditing agency, the General Accounting

Office [GAO], concluded VA could be wasting $1 million or more

every day critical health care restructuring decisions are delayed.

Today, more than 8 months, or $263 million later, GAO still reports the VA ‘‘has been unsuccessful . . . in its efforts to design a

capital asset realignment process.’’

So a significant portion of the $1.7 billion Congress added to the

Veterans Health Administration budget this year may be spent operating and maintaining unneeded facilities, rather than enhancing

access and improving the quality of needed health care for veterans.

The effects of delaying the hard decisions in Washington are felt

acutely here in New England. An older veterans’ population, declining in numbers, but now in need of more extensive, more expenVerDate 11-MAY-2000 10:29 May 23, 2001 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 C:\DOCS\70278.TXT HGOVREF1 PsN: HGOVREF1
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sive, health interventions, cannot wait years, or drive hundreds of

miles, for the basic care to which they are truly entitled. Today we

need to talk candidly and objectively about how the VA can sustain

and improve a health care system in New England that will meet

veterans’ needs in the new millennium.

I want to thank Congressman John Tierney for inviting the subcommittee to the Sixth Congressional District of Massachusetts.

We value his participation in this committee as an equal partner

with the chair. We value this opportunity as well to discuss these

important issues with those most directly involved, and we look forward to the testimony of all of our witnesses.

John, I would like to personally thank you for asking us to come

here and this committee oversees all of the VA, all of DOD, all of

FEMA, all of terrorist activities at home and abroad and when I

asked John what hearing was most important he said we needed

to talk about the VA and to meet in his district and that is why

we are here. We will do a lot of good listening today.

John.

[The prepared statement of Hon. Christopher Shays follows:]

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Mr. TIERNEY. Thank you, Mr. Chairman, and I want to thank everybody that has taken the time today to join us here at the hearing.

I want to be the first to officially welcome Congressman Chris

Shays to join us in this particular district and I can say that we

have a Congressman here as chairman of this committee who is

truly a person that we can work with and who understands these

issues and works very hard on them.

I want to also welcome our witnesses from the Veterans’ Administration, Dr. Murphy, Dr. Post and Mr. Conte with whom we

worked with many, many times, as well as the veterans’ agents

from the surrounding areas who will also be testifying in the second panel. I am glad that you could all be with us and join us

today.

Let me also welcome all the veterans in attendance and the veterans service organizations who have provided written testimony

for the record. It is imperative that we hear your concerns and your

viewpoints today. I look forward to listening to your comments

after the first two panels have concluded and you will see that we

have microphones in the aisles and that we will have an opportunity for folks to make comments and ask some questions.

Mr. Chairman, I have a written a statement from Representative

Anthony Vera, the State Representative from Gloucester that I

would like to ask be presented in the record. And I also have a

written statement from Mayor Nicholas J. Costello, the mayor of

Amesbury which I would like to ask be put in the record, as well

as a written statement from Congressman Thomas Allen of Maine,

which I believe is already in there and ask that you enter that in

the record.

Mr. SHAYS. Without objection, so ordered.

Mr. TIERNEY. I would like to acknowledge and welcome Mayor

William Scanlon from the city of Beverly who is also with us in the

audience today who has been a great friend of veterans and a number of other veterans’ agents who will not be testifying, but with

whom my office works on a regular basis and provide great service

to the veterans in this District.

In Washington, veterans’ health care is often analyzed as an

issue of national scope, focusing on the processing, reengineering,

streamlining initiatives and appropriations debates. Discussing the

issue in this way sometimes removes and detaches policymakers

from the concerns of individual veterans, veterans who live with

the system on a daily basis, veterans who rely on the system for

their most essential health care needs.

That is why I am particularly gratified today to have a hearing

analyzing the local point of view. In many ways, health care is

rooted in local systems and infrastructure, so it behooves us to extract ourselves from the daily Washington processes to come here

today and to analyze the issues from a different perspective, yours.

For veterans in the Sixth Congressional District of Massachusetts, the facility that provides the primary and specialized medical

care is the Edith Nourse Rogers Memorial VA Medical Center in

Bedford. This institution has been providing care to veterans since

1929. It has always been a VA facility and last year it handled

more than 186,000 visits.

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Today we have with us Mr. William Conte, the director of the facility who will provide additional background on the facility’s capacity and his efforts to deal with shrinking budgets.

A recent development, and one in particular that I am very excited about is the establishment of community-based out patient

clinics. We now have two, one in Lynn and one in Haverhill. They

greatly increase veterans’ access to health care. These clinics are

important to the effort to reach out to veterans and to serve them

in the communities in which they live. We have helped to move forward the application of a third CBOC in Gloucester.

Last year, the Lynn and Haverhill CBOCs handled more than

5,600 visits and I know the representatives on the panel will be

able to respond to questions about those clinics.

Although these are positive developments, there are also a number of challenges, both for veterans and the system that serves

them. Transportation, to and from VA facilities is a primary concern. Again, the clinics are extremely valuable in extending VA’s

outreach to other areas, but for veterans who need specialty care

or report for multiple visits, transportation hurdles may be too

great to overcome.

I understand that if veterans go to one or two clinics, they can

catch a shuttle to the Bedford facility if they need x-rays or other

services not provided at the clinics. If they need more specialized

services, however, such as an upper GI endoscopy, they may have

to take another shuttle still into Boston.

For veterans, the current transportation process can be insurmountable, especially if it involves anesthesia or other procedures

that complicate traveling alone. I hope we can discuss transportation concerns today, both at the regional and the local levels.

Long term care is also an issue that is gaining significance. VA

has highlighted outpatient solutions and in-home care, which have

their own advantages. If VA can assist veterans without uprooting

them from their homes, this solution benefits everyone involved.

My concern, however, relates to veterans with degenerative and

other conditions that eventually may require hospitalization and

inpatient treatment.

VA is now in the process of downsizing its inpatient capacity as

it redirects assets toward outpatient care. So how will short-term

shift affect the extended term outlook? How will VA be able to deal

with the increasing demand of long-term care when the baby boom

generation moves into this stage? And how do these concerns relate

to VA’s ability to comply with the Millennium Health Care and

Benefits Act?

These are just a few of the issues I hope our witnesses will address today, and although I know there are many more of interest

to the veterans in attendance, I look forward to hearing their testimony also.

Before concluding, let me just extend my thanks to several people from Veterans Memorial High School here in Peabody who have

helped to make this hearing possible: Principal Joe Patuleia, Elaine

Kirby, Richard Carey, Major Grover, of course, and the students of

the culinary arts and the Air Force Junior ROTC.

In addition, I would like to thank the Peabody Police Department

and Temple Beth Shalom for allowing us to use their parking lot.

6

I would also like to recognize Michael King, who is the director

of the North Shore Veterans Counseling Services, for his dedicated

service to our country and for keeping our North Shore veterans informed about the timely issues in his veterans’ column in the

Salem Evening News.

Finally, I would like to thank Chairman Shays again for calling

this hearing. As I mentioned, I think this type of local focus adds

immeasurably to our ability to address these issues. It is a special

privilege to have the opportunity for the subcommittee to address

issues specific to my own district.

I appreciate your willingness, Mr. Chairman, to hold this hearing

today in Peabody. I especially commend you for all the work that

you do in addition to veterans’ issues with the very serious matter

of terrorism and preparedness in this country for any event that

may occur and I look forward to today’s hearing.

Thank you.

[The prepared statement of Hon. John Tierney and the information referred to follow:]

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Mr. SHAYS. I thank the gentleman and we will just get some

housekeeping taken care of.

Pursuant to House rules and committee rules I note for the

record that the subcommittee requests that all witnesses appearing

in this hearing in a nongovernment capacity provide a resume and

a disclosure of Federal grants and contracts received and further

ask that all testimony be submitted for the record and remarks by

our colleagues be submitted for the record as well.

Without objection, so ordered.

I would also like to say that before calling our panel that this

committee has had an excellent working relationship with the Department of Veterans’ Affairs and we realize this is a partnership,

so this is not a committee that is just standing in judgment of the

VA. We also look at how Congress and the administration play a

role in providing better health care for our veterans.

At this time, I am not sure if my mic is on all the time. Mine

is not on at the time. I am not bringing the mic closer. I need the

people in the back to get it better.

At this time, we will call Dr. Frances M. Murphy, Acting Director, Under Secretary for Policy and Management, Veterans’ Health

Administration, Department of Veterans’ Affairs, accompanied by

Dr. Jeannette Chirico-Post, Director of Veterans’ Integrated Service

Network I; and Mr. William Conte, Director, Edith Nourse Rogers

Memorial VA Medical Center. I invite them all.

Remaine standing and I will swear you in.

[Witnesses sworn.]

Mr. SHAYS. Note for the record that the witnesses have responded in the affirmative.

Dr. Murphy, you have the testimony, but we are going to invite

both of our guests as well to respond to questions. That is why you

are all three under oath. I will note this committee swears every

one under oath. The only one who has ever gotten away without

being sworn in was Senator Byrd. All other Senators and Representatives have been willing to cooperate.

Thank you, Dr. Murphy.

STATEMENTS OF DR. FRANCES M. MURPHY, ACTING DEPUTY

UNDER SECRETARY FOR HEALTH FOR POLICY AND MANAGEMENT, DEPARTMENT OF VETERANS’ AFFAIRS; DR.

JEANNETTE CHIRICO-POST, DIRECTOR OF VETERANS’ INTEGRATED SERVICE NETWORK 1; AND WILLIAM CONTE, DIRECTOR, EDITH NOURSE ROGERS MEMORIAL VA MEDICAL CENTER

Dr. MURPHY. Good morning. Mr. Chairman, Mr. Tierney, Mayor

Scanlon, and honored guests. I appreciate the opportunity to appear before you today to discuss VA Health Care in the New Millennium. With me today are Dr. Post and Mr. Conte from the Edith

Nourse Rogers Memorial VA Medical Center in Bedford, MA.

I would like to take the opportunity to compliment the Air Force

ROTC and say it makes me proud to see our young people do so

well.

The past decade has been characterized by dramatic change in

the delivery of health care services in the United States. In the

past 5 years, the VA health care system has also had a tremendous

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transformation. VA has transformed itself from a disease-oriented,

hospital-based health care system to an integrated system providing a continuum of accessible, coordinated, patient-centered, prevention-oriented care.

We have seen demonstrable improvements in our capacity to

achieve consistent, reliable, accessible, satisfying and high-quality

care. We also continue to face challenges of reducing medical errors

in health care and meeting the needs of an aging population, of incorporating the explosive growth of scientific knowledge into daily

practice and of incorporating expensive new medical and information technologies, and of realigning our infrastructure to more effectively support current health care needs.

Structurally, ‘‘New VA’’ is composed of 22 Veterans Integrated

Service Networks [VISNs]. Each VISN forms a regional health care

system that provides a continuum of health care to veterans who

reside in a geographic area.

More than at any other time in our history, VA more closely mirrors—and in many cases exceeds—the best in private sector health

care. Indeed, the structural transformation underpins a quality

transformation. Significant organizational changes include: closing

more than 52 percent of all hospital beds since July 1994; reducing

inpatient admissions by 34 percent between 1994 and 1999; providing health to over 700,000 more veterans in 1999 than in 1994.

That is a 31 percent increase in the number of veterans cared for

by the VA. Within the networks we consolidated managements and

operation of 48 hospitals or clinics into 23 locally integrated health

care systems since September 1995. Also we approved and brought

388 new community-based outpatient clinics into operation since

1995. We will establish more than 60 this year and that means

that VA will have more than 1,200 sites of care across this Nation

in bringing health care services into more veterans’ communities.

Over that same period of time, we increased the rate of selected

surgeries and procedures which are safely provided in the ambulatory setting to 92 percent of surgeries that are performed.

Especially notable in clinical achievements are reduced avoidable

hospitalizations and lowered mortality, resulting in cost-savings

through reductions in avoidable health care expenditures.

For example, the rates of pneumonia and influenza vaccinations

provided to VA patients far exceed U.S. Public Health Service

Healthy People 2000 goals and available benchmarks. Also, lifesaving beta-blocker medications after heart attacks are provided at

VA hospitals at rates that exceed all available benchmarks in the

private sector. These two actions alone have saved, Mr. Chairman,

an estimated 5,000 lives since instituted. That is an incredible accomplishment in quality health care for veterans.

Similar improvements have been seen in other areas of preventative health services such as screening for cervical and breast cancer

and in the treatment of prevalent diseases such as diabetes and

mental illnesses. Simultaneously, patient satisfaction has increased. In fact, VHA scored 79 on the externally conducted American Customer Satisfaction Index. This is significantly above the

score obtained by the private sector health institutions who scored

only 70 on that scale. Loyalty and Customer Service scores are

even higher at 90 and 87, respectively.

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Mr. Chairman, the VA New England Health Care System has

shared in the accomplishments of the VA health system and in

some instances has led the way. Network 1 also faces the same

challenges that confront many other areas of the country.

I would like to take the opportunity briefly to discuss the accomplishments and challenges that are facing the New England

Healthcare System (Network 1). Network 1 is an integrated and

comprehensive health care system that delivers care to all six New

England States, Maine, New Hampshire, Vermont, Massachusetts,

Rhode Island and Connecticut.

Twenty-five community-based outpatient clinics are strategically

located throughout New England and provide increased access to

health care services for veterans. Network 1 has significant and

long standing affiliations with some of the most prominent medical

schools in the country. These include Boston University, Brown,

Dartmouth, Harvard, Tufts, Yale, Universities of Connecticut, Massachusetts and Vermont Medical Schools and the University of

New England. Funded research programs are another strong suit

in Network 1 with the third highest research funding in VHA.

Over the past 5 years, from 1995 to 1999, VHA faced a very challenging budget situation. Our budget in real dollars decreased by

23 percent over that time period. However, I am pleased to tell you

that with the $1.7 billion increase that appropriated for VHA in

2000 and a $1.3 billion increase that has been proposed in the

Presidential budget for fiscal year 2001, we believe that we will be

able to increase the access and decrease waiting times for veterans,

further increasing the quality of care delivered by the Veterans

Health Administration.

Network 1 has seen several changes in leadership during the

past year. Mr. Fred Malphurs was appointed as the Interim Network Director, following the retirement of the former Network Director. Mr. Malphurs has been instrumental in setting a course

that promotes teamwork, ‘‘open book management,’’ and greater

participation in network committees and strategic planning.

Recently, Dr. Jeannette Post was appointed as the Network Director after serving as the Acting Clinical Manager for 6 months.

I am pleased to tell you that she brings to this position excellent

management and clinical credentials and a passion for delivering

quality health care services to the veterans of New England. We

will provide effective leadership and expand the initiatives to provide quality, accessible health care services in an integrated delivery network.

I would like to turn the microphone over to Dr. Post at this point

to let her tell you about the initiatives that will take place in Network 1 over the next several months.

Dr. Post.

[The prepared statement of Dr. Murphy follows:]

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Dr. POST. Thank you for the opportunity to discuss the accomplishments and challenges that are facing the VA New England

health care system. Network 1 is an integrated and comprehensive

health care delivery system that delivers care in the six New England States. Twenty-five community-based outpatient clinics are

strategically located throughout New England and provide increased access to health care services for veterans.

Network has a significant and longstanding affiliation with nine

of the most prominent medical schools in this country. We are the

third highest research funding in VHA. Network 1 is committed to

provide quality health care services to the veterans throughout

New England. The goal is to provide the right care at the right

time and at the right level required to safely and compassionately

meet the unique needs of each veteran.

A major Network 1 initiative has been the development of this

integrated health care system based in primary care. This primary

care model has resulted in improved continuity, improved satisfaction and an increase in the number of patients served.

The Network opened a new CBOC in southern Maine on March

17 and we expect to open 12 new CBOCs this year. Feedback from

patients is one of the most significant measures of quality. We are

currently No. 1 in the country in overall quality of care as rated

by ambulatory care patients.

Network 1 was the first network to obtain the joint commission

of accreditation, network accreditation with commendation. It was

recognized for meritorious achievement as a finalist for the kinds

of quality achievement recognition grant last year.

Network 1 has embarked on a new mission to communicate more

often and in more detail with veterans, employees, affiliates, congressional offices, local unions and other stakeholders. A number of

communication tools have been developed that are responsive to

the needs of patients, employees and stakeholders and enhance the

understanding of network initiatives.

All nine VA Medical Centers are utilizing the computerized patient medical record. We have implemented a state-of-the-art information technology called Webtop which will allow a clinician anywhere in New England to access the electronic medical record for

any enrolled patient. Both of these systems will foster communication and consultation among physicians throughout New England.

One of the greatest challenges facing Network 1 is the need to

come together as one network instead of its current, parochial orientation of nine individual medical centers. Network needs to move

from a hospital-centered system to a Network patient centered system which provides health care services along the entire health

care continuum. The Network must re-engineer its business processes and implement clinical practice guidelines to ensure there is

a single, consistent standard of quality health care regardless of geographic location of care and delivery.

Another strategic goal of Network 1 is to integrate health services by fully implementing Care Line management. Care Lines are

intended to enhance the provision of uniform, high quality services

throughout the network by reducing variations in care and standardizing availability and coordination of services. This allows for

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improved management of patients along a seamless continuum of

care.

Another major initiative is the consolidation of the local Boston

facilities, Jamaica Plain, West Roxbury and Brockton. The consolidation will reduce duplicate clinical services and business processes. The Bureau of Resource Allocation System was developed to

match resources with patient needs across the country. Although

the network received reductions in resource allocations in the first

2 years, in fiscal year 2000 Network 1 received a 51⁄2 percent increase or $43 million more than the prior year. It is projected that

our next year’s funding will be a 2.9 percent increase equated to

$24 million.

Network 1 has a cost per unique patient that is approximately

$400 greater than the national need and has staffing ratios that

are some of the highest in the country. We have made strides to

reduce overall cost per patient, however, we need to gain additional

efficiencies through reorganization of health care delivery systems.

These efforts will improve the network’s ability to deliver high

quality care and serve more patients at a reduced cost in the future.

Thank you for the opportunity to discuss the achievements of

Network 1.

Mr. CONTE. For those who do not know the scope of the Bedford

Hospital, it is basically a long term care facility psychiatric care

with rehab focus, a large Alzheimer’s component and a primary

care clinic around the eastern Massachusetts area and a large research component.

Since this hearing today is being held in Peabody, MA, I will provide you with information of a few of the many successful local initiatives. VHA Network 1 appreciates the support and encouragement of the New England Congressional Delegation in the opening

of new community based outpatient clinics.

Congressional support was instrumental in the success of the

clinics in Lynn and Haverhill, and to the proposed clinic for

Gloucester. The clinic in Haverhill is located with the Hale Hospital, a facility owned and operated by the city of Haverhill, creating a mutually beneficial partnership with the community. The

clinic in Lynn is located in a private sector medical building. Both

the Lynn and Haverhill clinics provide primary care services and

have expanded recently to include mental health counseling.

The Edith Nourse Rogers Memorial Veterans Administration

Hospital in Bedford operates an Alzheimer’s care program that is

nationally known for its comprehensive quality care. It is comprised of an Outpatient Program, an Adult Day Care Center and

an Inpatient Program.

The Alzheimer’s care program is fully integrated with the Geriatric Research Education and Clinical Center known as a GRECC

in the VA facility. The Bedford GRECC program is a unique program in that it is fully integrated with clinical care, a full partner

with its academic affiliate, Boston University, and designated by

VHA Headquarters as a National Center to facilitate cooperative

efforts between the VA, private sector health care organizations

and pharmaceutical companies.

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To enhance the continuum of health care services provided to

veterans, the Bedford VA Medical Center has embarked on two innovative projects utilizing the Enhanced Use leasing authority. The

first proposal is to establish a cooperative venture with a private

sector organization for construction and operation of an Assisted

Living Center at the Bedford VA Medical Center with an emphasis

on Alzheimer’s.

In return for the ability to utilize VA property, the private sector

organization will provide bed space for VA patients at no charge.

This proposal is expected to be approved and construction started

in 2001. The second proposal would establish a cooperative venture

with the New England Shelter for Homeless Veterans, a nonprofit

organization for construction and operation of 40 units of Single

Residency Housing at Bedford. In return for the ability to utilize

VA property, the New England Shelter will lease the building and

this will help us offset some of our operational costs. This is a

change in the testimony. This proposal is expected to be approved

and construction started in the near future.

Another example of a VA-private sector partnership is in the

area of health care services to homeless veterans. A private sector

homeless services provider, Ms. Leslie Lightfoot, has received a VA

Grant to obtain, equip and operate a health care van in the greater

Worcester, MA area. This program will provide the van at scheduled, designated locations to perform basic health screenings and

followup.

The Bedford VA Medical Center will provide expertise in the

planning phases of this project and will provide equipment, supplies and personnel to support this important homeless outreach effort which is expected to be operational by this fall.

Thank you.

Mr. SHAYS. At this, Mr. Tierney, I invite you ask any questions

you would like.

Mr. TIERNEY. Thank you very much, Mr. Chairman, I thank the

members of the panel for their testimony.

I want to ask Mr. Conte a question first, but I think I would be

remiss if I did not share with the folks that are here, as well as

with the chairman, just the wonderful work that the folks at the

VA Hospital in Bedford have done and the cooperation that they

have given my office and the veterans’ councils and agents

throughout the district.

We have had a number of health fairs that probably could not

have happened without Mr. Conte and his staffs volunteering considerable amounts of their time on several days in this past couple

of years in Haverhill, in Lynn and out in Gloucester where people

gave their time to run the tests, to sign people up to make sure

that we had appreciation for the number of veterans who would,

in fact, utilize those services.

And so I want to thank you publicly and your staff through you

for the cooperation that you have had. And it went beyond that.

Once the CBOCs were actually cited first on the North Shore and

then in Haverhill. The staff worked with local veterans’ councils

and gave them a voice in where they would be located and how

they would be established and how they would be staffed and that

continues to go on, so we are very, very appreciative of that.

35

Last, let me just say we gave you a major headache at one point

in time when we put out a veterans’ newsletter that indicated that

there was a prescription drug benefit to which veterans were entitled and I think the next day you had over 500 phone calls rushing

into the clinics and your office was good natured and gracious

about building those and making sure that the veterans, in fact,

got the benefit of those services so on behalf of veterans I would

thank you for making sure that they were well served with the

right disposition and attitude when that increase of calls came in.

As you know, Mr. Conte, I am very much a proponent of the community-based outpatient clinics. Can you tell us roughly what resources these clinics that are in this district have had and how

many physicians and nurses they have and what type of care they

are generally provided?

Mr. CONTE. Yes. I will start with Lynn. Lynn was originally

staffed with the positions of a physician and a nurse practitioner

and administrative support and that would be roughly in the area

of about $350,000 worth of personal services and then in the Lynn

area we contracted with a medical building there and I believe the

lease was in probably the $30,000 range, so we are looking at about

$400,000 roughly that goes into that clinic when it started a year

and a half ago.

We have increased services. At this point we have mental health

practitioners going up there now, so I would say we are well up

over $500,000, according to that clinic. That does not count all the

new patients or the new prescription drugs and all the services we

provide back at the Bedford facility. Haverhill was brought up the

same way.

Both of these clinics were brought up as a startup initiative, let

it grow and let us meet the demand. Haverhill is very similar in

terms of its original start. It was a nurse practitioner, physician

and administrative support, again in the $300,000 to $500,000

range at this point in time.

Mental health services are expanding in both those areas as we

speak.

Mr. TIERNEY. Does the entire budget for those facilities come

from the Bedford facility?

Mr. CONTE. In the past, yes, that has been true and the issue

was that if we did get an outpatient clinic we would generate those

dollars within the facility and the VA facility at Bedford, we have

been very dynamic in rearranging, reprogramming dollars.

We have done a lot of sharing with other facilities. We have done

a lot of consolidations for things like administrative services. For

example, a good example, we used to have a large kitchen staff,

now we do cook/chill which is basically cooked in West Roxbury,

the food is prepared there, it is brought to the veterans facility and

that saves us a lot of dollars and that provided the dollars to expand to those clinics.

The Haverhill staff are part of the Bedford facility and so are the

Lynn staff, so is the Winchendon staff. There is another group out

in Winchendon that people do not realize has been there for many

years. Also the VCC in the Lowell area, Veterans’ Community Care

Center.

36

Mr. TIERNEY. And despite, has the Bedford facility been able to

maintain its patient case load, the waiting time has been about the

same and not increased?

Mr. CONTE. Two questions. The waiting time, 5 years ago, we

have a member of the GPRA, Government Performance Review

Act. We are a pilot site. We establish times that were in the range

of 7 days and less than 30 minutes to be seen in a primary care

clinic. Over those 5 year periods, I do not think we have exceeded

those times four or five times. We have a strong QA program that

monitors that, so we have been working with that for many years,

so yes, we have been able to maintain our times by shifting staff

in the ambulatory care.

The other issue is that the dollars that we have taken from programs have enhanced that ability to expand those clinics. We have

expanded some clinics and have been able to maintain those times,

yes.

Mr. TIERNEY. One of the issues I expect me hear about something today, but I heard about it quite frequently in our offices is

transportation. I understand there is shuttle service to the Bedford

facility, but I would like for you to take a moment, if you would

to describe how often the shuttle runs and what is entailed in participating in that transportation.

Mr. CONTE. Difficult question. They change quite a bit. There is

shuttle that runs from the Worcester clinic, excuse me, from the

Lynn clinic to Bedford and back, I believe four times a day, a morning run and the afternoon run. There is also a shuttle that runs

to the Haverhill clinic back to Bedford and then there is part of a

consolidated transportation network that is working out of Boston

that the VISN initiative startup was a VISN initiative about a year

and a half ago when they were working the transportation network.

We, ourselves, at the Bedford facility decided to run this shuttle

to try to get people back to the Bedford facility when they need

that kind of care and I think it has been reasonably successful. As

the clinic expands, there may be need for more transportation. Obviously, you identified that earlier.

Mr. TIERNEY. How is the staff of these programs being paid? Are

they being paid by the clinics themselves or?

Mr. CONTE. Out of our operating dollars at the veterans facility,

certainly.

Mr. TIERNEY. Are there any other plans for that network transportation concern in the future?

Mr. CONTE. At the VISN letter there is a Boston consolidated

transportation network and actually there was a contract let out

about a year and a half ago and there was an evaluation period.

We are going through that right now, for the private sector vendor

who was coordinating that transportation network in the Boston

area. Lynn and Haverhill are not included the initial startup of

that, so we ran the vans ourselves, but we have to look at that, yes.

Mr. TIERNEY. With the indulgence of the chair I would like to

continue. I am beyond my time for a couple of seconds.

Can you describe how someone who wanted to go to the clinic in

Haverhill would actually get to say Jamaica Plain or Bedford or

West Roxbury if they needed to get there, how that works?

37

Mr. CONTE. I believe there is a van that is going down to Jamaica Plain, but it is not as regular, I believe, as the one we have

running back from Bedford, but you could take two routes, obviously, public transportation being another option, but you could

take a van from the Lynn clinic to Bedford and then from Bedford

into Jamaica Plain which makes it a little difficult sometimes and

I believe we are starting an initiative to run a van from those clinics because they have gotten to the point where you have enough

demand. In the past there has not been that demand.

Mr. TIERNEY. Is the demand for the service of the clinics actually

helping our budget here locally, the way the current funding situation is going?

Mr. CONTE. I would think so. Our numbers alone have gone from

about 9,700 veterans to over 11,000 and we have been trying to put

a finger on that, if they were coming to Bedford and now to Lynn

or if they were new at Lynn and I would strongly support the idea

that more people are coming to the Lynn and Haverhill clinics because of access and therefore we are earning more dollars under

this VERA model, yes.

Mr. TIERNEY. Now a lot of veterans have asked questions about

the plans to implement the new millennium bill, maybe you could

help us first by telling us a little bit about the requirements of the

bill or Dr. Murphy or Dr. Post or whoever, just give a brief outline

about the millennium bill and then maybe I think somebody was

a little perplexed about the lack of funding, a vital functioning of

that particular bill and all that it calls for and I would like for you

to tell us what your approach is going to be in dealing with that.

Dr. MURPHY. I will start and then I will turn it over to Dr. Post.

The millennium bill is a rather complex piece of legislation. The

millennium bill provides for a continuum of long-term care. In fact,

it provides long-term care to veterans who are greater than 70 percent service connected and allows VA to provide that care on a

more consistent basis.

It also gives us the ability to provide noninstitutional long-term

care by allowing us to set up pilots for assisted living and to do

more home-based, long-term health care. It also changes some of

the provisions for the State homes.

As you can imagine, the implementation of this legislation requires many policy decisions and publication of regulations. We are

well into that process and expect to be able to move forward relatively quickly. In fact, Dr. Post spent last week down in Leesburg,

VA leading one of the seven subcommittees working on the implementation plan for that bill. It is a complex piece of legislation, but

it does give veterans more access to the long-term care that they

are going to need in the future.

Were there specific aspects of the bill?

Mr. TIERNEY. I was interested in the funding of it which I think

is problematically probably more on our level than yours, but I am

curious to know what your approach is going to be.

Dr. MURPHY. We did put specific funding into the 2001 budget

that will allow us to fully fund the long term care piece of that legislation.

In addition, the legislation set out VA authority to charge copayments for some long-term care and so part of what will pay for that

38

is some of the co-payments that we will collect from veterans who

use the long-term care.

Mr. TIERNEY. Does that also include—I was concerned that as

that bill was coming through Congress with the prescription drug

aspect of that. I was very concerned at the beginning, but there is

now an allowance for an increase in the co-pay on that. Do you anticipate that that is going to a severe increase, moderate increase,

no increase?

Dr. MURPHY. We do not believe that there will be a very large

increase in the pharmacy co-payments. The problem was that the

level of co-payment the VA was charging was not even paying for

the administrative costs of sending out the bills for the copayments. I think the copayments are likely to be under $10 and probably closer to $5 per monthly medication refill.

Mr. TIERNEY. Thank you.

Dr. POST. I just wanted to add to the comments that Dr. Murphy

just gave you about the implementation of the millennium bill. If

you believe that all health care should be local I think VA has

moved in the right direction by establishing an increasing number

of access points or CBOCs and in our network alone with the additional 10 to 12 that will happen in this year, that will be a plus.

The millennium bill affords us the opportunity to make all long

term care local and that includes not only the institutional care,

but the noninstitutional care and we in New England have already

started to move to enhance that access, our relationships with the

State Veteran Homes, the further development of the geriatric and

long-term care on that. We have additional development of 24 hour

day, 7 day a week contact with us from the emergency room.

Mr. TIERNEY. Can you tell me how that will work? Are you going

to reduce bed space now and bring it more out to the community

and more outpatient based. What about the long term care inpatient demand? When that increases in the future, will we have

what we need to address that?

Dr. POST. I think that is part of the process for us. Part of the

process is to decide where is the right level for the patient to be

maintained for the longest period of time for the patient to maintain his functional independence.

Mr. Conte talked about our Alzheimer’s unit at the Bedford VA

which maintains the patient from an ambulatory care through a

day care and then up through institutional care. I think that over

time the issue for us is to have the right size and I do not know

if I can predict the numbers that are there for right now.

Mr. TIERNEY. Are you in the process of doing any sort of survey

or determining what the likely demand for in-patient care is going

to be for baby boomers?

Dr. POST. I think that is part of our geriatric/long term care line

to make an assessment of where we should be and then to address,

as Dr. Murphy has said, through the millennium bill, the additional placement of those patients that are 70 percent or greater.

Mr. TIERNEY. Thank you. Mr. Chairman, why do not I let you

have a few questions.

Mr. SHAYS. Thank you. I am going to ask these questions as if

I were in Washington and not be concerned that I am asking them

39

in Massachusetts, but the purpose is to understand the challenges

and to give you an opportunity to respond to it.

In Connecticut, we felt we did our duty by consolidating

Newington and West Haven and making it one system which is referred to as the Connecticut Health Care System. You have a facility in Vermont. You have a facility in New Hampshire. You have

a facility—I am talking major facilities, not community-based

health care clinics, a major facility in Rhode Island as well. And

you have four facilities in Massachusetts, I believe, and now you

have consolidated two and I just want to sense, is there going to

be eventually one Massachusetts Health Care System coordinating

the major hospitals?

Dr. POST. The process to look at the delivery of health care in

Massachusetts was thoroughly reviewed. That review process

began some 2 to 3 years ago as we came to be an integrated delivery system. And actually, Mr. Conte and I were on one of the first

groups to look at what we should do in the network for those two

locations, 5 miles apart, Jamaica Plain and West Roxbury. West

Roxbury had already been joined with the Brockton VA I think

some 10 years prior to——

Mr. SHAYS. How many major facilities are we talking about in

community based health care clinics?

Dr. POST. Bedford, JP, Jamaica Plain, West Roxbury and Brockton.

Mr. SHAYS. Five facilities. I am sorry, four.

Dr. POST. Four facilities.

Mr. SHAYS. Right, consolidated into how many?

Dr. POST. No, Bedford is still unique. The Jamaica Plain, West

Roxbury and Brockton have been in the process of consolidating

and integrating into a single health care system.

Mr. SHAYS. And it will have one so then you will have two budgets.

Dr. POST. Right.

Mr. SHAYS. And the savings from that, it seems to me can then

be poured into—it does not go back down to Washington, it stays

up in District 1?

Dr. POST. Correct, in VISN 1.

Mr. SHAYS. When will that consolidation be concluded?

Dr. POST. It is projected to be finished within the next 3 to 4

years.

Mr. SHAYS. So right now we have five community based health

care clinics in Connecticut. Is there any plan to open any others,

do you know?

Did I ask the wrong question? [Laughter.]

Dr. POST. And I did not even answer yet.

Mr. SHAYS. Is that your final answer? I would just be interested

in knowing how the transcriber records that event. [Laughter.]

I saw some veterans actually dive for—as they are trained.

Yes?

Dr. POST. If I may answer the question, as we as a network look

at where care is delivered and I said it before and I will repeat my

phrase of health care is local, so there are additional CBOCs

planned for Massachusetts as well as Connecticut.

40

Mr. SHAYS. Will any of these go through—you have 5 in Connecticut, 6 in Maine, given the size of the State, 2 in Vermont, 10

in Massachusetts, 2 in New Hampshire and none in Rhode Island,

community based health care clinics. Do I have old information?

Dr. POST. No, that is correct.

Mr. SHAYS. Now do you have plans to increase the number in

Connecticut, in Massachusetts? Are there any specific ones that

you can mention?

Dr. POST. I would be happy to mention some of them. We actually have just submitted, I think it is four or five that have gone

into headquarters for the technical review that is required and I

will check on the site of the Connecticut one. I just cannot remember. I think it is Danbury.

Mr. SHAYS. I think you are right.

Dr. POST. OK, and in Massachusetts, it is the Gloucester clinic,

it is Quincy, two sites, Turners Falls in the western part of the

State of Massachusetts and additional ones in Massachusetts to be

considered. And in Rhode Island, there is one in Newport, Martha’s

Vineyard in Massachusetts as well is being considered.

Mr. SHAYS. Massachusetts now has three community based

health care clinics?

Dr. POST. That is correct.

Mr. TIERNEY. This is a powerful man.

[Applause.]

Mr. TIERNEY. These clinics have enabled you, it seems to me, to

provide a better service for those particular needs at a reduced

cost, is that correct?

Dr. POST. That is correct and as I mentioned in my opening testimony that as an integrated delivery system, as we move toward an

ambulatory care or primary care service line, we will develop as a

network a standard of care across the network that is to the best

practice so that the care that is rendered in Lynn and Haverhill

is the same that is rendered in Newington and West Haven clinics

in Connecticut. We can, as an integrated delivery system, then

grow in terms of meeting the needs of our patients.

As Mr. Conte said, the majority of care that is delivered in our

CBOCs is primary care. Good primary care can meet 80 to 85 percent of the needs of our veteran population. Following that, the

specialty services, the mental health services. As we know the population that we are managing, then we need to provide the additional support for both the mental health and the specialty clinics.

Mr. TIERNEY. Now the way the system works, as you service

more veterans, you get more resources provided, correct?

Dr. POST. Correct.

Mr. TIERNEY. So it is based on the number of veterans served.

Dr. MURPHY. Correct.

Mr. TIERNEY. And it strikes me that by expanding communitybased health care clinics you are reaching more veterans as they

get older who need this service who do not have to go into a larger

facility with the bureaucracy sometimes associated with the larger

facility. It is more personal and so on. I think the next hearing that

I want to know is why does one Member of Congress get three in

a State with only 10 Members, but that is for another hearing.

41

Mr. SHAYS. Let me just ask you another question. One of the

tragedies of our failure to properly—is there someone who is kicking the mic that we do not know about? It is a shocking sound.

Let us give it a try. Our failure to properly protect our blood supply resulted in the HIV virus working—that pathogen working into

our blood supply, but one of the silent killers was hepatitis C and

in the course of our hearings we learned about hepatitis C a number of years ago.

My sense is that the VA has done a better job than almost any

other health care network in terms of dealing with hepatitis C and

I would just like to know if, Dr. Murphy, you could give us a sense

of what is happening there?

Dr. MURPHY. I would be happy to. Thank you for the compliment

on our hepatitis C program. I think VA has been very proactive on

this issue. And one of the reasons for that is that VA or veterans

have a higher rate of hepatitis C than the general population. The

population in the United States has a rate of about 1.8 percent of

hepatitis C and veterans at least by our estimates from a 1-day

screening program have a rate of about 6.6 percent, so it is significantly elevated in the veteran population.

In our drug treatment programs it can be up to 40 percent of the

IV drug abusers being treated, so it is a very important problem

for veteran.

Hepatitis C can cause chronic liver disease, including cirrhosis

and liver failure and sometimes result 20 or 30 years down the line

in liver cancers. So it is important to identify the infection by

screening veterans and the risk factors include exposure to infected

blood products from transfusions or from IV drug abuse and also

other blood exposures.

If you go into a VA medical center the physicians and health care

providers will ask you about risk factors for hepatitis C and offer

you a blood test that can rule out hepatitis C. Prior to 1992 there

was not a blood test that could be done and so individuals who received blood transfusions prior to that date may have received infected blood products.

We have screened several hundred thousand veterans, in our

health care system and have found about 60,000 individuals who

are infected with hepatitis C. We have provided our health care

providers with guidelines for treatment. There are drugs available,

very good drugs that can help treat hepatitis C and prevent the

complications and so I would encourage any of you who might be

worried about being exposed to this infection to go into your local

VA medical center and get screened.

We are also providing a lot of education to our providers. We will

have done three national training programs, face to face conferences with our health care providers as of the end of this year.

We have done national teleconferences. We have participated with

NIH in training programs and with the American Liver Foundation. So VA has been a leader in this area.

Mr. SHAYS. Thank you. Would you tell me what veterans have

been most exposed to hepatitis C, what era veteran?

Dr. MURPHY. It appears that there was an epidemic that occurred in the 1960’s and early 1970’s and the highest rate of hepatitis C appears to occur in Vietnam Era veterans. However, any

42

veteran who is exposed to infected blood products would be at risk

for hepatitis C.

Mr. SHAYS. Let me go to Mr. Tierney in just 1 second. I want to

ask these two questions for the record and I would like to know

how are the allocations distributed to the facilities in VISN 1? How

do you decide what, how they are allocated?

Dr. POST. The process that has been used in the past is the historical information of workload that was done in the prior year and

then an adjustment made to that for various incentives that may

on in the facility. That has been the allocation up through this fiscal year.

Mr. SHAYS. And is it likely to change in the next few years?

Dr. POST. It is our intent as we move toward better definition of

an integrated delivery system to have the resources delivered, some

of it will continue to go to the facilities, but the majority of it will

be through our care wants.

Mr. SHAYS. Last question. What is the timeframe which VISN 1

hopes to achieve the goals of increasing the number of veterans’ users by 5 percent and to decrease the cost by 5 percent?

Dr. POST. This year. We hope to make that achievement this

year.

Mr. SHAYS. Thank you.

Mr. Tierney.

Mr. TIERNEY. Thank you. I know how good we are getting because we are not letting the interruptions bother us now. We just

go straight through.

Let me just say I understand some veterans need to obtain replacement copies of their discharge forms from the National Veteran Center in order to obtain various services and although turn

around time has significantly improved, I understand, there is still

quite a backlog. Could you tell us whether or not there are efforts

under way to address this particular issue?

Dr. MURPHY. I cannot answer the question specifically about providing the DD214 form, but I will find that information and get

back to you.

Mr. TIERNEY. Thank you. Also, the average processing time, I

guess, the original compensation claim is about 204.8 days. And I

am just curious, are there ways that we can reduce this for veterans. Sometimes these two problems interact and create a significant difficult and I just see that issue coming up over and over

again.

Dr. MURPHY. All three of us are with the Veterans Health Administration and the claims processing is administered by the Veterans Benefits Administration which is administratively separated

from VHA. However, I know that Joe Thompson, the Under Secretary for Benefits has been taking VBA through a reengineering

process.

The waiting times have actually gone up slightly in the past year

as they have been training more rating specialists and they knew

that their performance would get worse before it got better because

as you are training it takes more time and more resources to process a claim, but they expect that with the increased number of rating specialists that are being trained that in a very short period of

time processing time for claims should come down. So we are wishVerDate 11-MAY-2000 10:29 May 23, 2001 Jkt 000000 PO 00000 Frm 00046 Fmt 6633 Sfmt 6633 C:\DOCS\70278.TXT HGOVREF1 PsN: HGOVREF1
43

ing them great luck and we hope that their performance does improve in the very near future.

Mr. TIERNEY. Let me just ask you one last question, you mentioned that the network has a cost per unique patient, as you

phrased it. It is approximately $400 greater than the national average. Would you define for me that unique patient?

Dr. POST. You would like to know the actual cost?

Mr. TIERNEY. When you said that you have one type of patient

that was approximately $400 greater than the national mean you

mentioned that it was pertaining to a unique patient. What constitutes a unique patient?

Dr. POST. Actually, that term is referring to a unique Social Security number, so it is per individual and the way we calculate the

cost per patient by network is to take the total resource allocation,

the number of dollars for Network 1 and divide it by the number

of veterans that are being served. So that is the unique veteran.

The allocation is actually done as a basic and a complex patient

and the complex patients get almost 10 times the number of dollars

that the basic care patients do, so we do make some adjustment for

the complexity of the medical care required.

Mr. TIERNEY. Thank you for clarifying that. Let me end, Mr.

Chairman, with just a couple of questions about proposed communications.

During your statement you described the new communications

council and you mentioned several electronic means of communication. Do we have an estimate of the number of all the veterans that

actually use computers? Do we have any statistics on that?

Dr. POST. I do not have the number of veterans who have access

to computers. I can tell you that in many of our facilities we are

trying to provide them that opportunity.

Mr. TIERNEY. And you have some idea, you must have an idea

of how many veterans actually receive your printed newsletter?

Dr. POST. I am sure that we have that number. I just do not have

it off the top of my head. I apologize.

Mr. TIERNEY. Since this is going to be the cornerstone of the new

VHA where else can veterans obtain information related to the new

services, charges of existing services, is there anything else that

veterans here and others ought to know about, ways that they can

access information?

Dr. POST. Other than the printed material, there is access on the

Web to the VISN 1 Website which has lots of information on it

about the CBOCs, the services that we provide and what is available to them.

Mr. TIERNEY. Thank you very much. I would like to thank all

three of you for your testimony here this morning and for joining

us.

Mr. SHAYS. I would just conclude by making this comment. I

think the most significant complaints we have from our veterans

tend to be with the major facilities, the waits, the bureaucracy and

so on. I think and I may find it is different, so I am sharing it with

all of you to get your comments when you take to the mic, but I

think the biggest area of compliment comes with the community

based health care clinics, so it will be interesting to see from our

44

veterans if that holds up. Is that something, is that consistent with

what you are hearing?

Dr. MURPHY. That is actually very consistent with what we hear

from veterans at the national level and at the local level. In fact,

that is why we chose access and waiting times as a major initiative

that we will take on in 2000 and 2001.

Veterans want to be able to get in to see their physician in a

short period of time. We have made a commitment that every veteran who calls for a first time primary care appointment will be

seen within 30 days and they will be seen for a specialty appointment within 30 days. We know that in many facilities we are not

meeting those goals at this point.

Sometimes for services like orthopedic consults or ophthalmology

consults or hearing testing, the waits are considerably longer. And

in order to help us understand how we can reduce the waiting time

for appointments, we have actually worked with the—we have an

IHI initiative and it is amazing what we have learned through

that.

We have looked at how we have organized clinics. We have found

about even changing the number of nurses or doctors assigned to

that clinic. In one case we were able to reduce the waiting time

from 159 days down to 7 days, just by changing the way the clinic

was organized. That is astounding.

So that kind of reengineering and improvement process can provide better service to veterans and it really did not take any increased dollars. It just took a focus on making a change.

Mr. SHAYS. We are preparing to go on to our next panel, but if

any of you would like to just make a closing comment, I would be

happy to have you do that.

Mr. CONTE. I would just like to thank John and the rest of the

people that work with John for the support and we have brought

on these clinics. I really do not think we could have done it without

the support of congressional people and working with the community and I think that is a real example how the VA should do this

in the future.

Mr. SHAYS. Thank you. Dr. Murphy.

Dr. MURPHY. I also want to thank the chairman and all the

members of the subcommittee. You have been extremely supportive

of the re-engineering process and the transformation of VHA. You

have been clear with the Department that what they want to see

is better health care to more veterans in a timely way and we

thank you for your efforts on behalf of veterans.

Mr. SHAYS. Thank all three of you.

At this time we would call our next panel.

All four of our next panelists are directors of Veterans Services.

We have Mr. Robert Hogan, town of Burlington; Mr. Michael

Ingham, city of Haverhill; Mr. Donald Welsh, city of Gloucester,

and Mr. Jean-Guy Martineau, city of Salem.

Will all four of you gentlemen raise your right hand, please?

[Witnesses sworn.]

Mr. SHAYS. Thank you. Note for the record, all four of our witnesses have responded in the affirmative. And I am going to have

you testify in the reverse order I gave you, so Mr. Martineau, I will

45

have you go first, then Mr. Welsh, then Mr. Ingham and Mr.

Hogan, in that order.

STATEMENTS OF JEAN-GUY MARTINEAU, DIRECTOR OF VETERANS SERVICES, CITY OF SALEM; DONALD T. WELSH, DIRECTOR OF VETERANS SERVICES, CITY OF GLOUCESTER;

MICHAEL G. INGHAM, DIRECTOR OF VETERANS SERVICES,

CITY OF HAVERHILL; AND ROBERT C. HOGAN, DIRECTOR OF

VETERANS SERVICES, TOWN OF BURLINGTON

Mr. MARTINEAU. Thank you, Mr. Chairman.

With well over 1,000 visits to the VA I feel qualified to tell you

what has taken place in the VA health care system here in the

Northeast. Within the past 9 years I have had a first hand look at

the Department of Veterans’ Affairs health care system.

Daily, the Salem Veterans Services Department provides transportation to local VA medical centers. This includes the VA in Boston, Bedford, West Roxbury, Causeway Street clinic as well as the

clinics in Lynn. My visits to these health care centers has brought

me into contract with a great number of VA administrators and VA

health care providers. I have also worked with VA social workers

and patient representatives at the Chelsea Soldiers Home and the

New England Shelter for Homeless Veterans in Boston.

The impact of health care restructuring and reallocation of funding priorities has had the ‘‘down sizing’’ effect on the quality of care

for veterans. Once a veteran has completed the eligibility process

and enrolled in the health care system, he or she will not be seen

by a primary care doctor for a month or more. Once they are assigned a primary care doctor, the veteran finds that the doctor is

not experienced or is a medical student. I have found this to be

particularly true in the mental health clinic in Bedford. Also, with

so many foreign doctors, especially in the J.P. hospital, many veterans cannot easily communicate with their doctors. Real communication and patient confidence in their doctors is lacking.

Also medical tests, which are required for proper doctor diagnosis

in many cases cannot be given on a timely basis. Recently, one veteran I transported to the VA in February could not get an MRI

until this coming May, a 3-month waiting period. I do not think

that is good medical care. Beyond the inadequate medical care

mentioned, personnel and administrative problems exists, morale

among workers is at a long term low.

Down sizing has resulted in many good experienced personnel retiring or having to do two or three additional jobs. This is especially noticeable in the social services and patient support groups.

Another major problem caused by ‘‘down sizing’’ is the complete

‘‘inaccessibility’’ of existing medical units.

Long term, in patient nursing home care is for all intents and

purposes unavailable. I have one veteran who filed for nursing

home care 4 years ago. He is 100 service connected and we are still

waiting for him to be admitted. Unfortunately, this case is a good

example of the lack of any nursing home care for our veterans.

I have some recommendations. As an experienced and concerned

veterans advocate, I would be wrong not to take advance of this opportunity to offer some recommendations to improve the VA health

care system.

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Reallocate funding to allow for Bedford VA to provide timely and

appropriate nursing home care for all veterans who are 50 percent

service connected.

Target increased funding to the directors of Bedford and Boston

to make sure that the existing administrative staffs have the funds

to provide proper qualified and more experienced doctors and medical care providers.

Provide more bed availability for the in-patient study and inpatient care in the GRECC unit which deals with dementia and Alzheimer health care.

Increase the funding for existing outpatient clinics as well as providing for more neighborhood VA clinics.

Gentlemen, you have only given me 5 minutes to provide testimony on 9 years of travel and first hand knowledge of the VA

health care system. Five days of testimony would not be enough.

So let me summarize by saying that I would never subjugate myself, a Vietnam veteran, or any member of my family to the VA

health care system.

I have always, in the past, in all my work’s challenges, where I

have spoken or testified had one model and that is ‘‘better to light

one candle than to curse the darkness,’’ so if I see one hope it is

in the newly opened and ever increasing VA clinics in Lynn and

in Haverhill.

In ending, I would be remiss if I did not thank Mr. Conte, the

director of Bedford and his staff. Although Mr. Conte and I have

in many cases agreed and in many cases disagreed, he has always

and his staff have always made themselves available to me.

I want to thank Congressman Tierney. I have worked my 9 years

with previous Congressmen Marvoulas, previous Congressman

Torkelson and now with Congressman Tierney and he is one of the

bright stars that represent us in Washington insofar as being a

champion of veterans’ issues and veterans’ concerns and I want to

thank Congressman Tierney for that.

And one guy I want to thank that is in the audience and there

are many people that I could single out, but you know, with the

downsizing of the VA, to get immediately health and direct care,

to make a difference, you can it right away if you go to New England Shelter for Homeless Veterans.

Thank you, Tommy Lyons and your staff and also the Chelsea

Soldiers’ Home. I don’t see anybody here from the Chelsea Soldiers’

Home, but God bless them too. And I want thank all of you and

the chairman and the congressional staff that is here for allowing

the veterans to have this opportunity to listen to you, for you to

come to us and I want to thank all of the veterans that come here

that show enough concern to listen what you have to say. God bless

the veteran.

[The prepared statement of Mr. Martineau follows:]

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Mr. SHAYS. God bless the veteran and thank you.

[Applause.]

Mr. SHAYS. Mr. Welsh, if you would just get that mic and just

lower it down a bit.

Mr. WELSH. Mr. Chairman, Congressman Tierney, fellow veterans, ladies and gentlemen, good morning.

My name is Don Welsh, as has been mentioned. I am the director

of Veterans’ Services for the beautiful city of Gloucester, MA and

I do appreciate the opportunity to address this committee about the

State of VA health care in my area of Massachusetts which I will

refer to as Cape Ann. Having spent 24 years in the Marine Corps

I can tell you I thoroughly enjoy taking care of veterans and the

more we can do for the veteran, the better.

Let me start by saying the status of VA health care for the veterans I represent is generally speaking not good and it is getting

worse. But I have a reason for saying that. It is because of the difficulty for veterans of Cape Ann to get to VA health care facilities.

There are none in Cape Ann. Thus, these veterans have to travel

many miles to the nearest facility after waiting a lengthy period for

an appointment and often have to go back for a second or third

time to complete treatment.

What we need is a community based outpatient clinic [CBOC], in

my area. You have heard a lot about that already this morning. I

am well aware of the CBOCs that in recent years were opened in

Haverhill and Lynn and the great relief they provided for the veterans in and near those cities. And as you have already heard,

thanks to Congressman Tierney and his staff, application for a

CBOC in my area has been made. How great it would be to open

a VA clinic in Gloucester to service our aging veteran population

which finds it more and more difficult to get around.

Let me point out that in my city of Gloucester there is a higher

percentage of veterans per capita than anywhere else in Massachusetts. It has been calculated that the average number of veterans

in relation to the overall population of each city in Massachusetts

is about 11 percent. In Gloucester, the veteran population is about

21 percent.

And as I have mentioned it is an aging population. World War

II veterans are in their late 70’s or 80’s and the Korean War Era

vets are not far behind. It is very difficult for them to travel long

distances for VA treatment. Many of them just go without much

needed services, rather than make repeated trips to a VA facility.

As Tom Brokow so eloquently wrote in his book, ‘‘The Greatest

Generation,’’ which was about World War II veterans, ‘‘They persevered through war . . . and then went to create interesting and

useful lives in the America we have today . . . They answered the

call to save the world from the two most powerful and ruthless

military machines ever assembled . . . but they did not protest.

They won the war; they saved the world.’’

Now, these veterans and veterans of other conflicts need our

help. They need better health care services and the VA can and

should be the instrument for those services. Let us not let our veterans down.

As everyone knows, HMOs are cutting back on providing prescription drugs and this is becoming a real burden for many of our

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veterans, particularly those who are on fixed incomes. This is an

area where the VA can pick up the torch and provide relief. But

in order to do so we need more facilities, staff and dollar resources.

Another area that should be addressed is the need to provide

dental care for our veterans. Today, that service is almost nonexistent. I get inquiries every week from veterans about availability of

dental care, but very few veterans are eligible under current rules

for such VA health care. With skyrocketing dental costs and again

with an aging veteran population, a more liberal dental policy

should be adopted by the VA.

I will close with a request for another area to be addressed by

this committee. It concerns communication by or about VA health

care services. What I am experiencing these days with veterans

who are being discharged from active duty is that many are not informed about the VA services available to them. It should be a

mandatory policy that every member of the Armed Forces be given

a Veterans’ Affairs briefing prior to release from active duty. If that

is a policy, it is not working in many cases. As a result, veterans

are missing out on benefits, particularly in the health services

area.

Thank you very much.

[The prepared statement of Mr. Welsh follows:]

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Mr. TIERNEY. Your last suggestion is something that we will just

separate right now and we will write a letter to the Secretary of

Defense and those who have direct responsibility. It is an excellent

idea. If it is happening, I am not sure if it is a requirement. I

agree, I am not sure it is happening. And we will make sure that

that is something we deal with right away when we get back. It

is an excellent suggestion.

Mr. WELSH. Thank you, Mr. Chairman.

Mr. SHAYS. Mr. Ingham.

Mr. TIERNEY. I have already tasked one of my task. I will have

her announce her name later, so if it does not happen, you will

know who to call.

Mr. INGHAM. Congressman Shays, Congressman Tierney, fellow

veterans, the ROTC students here—I just left 2 weeks at the Air

Force Academy, the Air Force Reserves and hopefully, you students

will attend that college and serve.

As the Veterans Services director for the city of Haverhill, MA,

one of the most common requests from veterans of my office is assistance with medical care and prescriptions.

With this in mind, I was very fortunate to meet William Conte,

the director of the Bedford VA and formulate plans for health care

services for veterans outside of the Bedford Hospital. These were

dramatic steps for the VA to go outside the traditional system of

providing care and bring health care services directly to the veterans in their community.

The first step was to develop a survey to define the health needs

of the veterans and what issues that might be preventing them

from using the VA health care service. Along with local organizations, the Veterans Council of Haverhill, we held a health day with

medical teams from the Bedford VA Hospital. Over 700 veterans

and their families attended.

The results of the survey indicated that a lack of knowledge of

the VA system and services that were available was the primary

reason for not using the VA. The second problem identified was

transportation as many of the veterans were elderly, driving to distant VA facilities was too difficult. The survey also showed priorities of care that the veterans would utilize. The most overwhelming need was assistance with prescriptions. An interesting point of

the survey was the income level; many veterans earn under

$25,000 annually. Many veterans identified needs that related directly to age such as ophthalmology, cardiology, urology and

rheumatology.

With the health needs established, transportation issues to address and education priorities outlined, we brought our findings to

Dr. Fitzgerald, the director of the New England Health Care System for submission to the VA for congressional consideration.

Thanks to the support of Congressman Tierney, local and State

officials, veterans organizations, the Veterans Outreach Center and

Veterans Services of Haverhill, we were able to approve as a site

for a veterans community based outpatient clinic.

With staffing from the Bedford VA Hospital and site work completed, the Haverhill Clinic opened in November 1998 at the cityowned Hale Hospital. The staff members, half of whom work parttime out of the Bedford VA, the clinic is now serving over 1,200

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veterans. With new patients enrolling daily, staff and services continue to increase with the demand.

Substance abuse and psychological care is now available twice a

week and plans are to expand the service with added space when

available. Issues such as agent orange and the Gulf War Syndrome,

as well as assistance with VA compensation claims can be addressed at the clinic. The Haverhill Clinic staff often assists agents

with placement for substance abuse, Post Traumatic Stress Disorder treatment, often while the veteran is in the Veterans Services Office and in need of immediate help.

The clinic is only primary outpatient care, but importantly the

Haverhill Clinic is tied into a network of extensive health care between the Bedford VA and the Boston VA hospitals. The clinic provides accessibility to a coordinated and a continuity of care with

courtesy, family involvement and patient education. In a new era

of health care, the VA must reach veterans and educate them on

their benefits, and we in the service of veterans are responsible to

do the best we can to see that they receive the benefits available.

The Haverhill Community Based Outpatient Clinic has dramatically impacted the veterans of Haverhill as well as other communities in the Merrimack Valley and lower New Hampshire. The

overwhelming response of the veterans using the clinic is that they

are totally satisfied with the treatment they received, both personally as well as physically.

Dr. Balse and his staff have done an outstanding job providing

health services to veterans that should be used as an example for

future clinics throughout the country. I have had veterans tell me

how much their lives have changed with the care they are now receiving at the Haverhill Veterans Outpatient Clinic.

Some feel their lives were saved as a direct result of visiting the

clinic. I know of one veteran that thought he was in good health,

and upon a visit to the clinic found he had a life threatening heart

condition that resulted in cardiac surgery that was performed by

the VA doctors at Jamaica Plains, Boston.

The pharmacy program is probably the most used service at the

clinic. Medications are requested by the primary doctor and filled

by mail from the Bedford pharmacy. Veterans are saving substantially on medications enabling them to lead healthier lives as well

as a better standard of living.

Bedford, Lynn and Haverhill, due to the marriage of health care

services provided over 190,000 visits to veterans in 1999, in these

hospitals alone. That equals to approximately three visits per veteran in the system. This is a dramatic result for 1 year in business

and we have only reached approximately 15 percent of the 36,000

veterans in the Merrimack Valley.

As I mentioned earlier, transportation is a primary reason veterans are not taking advantage of the VA health care system. Many

veterans with illnesses depend on family members to take them for

medical treatment. This is a stress on the entire family, not just

the veteran.

With the clinic centrally located in the Merrimack Valley, many

veterans are able to take advantage of care they often went without. Haverhill is very fortunate to have a van and a driver under

the Department of Veterans’ Services to take veterans to the VA

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hospitals. The Northeast Veterans Outreach Center is also under

the Department of Veterans’ Services, provides transportation to

the clinic with a van donated by the Massachusetts Department of

Disabled American Veterans.

Haverhill also provides transportation through the Department

of Human Services. This is free transportation for Haverhill’s elderly, handicapped and veteran residents. Transportation is available

from the Haverhill Clinic to the Bedford VA with a daily shuttle.

Haverhill also has the MVRTA bus system.

The problem for veterans outside of Haverhill is getting to the

clinic as well as transportation to VA hospitals in Boston. Expanded public transportation, discounts for existing transportation,

or grants to towns and cities to provide limited transportation for

veterans will make it possible for them to take advantage of the

health services available.

It is in our best interest to see that veterans are made aware of

the advantages of the New England health care system. Prevention

and treatment will ensure healthier and more productive lives and

save on taxpayers in the future. Many veterans have service related injuries both physically, as well as psychologically, the Haverhill

Clinic fulfills and obligation to them for their service to our Nation

with the best health care we can provide.

We are here today to request of you to express to Washington

that it is imperative to maintain the quality of our VA health care

system and to see that adequate funds are there in the new millennium for a generation that preserved the freedom of this country

that all of us in the 21st century will hopefully enjoy.

I wish to close by thanking you for listening to our comments

today and commend you for your efforts to best serve all veterans

of the U.S. Armed Forces.

Thank you.

[The prepared statement of Mr. Ingham follows:]

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Mr. SHAYS. Thank you, Mr. Ingham.

Mr. Hogan.

Mr. HOGAN. Chairman Shays, Congressman Tierney, Mr. Conte,

ladies and gentlemen and fellow veterans, thank you for allowing

me the opportunity to discuss the impact of VA health care service

restructuring and resource allocation in the delivery and quality of

health care.

I have three areas that I intend to address here today, one being

long term care for our veterans, another is continued access to VA

health care services for all veterans, and finally and briefly, some

comments on hepatitis C care and funding.

We need to make sure that the VA health care system is sound

enough and funded well enough, not for the healthy among us, but

for those among us that hope for quality health care during their

journey through this life and at the end of our life. We need to live

up to the promises and expectations of our elderly veterans who

need the coverage that the VA health care system promised them,

over the five, six or seven decades.

That coverage may take several forms, such as VA nursing home

care, community based nursing home care, and nursing care for the

veterans in their own home. But we cannot be told that there is

no room at the inn or that specific alternative care that is promised

has not yet be established or funded.

The funding for the new Millennium Health Care and Benefits

Act should be applauded for its beginnings, but it must continue

to grow and expand with the very increasing needs of our veterans

as they age and need proper medical care.

In the March edition of VFW Magazine, Republic Congressman

Bob Stump stated that this health care package is a blueprint for

the next century. Well, that sounds good, but without the required

funding, the blueprint will sit and collect dust and the lack of funding can in no way diminish the VA’s obligation to maintain and deliver proper and appropriate health care to our veterans. And it is

the responsibility of every Member of Congress to help the VA meet

this obligation. In that same edition, Democratic Congressman

Lane Evans reaffirmed Congress’ proud support for our Nation’s

veterans.

Now comes the difficult task of trying to wed that concept to reality. The passage of the Veterans Millennium Health Care and

Benefits Act in November of this past year has good direction, but

there needs to be significant plans on how to get to the goals stated, and money is one key component in that plan.

The bill directs that the VA operate and maintain a national program of extended care services including geriatric evaluations,

nursing home care, both in-house and contract, adult day care,

domiciliary care and respite care. With a national nursing home

crisis we are seeing nursing homes closing due to cutbacks in Federal funding. In Massachusetts alone, 93 of the State’s 580 nursing

homes are already in bankruptcy with 13 homes closing over the

past 2 years.

The VA should not depend on there being enough good quality

nursing homes available and with there being almost 5,000 complaints against nursing homes sin this State alone last year, the

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good quality part of that equation is also in doubt. The VA should

not be dumping its veterans out to lesser quality care.

The Millennium Health Care Act requires the VA to develop and

begin to implement a plan for carrying out the recommendations of

the Federal Advisory Committee on the Future of Long Term Care,

and that the VA increase both home care and community based

care options.

The elderly veterans who need this care now are the builders of

this great society. They sacrificed in war and they sacrificed in

peace and now just because they have aged does not mean the VA

and this country can forget them. They are an important part of

this great society and they have earned the right to expect to be

treated with dignity and be accorded the care any decent society

can afford, not years from now.

Throughout the 20th century, brave young men and women,

young boys and girls actually, who gave up their youth and the

comfort of their home and the safety of their families volunteered

and were drafted to serve their country and on many occasions either died or were injured because of that service to their country.

And what is not in the testimony, Mr. Chairman, if I could just remember the 19 Marines who passed away this weekend and note

that service to this country can be hazardous both here and around

the world, both in peace and in war.

Throughout America’s history, American veterans have served

and served well. They saw democracy challenged, here and around

the world and they defended it. They saw civilization threatened

here and around the world and they rescued it. They saw human

rights endangered and they sought to restore them.

Their heroism was prompted by faith in the fundamentals that

have guided this Nation from its beginnings. The idea was that liberty must be protected, whatever the cost. And the VA health care

system owes that same dedication to those men and women, whatever the cost.

And the VA must consider itself a supplier of a service and that

customer satisfaction is their top priority. The VA must develop a

communication plan so that anyone and everyone at the VA who

answers the telephone or sits at a desk must know what the game

plan is and where the resources are for the veterans and their families and the VA must be user friendly. The VA must be veteran

friendly.

And Congress to guarantee permanent funding for all veterans.

We cannot continue to inflict emotional distress upon the veterans

who quality for VA health care, that they will not have this taken

away from them based simply on cost considerations.

There is a health care prescription medicine crisis in the broader

health care structure that affects the VA health care system. Many

veterans who have private health insurance have no prescription

coverage for the drugs they need. Even in our most extensive public insurance program, Medicare, three out of five seniors in this

country do not have dependable drug coverage.

According to a recent report from the House Government Reform

Committee of which both Congressman Tierney and Congressman

Shays are members, drug companies charge older Americans discriminatory prices. Seniors in many parts of this country, including

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New England, are being forced to pay on average, more than twice

as much for prescription drugs than other customers.

Health care is one of the most important issues in this country

today. And it is so because of the explosion of health care crises

around the country. President and future health care crises will

send veterans to the VA in droves to secure the proper health care.

The VA will need to be ready to handle that need and the VA must

continue to provide care to the veterans that has been promised to

them, that VA health care must provide quality care to the right

patient at the right time and at the right level of care.

If we do not take dramatic steps now to address these issues, it

will only be harder for us down the road to be more diligent to ensure good quality care for our aging veterans.

And finally and quickly I would like to comment about hepatitis

C care and funding. Hepatitis C is a fairly new, yet very disturbing

medical risk and the veterans are on the high side of the curve

when it does come to those infected, as you heard us talk earlier.

It is also very costly and it will be a major impact on the VA budget line item. Treatment can be expected to run a minimum of

$10,000 per year for each veteran infected with the disease and future prevention and treatment to try and prevent additional damage to one’s liver are also considerable. It is on the radar screen

for one very good reason. It is important.

Thank you for allowing me this opportunity to address these

issues.

[The prepared statement of Mr. Hogan follows:]

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Mr. SHAYS. Thank you very much. I should have asked. I make

an assumption and maybe incorrectly that all of you have served

in the military and I would love for you to each just share where

you served and what branch.

Mr. HOGAN. All of us have served. I served in the U.S. Army and

I served in Vietnam in the late 1960’s.

Mr. SHAYS. Thank you for your service. Mr. Ingham.

Mr. INGHAM. Yes, I served in the U.S. Air Force. I was there during the Vietnam Era. I served in Germany and in the United

States. I was activated for Desert Storm. Again, I served here in

the States at Westover Air Force Base and I am currently in the

Air Force Reserves as a Senior Master Sergeant. I have approximately 26 years and still going.

Mr. SHAYS. Sergeant, thank you for your service. Mr. Welsh.

Mr. WELSH. Twenty-four years in the Marine Corps, starting

with Tet Offensive in Vietnam, finishing up with Desert Storm.

Mr. SHAYS. Thank you. Mr. Martineau.

Mr. MARTINEAU. I served from 1968 to 1972, U.S. Navy with 2

years in Vietnam.

Mr. SHAYS. Thank you, sir. Thank you all for your service.

[Applause.]

Mr. SHAYS. I am going to recognize Mr. Tierney, but I am going

to ask you a question now that I would like you to just think about,

if he is not asking you a direct question. And I would like you, I

want to make the assumption that the clinics tend to be more user

friendly and that they are a relatively new innovation of the VA

that you are pleased with, but I would like to know if that is true.

I would like to know the best and the worse VA clinic and I

would also like to know the best and the worse of the major facilities, what you think, so for instance, Mr. Martineau, I am going to

force you to think of something really good about the major facility

and we will get to it later. I will get the answers to my questions

when Mr. Tierney is finished. Thank you.

Mr. Tierney.

Mr. TIERNEY. Thank you. As Irish as I look, part of me is French

so I know for sure that it is Martineau on that and I hope, I see

that you have so much to say and so little time to say it, it is always easy to speak for about an hour when you are passionate on

an issue, but not quite as easy to speak for 5 minutes. So the next

time you turn to C–SPAN you will see Chairman Shays and I

struggling to get our thoughts in in 1 minute and you will know

of the difficulty that is there.

Let me just say, Mr. Chairman, as I waive the deduction, you see

four of our veterans’ agents who I am proud to have in our District

and work with and they are just an example of the great veterans’

agent that we have in this District and that make our job that

much easier and they represent the veterans so well. So I want to

thank you publicly for the work that each of you do and for those

that are in the audience that also work with us.

Jean-Guy, I know you are busy thinking of Chris’ question, the

chairman’s question, but I do want to ask you, I know for a fact

the amount of time that you spend on transportation, you personally, take any number of veterans where they have to go and Mr.

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Ingham, I am going to ask you the same question because I know

you do a lot of the same and I suspect that the others do also.

What can we do to improve the transportation situation between

the veterans’ homes and the clinics and the clinics and the hospitals in Jamaica Plain, in West Roxbury and in Bedford?

Mr. MARTINEAU. That is a very complicated question. Basically,

it is almost impossible to really improve the immediate needs of

transportation because the majority of the veterans that we transport to hospital, the reason why we do it is because they cannot

take public transportation because they cannot even go to the clinics because they are either in wheelchairs or they have walking

problems and they have to use walkers.

So we have to literally get them from their doorstep to the door

of a parking lot over at the VA Clinic in Lynn and we do transportation, of course, as we told you at the Chelsea Soldiers’ Home as

well as the VA Clinic in Boston and the one in Bedford.

And again, many of these elderly veterans are World War II veterans and now Korean War veterans do have mobility problems. So

to improve the transportation I think what you would have to do

is guarantee funding for transportation that is more personal and

more accessible to those veterans who cannot walk on their own.

They cannot even get up from a wheelchair on their own without

assistance.

So it is nice to have a car. It is even nicer to have a DAV van

and I compliment the DAV. I can go on complimenting other organizations. However, unless you have someone who can physically

assist the veteran out of his wheelchair or help him with his walker, he or she with his walker, it will not really make an immediate

difference, but again, any support in funding that you can give on

the short term and the long term directly to the cities and towns,

veteran funding directly targeted at the clinics to provide transportation would be a definite assistance.

Mr. TIERNEY. Thank you.

Just by way of note I am going to talk to the chairman about this

at some point in time and the committee members, probably trying

to establish some sort of a pilot program, but I do not know just

where we are going with it yet.

Mr. Ingham, maybe you can give us some suggestions too about

what we might think of in terms of trying to get together an idea

of how we go about this and also tell me if you would about Mass.

Ride and whether or not positively impacts or gives you any assistance in this area?

Mr. INGHAM. One of the important issues is not so much as getting the vehicles. There are many organizations out there who are

willing to donate vehicles. It is finding drivers. Volunteer drivers

are very difficult to get. I deal with a lot of volunteer drivers for

elderly transportation as well as for veterans and it is more a funding issue.

If you make it through either grants or through the government,

really any kind of forms of funding where you make this affirmative position for driving is probably the largest improvement that

you could do for help getting veterans into the hospitals.

As far as the outreach center, they looked for quite a while to

get a volunteer driver. They had a van donated from the DAV, but

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again, the most difficult part was finding a volunteer driver. So I

think if there is any way that you could push for funding, through

grants or whatever forms you can to get a permanent driver that

would basically be the best solution.

Mr. TIERNEY. Thank you. Mr. Hogan and Mr. Welsh, I would like

to talk to you a little bit about the communication aspect.

Mr. Hogan, you indicated that not every veteran is aware of his

rights, what might be available to him or her within the health

care, VA health care system. Can you tell us what you believe is

the most used source of information by veterans, at least from your

information?

Mr. HOGAN. I have most access in my community to the local

newspaper, the local cable and I work very well with Mr. Conte

and Mr. Bill Davis from the Bedford VA and for the chairman’s information, my proximity to the Bedford VA is rather close, so I

have a different perspective than the other gentleman.

I think if the VA and its representatives were to continue to do

that, to work with the agents and the service organizations within

the communities to have them disseminate the information, when

I came on board as a veterans’ agent, I was surprised at how little

so many of the veterans knew about what was available to them

through the VA. So I think the VA by itself putting out a newsletter on a Website is one thing, but I think they have to network

just as well with the agents and the service offices within the communities.

Mr. TIERNEY. What sort of information you get as veterans

agents when you are dealing with the Veterans’ Administration?

Mr. WELSH. You mean—— Mr. TIERNEY. The Veterans’ Administration, how do they communicate with you and how often do you meet with representatives,

how often do you get either e-mails—— Mr. WELSH. The Website is a good source. There is also a book,

we call our bible so to speak. It is ‘‘What Every Veteran Should

Know.’’ I use the 800 number a lot. There is no problem with communication between an office like mine or the other veterans’ offices across Massachusetts. Massachusetts is unique with this veterans’ benefits, the agents that we are.

I think there is only one or two other States that have the same

system, so the veterans in our communities can come to our office

and ask any question whether it is a State-related question or Federal VA and we have all sorts of way to get this information, as

I mentioned, not only by the literature that is put out, the Website,

but also the regional number and I have had no problem in getting

good feedback from the VA system and in particular, the health

care system.

I want to make a little pitch here in case I am not asked about

the Bedford system. I think they are super. They provide a great

service and I know the veterans from Gloucester, at least the majority of them and have never had one complaint about the VA system in Bedford.

Mr. TIERNEY. While I have you at the mic, I know that you believe strongly in traditional clinics, community based outreach clinics. Could you take just a moment to put on the record what that

would mean to the average Gloucester veteran resident?

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Mr. WELSH. A lot. As I mentioned there are so many veterans

in Gloucester and particularly from the World War II area, many

on oxygen. There is no transportation system to the other facilities,

something that I know your office and I will be working on. And

particularly for those World War II veterans, just to be able to go

down the street to a clinic if we had one in Gloucester, I would be

happy to go pick them up at their door and take them because it

is just so difficult for them to get out. We have facilities in Gloucester and I know again for the older veterans it would just be a tremendous thing.

And even the younger veterans, many of them do not have the

ability to drive. They have problems that keep from even taking

public transportation, but particularly for the older veteran it

would be a tremendous thing.

Mr. TIERNEY. Thank you very much for that. Let me just ask one

last question, Mr. Ingham. I am gratified that so many veterans

find the community clinics helpful as you indicated, but in the

course of your testimony described as key to the earlier detection

and prevention as well as life saving capabilities, things that have

talked about, do you have a specific example in mind when you

mentioned those issues?

Mr. INGHAM. I have a specific case. An individual came into my

office. He was having a hard time in trying to get health insurance

and he came and asked me how could I help him out and that was

right when we started the clinic, he was probably one of the first

ones to get in. He was the individual I was talking about that had

the heart condition. So he went in, got into the system, saw Dr.

Balse, was found to have a heart condition, went through the VA

system, was treated and still comes in to see me regularly.

We did have another individual, Walter Hamal, who is our last

World War I veteran. He was also one of the first into the clinic,

as our first customer, basically. Unfortunately, he just passed

away, but he did take quite advantage of the system and was very

happy for it.

I want to bring up one point brought up earlier by Congressman

Tierney, two, possibly three. I think it is because of his commitment and a stronger point was education. We throughout the veterans organizations in Haverhill, we all as veterans’ councils, came

together very closely as a unit to get the clinic into Haverhill and

because I think of that we are able to get more education out there

and there was more information brought into the community. So

that is a big reason that we do have the clinic.

Mr. TIERNEY. Well, you lobbied it last night, the staff tried to get

me lost in Boston, trying to explain how difficult it is to get into

Boston from here, so it never ends. They work on everyone.

One last question. This is just a curiosity question, Mr. Welsh.

I want to know if it is ever been determined why we have the higher concentration of veterans in Gloucester?

Mr. WELSH. Fishermen. Many of them are natives.

Mr. TIERNEY. Last, let me just reiterate as some of our witnesses

have said before, we have an excellent homeless shelter here and

Tom Lyons is in the audience and does a great deal of work with

that. We have spent a lot of attention in Congress trying to deal

with special veterans’ issues, that is one of them, obviously and I

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just want to add my commendations to Tom and people who work

with him for the great work they do.

Mr. SHAYS. I hope he will address the committee so we will have

him on record as well.

Mr. TIERNEY. Thank you, Mr. Chairman. Thank you, witnesses.

Mr. SHAYS. I am wanting to know the best and worse of both the

clinics and the primary VA facilities. And Mr. Hogan, I will start

with you.

Mr. HOGAN. The best part of it, I think, is the care, once you get

into the door.

Mr. SHAYS. Which facility?

Mr. HOGAN. I am with the Edith Nourse Rogers, again, I am the

director which is next door to Bedford.

Mr. SHAYS. So you do not really utilize the clinics?

Mr. HOGAN. No. But the care in the facility, I think, is wonderful

once you get through the door. The worse part sometimes is beds,

there is not enough time and with the aging population, an awful

lot more people with education are trying to use the facility, so I

think sometimes the weight could be the worse part, but I think

the care, once we get through the door is the best Bedford has to

offer.

Mr. SHAYS. Mr. Ingham.

Mr. INGHAM. I think the best of the care dealing with the CBOC.

A comment was made that their staff should be commended, Dr.

Balze, the nurses, nurse practitioners, everybody there is just excellent and willing to work with the veterans. It has been a unique

experience to start just developing the clinic and where we went

with that and getting the organizations together with a letter of

writing and calling of Congress and everything.

But the work of the facility, like the Bedford VA is so advanced

to look ahead into the future as Mr. Conte did, we started out with

really nothing and got health care into Haverhill. It is just an

amazing event.

Mr. SHAYS. What about the larger facilities?

Mr. INGHAM. I think the problem with the larger facilities is

transportation, getting into them. A lot of the older veterans, especially, are intimidated trying to take the services to get in there.

And I think our future too with the geriatric type situations. We

were just told as agents at our last meeting that there is a high

rate of Alzheimer’s with veterans and they do not really know why.

It seems that in the general population that veterans—— Mr. SHAYS. What would be the best that you would see in the

larger facilities?

Mr. INGHAM. Probably just the overall care. They can handle

anything from cardiac, heart conditions, all type of care. It is there,

it is available and it is a shame that many are not taking use of

it.

Mr. SHAYS. Mr. Welsh.

Mr. WELSH. As I have already mentioned I believe the Bedford

Medical Center is the best in the area. I am not very familiar with

Haverhill because people do not go from Gloucester to Haverhill,

but those that have gone to the Lynn outpatient clinic seem to be

satisfied. The worse is the clinic on Causeway Street in Boston,

that is my——

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Mr. SHAYS. So your point rather than saying what is the best or

the worse of the clinics, you are actually saying which clinic you

think needs the most improvement?

Mr. WELSH. Yes sir.

Mr. SHAYS. Let me just quickly, why do you think that needs the

most improvement? Just in terms of the interaction or parking or

what, the facility itself?

Mr. WELSH. When we talk about the outpatient clinic?

Mr. SHAYS. Yes.

Mr. WELSH. In Lynn, there is no problem with parking. You cannot get to Lynn from Gloucester. It is one of those tough things,

but there is adequate parking. I think the people are very courteous and that is why I do not have many complaints about the

Lynn outpatient clinic. Causeway is a big problem because there is

no parking and there seems to be a different attitude at the

Causeway—— Mr. SHAYS. Do they have more queuing up there? Is it more like

the traditional motor vehicle department?

Mr. WELSH. I think there is more of a downsizing of Causeway.

Someone else could answer it better than me, but it seems as

though it is going away.

Mr. SHAYS. OK, Mr. Martineau.

Mr. MARTINEAU. Mr. Chairman, I am not here to throw hand

grenades, maybe a few rocks and pebbles, but not hand grenades.

Mr. SHAYS. He says that because he is a veteran not only of the

service, but a veteran of the city council and they know how to do

this. [Laughter.]

Mr. MARTINEAU. I am a good Republican, Mr. Chairman. [Laughter.]

Mr. SHAYS. I want to give you special time. I have not met a Republican in Massachusetts, so this is—[laughter.]

Mr. MARTINEAU. I knew we had something in common, Mr.

Chairman. You know, I just want to preface my remarks by saying

that I find my responsibility with the veteran initially is to give

him the best first visit he can get at a VA health care facility.

This is why I personally take that veteran to the hospital, clinic

myself, so I know what I am talking about. I do this almost on a

daily basis. So I had some initial problems with the Lynn clinic as

the Congressman knows, and his staff. He is got a fantastic staff.

And they have ironed those problems out.

The good part about the Lynn clinic is many of our veterans will

go there on their own. It is a short ride today and it lessens their

transportation time. The bad part about the Lynn Clinic is many

of the veterans will travel to the Lynn Clinic and then will find

that they will have to leave the Lynn Clinic, take a shuttle and go

to Bedford of JP for testing.

Mr. SHAYS. So these are services they are not really going to get?

Mr. MARTINEAU. And I will be at Bedford or I will be at Jamaica

Plain and once I get there and transport my veterans there, some

of the veterans will recognize me who are on a shuttle from Lynn,

will ask me to take them home from Bedford and take them back

to Lynn because it is really on our way back to Salem.

So as far as the Lynn Clinic goes, my hats off to the decisionmakers to go that route. I think the neighborhood clinics as Lynn

73

and elsewhere are very important because generally speaking it

does save time in the veterans’ traveling day.

Mr. SHAYS. How about the primary major facilities? What is the

best and the worse?

Mr. MARTINEAU. I can speak for a long time on Bedford and Jamaica Plain and the Causeway Street clinic, but let me just generalize, because—I do not understand communication between Bedford and Boston. There is none. I have had one veteran as recently

as a couple of months ago who had been treated in the JP Clinic

in Boston, the Jamaica Plain for years and it took him 4 hours administratively eligible for medical care in Bedford, 4 hours. So here

is a guy that had VA health care in Boston and going to Bedford

he had to be re-enrolled all over again.

Mr. SHAYS. Fair enough, so communication—— Mr. MARTINEAU. Computer linkup, Mr. Chairman.

Mr. SHAYS. And common sense.

Mr. MARTINEAU. Yes, there is no—I do not know what the computer linkup is, but as far as I can see, there is not any.

The other problem that I have experienced is going in with the

veterans, the doctors are not experienced for the most part. You

have too many foreign doctors and you have too many doctors that

are really not experienced. They are students who are practicing

medicine on our veterans and I do not think that is right.

Mr. SHAYS. OK.

Mr. MARTINEAU. Insofar as the administrative staffs, I think that

now too many of our administrators, health care providers, social

workers and patient representatives are doing two and three jobs

and I do not think—it is because of the downsizing effect and I

think that is a drawback.

Let me just say some good comments that I would like to make

about Bedford and Jamaica Plain. Accessibility to the administrators and the social workers in these hospitals is excellent. I have

never been refused on a moment’s basis. They have always taken

time from their day. I do not know if it is because I will go to their

bosses.

Mr. SHAYS. But it is a very important positive and it is nice that

you are expressing that. So access is there and that is great to

hear.

Mr. MARTINEAU. Also Bedford provides terrific adult day care

and especially their branch office over at the Chelsea Soldiers

Home. I think that could be expanded, but I congratulate Bedford

for their adult day care and the services that they provide with

their staff at the Chelsea Soldiers Home, that is really great. But

you know what is really fantastic about both Bedford and Jamaica

Plain and that is their detox.

A lot of homeless veterans can get detox in Bedford and Jamaica

Plain and when you take them they immediately get the care that

they need.

They have teams of people that surround themselves with these

veterans and take care of their emotional needs, their physical

needs, their rehabilitation needs, getting them back on their feet,

both personally, professionally, medically and also followup. So as

far as detox goes in Bedford and Jamaica Plain. They are the best.

So that is about it.

74

Mr. SHAYS. Thank you very much. I have some questions that I

would just love to get on the record. I am going to look for shorter

answers because I do want to hear from the veterans that are

going to speak. By the way, I would invite you all to stay up there

if you like while the veterans are making comments and if it is not

abused invite you to make short comment periodically about what

you have heard, if you would like.

I would like to first ask have you noticed an increase in veterans

taking part in the VA health care system? If the answer is yes,

why do you think this is the case? If no, what can be done to encourage veterans. I not looking for long answers, but are you seeing

the increase and then respond why you think your answer is what

it is.

We will go with you, Mr. Martineau, first since you have the mic.

Mr. MARTINEAU. As it has been stated by my fellow veterans’ advocates up here, we have definitely seen an increase in people

going to the VA because of the downsizing of the HMOs and the

downsizing of their private health services.

Mr. SHAYS. OK, the reason I am having trouble with a French

name is because I am married to a French woman named Deraine

so there is no excuse.

Yes?

Mr. WELSH. Definitely an increase in veterans signing up because we have had some great health fairs, thanks to Congressman

Tierney’s office. Also, our veterans’ services organizations in

Gloucester, AMVETS, VFW, American Legion, they have gotten the

word out, so communication, publicity, we have newspaper articles

from time to time, veterans say I can sign up and they do.

Mr. SHAYS. I know Mr. Martineau was responding, nodding the

head as you made that point too, so Mr. Ingham?

Mr. INGHAM. Yes, definitely, the CBOC in Haverhill is seeing an

increase close to approximately 50 a month. I said 1,200 over the

year. I think most of it is due to education and the biggest is on

word of mouth. Veterans talk to veterans. That is one of the biggest ways of getting it around.

Mr. SHAYS. Mr. Hogan.

Mr. HOGAN. I agree also. I think there is an increase of use going

on right now. A lot of it has to do with the publicity that we are

able to get out through veterans’ newsletters, newspaper articles.

Once the veterans realize that they are eligible now and I think

one of the big issues right now is that there is a pharmacy use and

the hospitals because of the explosion of co-payments and insurance problems with medications and pharmaceuticals, they are

going to the VA and they are signing up.

Mr. SHAYS. Let me do this, let me—if you do not mind staying

up there you are welcome if you have to leave for a second and

want to come back. We will invite from our audience anyone who

wants to make some comments and this is how it is going to work.

I am going to ask, Karen, I am going to ask you to get their

name and address on a file card after they have spoken so we can

get the transcriber the exact spelling of your name. We are going

to want to know if you served, where you served, what branch you

served in and where you served. We can use the portable mic if

that works.

75

Jason, you have the mic. Let us do that.

Mr. TIERNEY. Mr. Chairman, just 1 second. I think it should be

noted for those that might not already know it, several of the veterans service organizations have representatives here, but they have

also been invited by the chairman to submit for the record. We

would like to have that and it will all be entered on the record.

Mr. SHAYS. It will all be entered into the record. So sir, I see you

are standing up and we will invite you on that side.

Let me ask you, are there mics on both—we do not need the portable mic—do the mics work that are there? Can you turn the floor

mics on to see if they are—would you see if that one works? Just

speak into it a second. Yes, both of them work, so we will use that,

Jason, so we do not need you to hold the mic there, but Karen,

when they are done, get the full name and address so we will be

able to have it on the record.

OK, and if you would state your name, if you served, the branch

of service and where you served.

Sgt. BRYAN. My name is Staff Sergeant Edward J. Bryan. I am

still active in the Massachusetts National Guard. I joined the service in 1974, U.S. Army.

Mr. SHAYS. Let me say this. I am going to do 2 minutes a statement. Is that all right?

Sgt. BRYAN. Yes. I only have a few basic questions, they are kind

of loaded ones, but I am not throwing hand grenades.

Mr. SHAYS. You have got a lot of pages, that is why I am concerned.

Sgt. BRYAN. I already submitted them for the record.

Mr. SHAYS. OK, sir, again your name.

Sgt. BRYAN. Edward J. Bryan.

Mr. SHAYS. Mr. Bryan, thank you.

Sgt. BRYAN. I served with the 1173rd Transportation Terminal

Unit in Boston. Went to Saudi Arabia. I am now retired from the

fire department because of my Gulf war service and I am disabled

from the National Guard from my Gulf war service.

I have a couple of questions. I know you are here, there is a $1

million plus a day that you are worried about from the GAO, you

stated that in your statement. I know it is a problem with the U.S.

Government and going to combat like World War II veterans, Vietnam veterans, Korea, Gulf war and other conflicts, I think the

budget should be either level funded or increased. I got an increase

of $25 billion in the statement that I submitted. The reason why

is because we just had a conference in Washington on April 5th

and the next hall over was asking for $600 billion for infectious diseases. That is a concern.

The first question I wanted to ask today was on the program up

here in Bedford. Are the biopsies sent to the Armed Forces Institute of Pathology? Now how are we going to get to the bottom of

Alzheimer’s Disease if nobody is recording it? I found that out at

Walter Reed Institute last summer. I am doing research on Alzheimer’s itself because there is an interaction between Gulf war

veterans, Vietnam veterans and ADD people.

Question No. 2, Persian Gulf war appointments are not being

done in Massachusetts. They are not being followed, according to

Public Law 103–446. I got a letter from Colorado with a gentleman

76

having problems. We are seeing this all across the Nation. This is

a national problem.

I am a member of Merrimack Committee here, VISN 1 and we

are trying to address that problem with a basic test versus a full

screen test. We are trying to get that through all the way to VISN

1 and all the way to the Network Director, Mr. Clark, I think it

is.

Mrs. Murphy stated on HIV and hepatitis C, but she did not

mention leishomeniosis or other infectious diseases. Whatever the

cost——

Mr. SHAYS. Mr. Bryan, I am going to interrupt you a second. I

am just going to have—we do not have so many people here that

I maybe can adjust the time. We are going to try to get out of here

by 1:15 at the latest and I would like to just ask how many people

would like to speak and then I am going to—keep your hands up

nice and tall. I am going to be real strict then.

I am going to say 3 minutes at most and the questions are going

to be rhetorical in the sense that we are going to have them in the

record and then we are going to try to get some answers for them

and we will make the answers part of the record as well. OK, is

that something we can do.

So yes, you have about a minute left and thank you.

Sgt. BRYAN. Because I found out that doctors are not doing the

tests because the VA, thanks to the VA in Washington put out

these big booklets that all of the doctors are supposed to review,

but they are only reviewing the little booklet and they are doing

the tests. They have to look at the whole spectrum. So that is a

big national problem.

A lot of the times you will look back at these suffering Gulf war

veterans and Public Law 103–346 is not fully enforced and I think

that is a key question, enforcement of it. I got that in the documentation and I want to—I know there are State issues here also,

but there are major problems. You are going to be hearing from me

and a few other Gulf war veterans throughout the Nation, your

committee, within the next several months to another year because

we need much more treatment trials and the two treatment trials

that are out in the VA are not very promising.

We need at least 10 more before September and I want to be trying to work with Dr. Pughsner. I am having troubles, but it is an

IG complaint, but I want to see if I can step through your committee to get that accomplished.

Thank you.

Mr. SHAYS. I would be happy to have you work through our committee. I will invite you all, just take notes and at the end when

they are done I will invite just brief comments from all of you on

any comments you want to say that you have heard. Thank you,

Mr. Bryan.

Sgt. BRYAN. Thank you, Congressman Shays for sticking your

neck out. Thank you.

Mr. SHAYS. Thank you, sir. Sir?

Mr. HART. Good afternoon, sir. Mr. Chairman, Congressman

Tierney, my name is Terry Hart. I am the veterans’ service agent,

director of Veterans’ Service from Ipswich.

77

Mr. SHAYS. Excuse me, I am just going to interrupt you just a

second. Karen, are you doing it? I want to make sure that the

names are totally verified with the individual after you get them.

OK, thanks. I am sorry, sir.

Mr. HART. No problem, sir. Seeing as the veterans’ agents up

here represent the Army, Air Force, Marine Corps and Navy, I

wanted to let you know that I represent that fifth service, having

spent 27 years in the U.S. Coast Guard.

Mr. SHAYS. Yes sir. As did my brother.

Mr. HART. I am adjacent, my area, four towns, adjacent to

Gloucester, the towns of Ipswich, Essex, Hamilton and Wedham

and I have been using the clinic at Haverhill significantly in the

last year that I have been a veterans’ agent, sending people there

right, left, up and down. Would also very strongly support the concept of a clinic at Gloucester.

I have a lot of people who drive very little and being stuck in the

middle there between major cities of Gloucester and Haverhill,

major for our area anyway, we have some of our senior veterans

who will go to Haverhill, will not go to Gloucester. Others who will

go to Gloucester, will not go to Haverhill. So we like the idea of

having a clinic in Gloucester as well.

I would also like to make a couple of comments with respect to

what has gone on this morning. Dr. Post indicated that there will

be an increase probably in the cost of co-pays for pharmaceuticals

through the VA clinic. I would like to go on record as stating that

I hope (a) we can extend that then to a 90-day prescription in

terms of the co-pay cost because I think that is a logical extension. Right now, it is $2 per 30-day supply per prescription. If somebody can get a 90-day supply for whatever the co-pay goes up to,

I think that would be a logical way of doing it since you said the

cost is based on the administrative costs.

By the same token, you should know that that is one of the key

drawing cards for us to send people to your clinics is the idea that

those costs to pharmaceuticals going down is a big factor in people

wanting to use the VA clinics. I would also like to praise Mr.

Conte. As a member of the Northeast Veterans’ Service Officers Association we met at Bedford a month or so ago and the suggestion

was made by me that they ought to have some of us on their board

of advisors. Mr. Conte now has four of us, including myself on his

board of advisors for Bedford VA and I think that improves the

communication tremendously in our area.

And communication is the key. What we find, of course, is many

service organizations represented here, each of them have members. They have their own newsletters. We all go through the newspapers to try to get our word out to people. The Department of Veterans’ Services provides word as well as they can, but until we get

some sort of linkage in communication. We are still not reaching

all the veterans and that is a key part of what we are doing, sir.

Mr. SHAYS. Thank you very much.

Mr. CALLANAN. Good morning. My name is Dan Callanan. I was

born in 1924, joined the Marines on my 18th birthday. Three years

later I was lucky enough to come back from the Pacific without a

scratch on me. I was told that the Veterans’ Administration was for

people with disabilities. I did not know anything about anything to

78

the contrary, but I visited many of my old mates at VA hospitals,

people without arms and legs, people I had known, people I got to

know.

Recently, thanks to you people in Congress, you have passed a

law which provides prescription drugs and I came out here today

to thank you for that and to leave with you a bunch of eyedrops

which cost me a small fortune in the past year and a half.

I say a small fortune, but I had a detached retina. I do not know

what caused it. It happened in August a year ago while I was mowing my lawn. I thought it was just another fleck of dust that comes

out of this power plant in Salem which is soot all over the neighborhood, but maybe it was a bee that bit me, but before the day

was over a retina surgeon at the Lynn Clinic told me it was detached retina. I went almost a whole year without being able to

read a newspaper, spending a lot of money on eyedrops. Now I am

getting them for $2 each. According to the letter that I received

last week, it is on file here. Thank you for this opportunity.

Mr. SHAYS. Thank you very much.

Mr. CASCELLA. My name is Craig Cascella. I am a retired sergeant in the Marine Corps. I served as a Military Police Officer in

Quantico, VA and I was also stationed in Washington, DC. I served

as Presidential Security Guard. Mr. Chair and members of the

committee——

Mr. SHAYS. You know what, we have a problem. And that is we

need to get you on tape. So I am going to let you start over again?

We will insert the written statement in the record then. The reason

I said that this is not just an exercise in futility. We actually transfer this transcript. Then the staff studies it. Then we make recommendations and so this is not idle chatter that you are participating in. This is a congressional hearing in which what you say

we hope to have some impact in what happens in government.

Let me just do this. I am going to have, I am going to see if we

can solve the problem of you being on the mic and I am going to

just interrupt. I am going to have someone else speak and let me,

see, Karen, you put your head together and think how we can do

that. If you do not mind, I am just going to have you wait a sec

and have this gentleman speak.

Are you going to be here later, sir? Will you be here for a while?

Mr. CASCELLA. Yes.

Mr. SHAYS. OK, let us see if we can solve the problem getting

you on the transcript. Yes sir?

Mr. BOWERS. Thank you, Mr. Chairman and Congressman

Tierney. I am Alan Bowers, third national junior vice commander

of the Disabled American Veterans [DAV]. I was medically retired

from the Air Force in 1974 after I injured my spine when I ejected

from an aircraft in Vietnam. I am here to present the views of the

nearly 45,000 members of the DAV and auxiliary who reside in

Massachusetts.

We have submitted to you, sir, a written text and we respectfully

request that that text become part of the record.

Mr. SHAYS. That will be part of the record.

Mr. BOWERS. Thank you, sir, and I will just make a couple of

quick comments to highlight a couple of points.

79

Since 1985, the buying power of VA medical care appropriations

has fallen because of inflation. The total 2000 VA medical care appropriation is worth only 82 percent of the 1985 appropriation.

That decreased buying power has adversely affected the Department’s ability to provide safe, quality assured care.

In 1996, VISN 1 had $856 million. In 2000, it has $867 million.

That equates to a 1.21 percent increase in allocations and MCCF

receipts over 5 years. I note from a fax that I received from the National Office of the DAV Friday afternoon that on April 7th in the

morning, the Senate passed the Johnson amendment which would

add $500 million to President Clinton’s proposed $1.4 billion increase. That is completely in line with what the DAV independent

budget requests and we would hope that the House would go along

with that effort and match that effort. It would go a long way to

helping the VA have the dollars they need to give quality care.

With respect to the hepatitis C, Dr. Murphy mentioned the 1-day

test sample where approximately 6.6 percent of the veterans tested

came up positive for the virus. Under VERA, veterans who have

the virus are considered basic care patients. As I understand it,

that means that the VA or the VISN gets $3,249 a year for that

patient. We suggest that a health care diagnosis should be reimbursed at the rate of a complex patient.

One of the individuals testifying this morning mentioned high

staff ratios in VISN 1. But in fact, the DAV has heard testimonials

from frustrated and demoralized health care providers, including

physicians and nurses, when they are working with sicker patients

and they are working longer shifts or perhaps even double shifts,

both the patient and the provider are at risk. So we ask you to take

a very hard look at the staffing levels and make sure that they are

adequately staffed so that there is quality care and there are no

medical errors.

Mr. SHAYS. I am going to extend your time a little bit here. How

much longer do you need?

Mr. BOWERS. One final comment. I just want to say thank you.

The Disabled American Veterans has one purpose, to build better

lives for disabled veterans and their families. We rely on you and

the VA to help us provide safe care, adequate care, accessible care.

The DAV pledges to work with you and I am confident that together we can build better lives for the individuals who fought for

America’s freedoms.

Thank you very much.

Mr. SHAYS. Thank you for your service. It is wonderful to have

you up front so I can see your smiling face in the light.

Mr. CASCELLA. It is great to be down here.

Mr. SHAYS. Is this mic on now?

Mr. CASCELLA. Do you want me to start with my intro again or

do you know who I am?

Mr. SHAYS. Yes, I want you to start all over again. Thank you

for your cooperation.

Mr. CASCELLA. It is no problem, Mr. Chairman. My name is

Craig Cascella. I am a retired military—from the Marine Corps. I

was a sergeant from 1988 to 1992, stationed in Quantico, VA and

also in our Nation’s Capital, Washington, DC. I was a military poVerDate 11-MAY-2000 10:29 May 23, 2001 Jkt 000000 PO 00000 Frm 00083 Fmt 6633 Sfmt 6633 C:\DOCS\70278.TXT HGOVREF1 PsN: HGOVREF1
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lice officer and also served as a Presidential security guard for

Presidents Reagan and Bush, respectively.

I am currently the secretary of the New England Chapter of the

Paralyzed Veterans. On behalf of our members, I would like to

thank you, Mr. Chairman, and members of the committee, for holding this hearing in our area and allowing us to provide this statement.

I have submitted copies of my written statement and I hope that

they have been distributed to you. If not, I would be more than

happy to give you another one.

First, I would like to comment on the fiscal year 2001 VA budget

that was submitted by the administration. For the first time in

many years, a reasonable increase has been proposed for veterans

health care. The $1.5 billion total increase including the $1.355 billion for health care is a good and welcome beginning, although it

is less than the $1.9 billion increase that is recommended by PVA. It is our understanding that the $1.9 billion increase is more in

line with what the VA requested to pay for all existing and new

programs. The PVA recommendation is based on careful analysis

of present and future health care trends and includes the costs of

the new initiatives such as emergency care, hepatitis C and long

term care provisions called for in the Veterans Millennium Health

Care and Benefits Act.

The PVA has recommended a $20.66 billion appropriation for medical care. This amount represents a $1.8 billion increase over

the amount provided in fiscal year 2000. The PVA has recommended a $386 million appropriation for medical and prosthetic

research. This represents a $65 million increase over the administration’s flat line request. The PVA recommends a $71 million appropriation for the medical administration and miscellaneous operating expenses account. This represents a $6 million increase over

the administration’s request.

In total, the PVA has recommended a total increase for Veterans’ Health Administration of $1.9 billion, $555 million over the administration’s requests which includes nearly a $1 billion increase just

to meet the routine escalating costs such as salary increases and

inflation.

Mr. Chairman and members of the committee, we ask that you

support the recommendations of PVA. We also ask for your assistance to insure that the VA receives the funding that it needs to insure that veterans who rely upon the VA for their health care

needs are accorded adequate and quality health care.

Let us work together, building upon the accomplishments of last

year to secure for a solid budget base for health care in the years

ahead.

We ask you to reaffirm our Nation’s covenant to veterans and to

remain faithful with generations of promises.

Last, I would like to comment on a local issue.

Mr. SHAYS. If you could just bring it to a conclusion.

Mr. CASCELLA. Yes, Mr. Chairman. Analysis showed that millions of dollars could be saved if the West Roxbury at Boston VA

Medical Centers were consolidated. In order to complete a successful consolidation, some construction and renovations were needed

at approximately a cost of $30 million. At first it was thought the

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VA Central Office would provide all funds needed for construction

and renovations. That thinking proved to be wrong.

The VISN will have to provide the funding for the entire consolidation. We have learned that in order to fund the cost of construction and renovations, the VISN will have to use all of their minor

construction funds and equipment purchasing funds for the next 3

years. We believe that this is the wrong way to fund the consolidation.

Overall, quality of health care provided and quality of care in not

purchasing replacement equipment or new equipment will be sacrificed. We believe that the VA Central Office must provide the

necessary funds to complete the consolidation.

Mr. Chairman and members of the committee, we ask that you

look into this matter and encourage the VA Central Office to provide the necessary funding to complete the consolidation that will

eventually save significant resources.

Mr. Chairman, that concludes my statement. Again, I thank you

for coming to our area and allowing us to present our comments

to you all. Thank you.

Mr. SHAYS. Thank you. And I appreciate you being flexible with

us in coming up front like this so we could record your statement.

Mr. CASCELLA. Thank you for being flexible.

Mr. SHAYS. Thank you. Who would like to speak at this moment?

Ms. MAGUIRE. My name is Hilary Maguire representing the Veterans Northeast Outreach Center in Haverhill, MA. I also served

on the 782nd Maintenance Battalion under the 82nd Airborne Division during Desert Storm.

Just for a real quick note to clarify, our van was donated by the

VFW of Massachusetts and also Congressman Tierney, just so you

know in regards to your question about 214s. There is a number

in Boston. It needs some revamping, but it is another option for

those that live in Massachusetts trying to get their 214s.

My question today and I hope at some point there will be some

clarification, I have had several women come into my outreach center who suffered from sexual trauma while on active duty. I have

read the law. It is my understanding that they are eligible for sexual trauma counseling, but I do not know if it needs to be clarified

or if they are eligible for health care benefits.

Two women have come into my center and have been denied benefits due to their time while on active duty. It is my understanding

that they need to serve a minimum of 2 years. I am hoping that

maybe this could be addressed and the 2-year eligibility requirement dropped.

Mr. SHAYS. If they have served less then 2 years, they are not

entitled to benefits?

Ms. MAGUIRE. Yes, that is the answer that they have been given.

Mr. SHAYS. I am seeing a shaking of the head of someone who

is in a position to know, so let us say this. We will get the answer

and hopefully respond to it to you before we leave today.

Ms. MAGUIRE. Thank you.

Mr. SHAYS. Thank you. Will you make sure that happens, please?

Mr. DALEY. Good morning, Congressmen, Tom Daley, State Adjutant for the DAV. And I just want to say on that DD 214, Congressman, in Massachusetts, anybody who has received a bonus in

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Massachusetts going all the way back to the first World War, the

Department of the Adjutant General’s Office will have a copy of

that discharge.

Mr. SHAYS. Thank you.

Mr. DALEY. And also I would like to present this written testimony concerning the hepatitis C, Gulf war veterans compensation

and DIC entitlement which I will—— Mr. SHAYS. Excuse me, 1 second. Do we have a tape problem

here? No problem. We will take care of it. We want it on the record.

I have to tell you this is my most favorite part of the hearing.

Mr. DALEY. I will be submitting written testimony on long term

care, hepatitis C, Gulf war and veterans issues and conversations

with DIC, means testing, etc.

I just want to say we have good working relationship with the

veterans agents in Massachusetts. They are very supportive of us

and we work together on case loads. Dan Stack, a supervisor here

for the DAV National Service Office, so we do work together.

Roughly 15 of the 20 percent of the veterans across this country

belong to veterans organizations and the rest of the veterans do not

even know what is going on in this country. That is the problem.

In Massachusetts, to be a veteran in Massachusetts, you have to

have 1 day wartime, 90 day service. We have a lot of veterans in— I know that is not a Federal issue, but it is important to us because

we are trying to get legislation passed in Massachusetts to pick up

all what we call old war veterans and we want to make sure that

they are included in the benefits across the Commonwealth because that will enhance, that will bring in issues, that will bring

more people and more penetration into the VA system. We are trying to work on that now.

So again, concerning the veterans issues in the Commonwealth.

On that 90-day, 1 day wartime, they are not entitled to benefits because they are not entitled to real estate exemptions. They are not

entitled to Chapter 115 benefits administered out of the Department of Veterans Affairs and they are not entitled to Civil Service

preference.

But my own opinion is if anybody who puts the uniform on in

this country is entitled to benefits, so I would like to see that happen. We are working on it in Massachusetts, the DAV and all the

veterans organizations to pick up all the old war veterans and I am

sure that it will help the VA long term care down there, more veterans penetrating the system into the VA health care system.

That is all I have to say, thank you very much.

Mr. SHAYS. Thank you very much.

Mr. BOUTIN. Mr. Chairman, Congressman Tierney, my name is

Gerard Boutin. I am Commandant for the Marine Corps League for

the Department of Massachusetts and I have two very quick questions. The first concerns the screening for the establishment of the

Lynn Clinic which I think is a great thing.

At that time they were looking for members to sign up so they

could have a large member on their rolls. I just recently have been

re-enrolled and one of the things that they state is what if I am

sick when I am traveling. It says you may receive health care at

any VA health care facility in the country, well, that is really not

true.

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Recently, I was in Florida last February and I noticed a sign for

a VA clinic so I went in and I presented my card and said if I needed medical assistance could I come into the clinic and their answer

was no. You are not in the system. And they proceeding then to

give me a whole bunch of paperwork that I would have to fill out

and which I brought home.

Shortly thereafter, I went over to St. Petersburg and had to take

a blinded veteran to the VA hospital and I did the same thing. I

asked if I had to take care of any medical problems and I presented

my card again, I said could I come to this facility and the answer

again was no. You are not in the system.

So I really do not understand if we are in the VA and we are

not in the system, as I understand in asking questions when I get

back, we are here in the system in Wheaten and that is about it,

but it does not take care of when we travel and I think a lot of the

veterans, that is what they need. We will look for the benefit if we

are traveling.

Second, I am receiving bills from the VA because the VA cannot

bill Medicare for services and maybe you know all about that and

I would like to bring that up as a point. The VA, as I understand

cannot bill Medicare for services. Therefore, any services that I get

in the VA hospital in Bedford, I have to pay out of my own pocket.

Mr. SHAYS. I was under the impression that services were available wherever you are and so I would like to nail that one down

and maybe that can be dialogued before we leave directly with Dr.

Murphy or our other two panelists who were there.

Mr. BOUTIN. Incidentally, you asked, I was in the Marine Corps

from 1946 to 1952. I served as a Staff Sergeant with the 2nd Marine Division.

Mr. SHAYS. Thank you for your service, sir. Yes sir?

Mr. BECKER. My name is Bernard Becker. I am a past State commander and past regional commander of Jewish War Veterans. I

served in the Air Force from 1950 to 1954. VISN 1 as far as I am

concerned stinks. We are closing up wards at hospitals. We are

closing buildings at Brockton VA and then people who have the

Alzheimer’s cannot find a place to go. They are told by their families, take them to a private place and they will take care of them.

As far as I am concerned they should keep these buildings open,

keep the wards open and take care of the veterans in the facilities.

Holyoke, Chelsea Soldiers Home, there are waiting lists. They cannot put any more in there, but when they are closing up these

buildings, I cannot see why they cannot keep them open and put

the veterans in those buildings and I also have from my national

organization, they did send me a fax on veterans issues.

Mr. SHAYS. Thank you.

Mr. CALOMO. Thank you for letting me speak today. I am a past

Vietnam combat medic and I served in the Army in the 199th. I

am from Gloucester, MA and I support Colonel Welsh, a veterans’

agent, because of the veterans, I am the past city council of

Gloucester, and many—— Mr. SHAYS. You are not a Republican?

Mr. CALOMO. No, I am a Democrat. [Laughter.]

I am sorry, I am a Democrat. I have had many veterans also call

me and tell me they cannot get transportation to Bedford or Boston

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and I myself go to Bedford and Boston. I go to Jamaica Plain and

I have a lot of trouble driving into Boston, so I do not do that. I

take the train and I spend the whole day trying to get to my appointment and get back to Gloucester.

Also a lot of the veterans cannot get a ride from Boston to Bedford. They have tried. A lot of time the drivers are unavailable

through the DAV. They do have vans, but a lot of times the drivers

are unavailable. So it is hard to meet scheduled appointments.

I also work for a home health service and I have had clients that

ask me to take them and I have done that. So at this point I reemphasize a real need for us to have something in Gloucester, a medical facility.

Thank you very much.

Mr. SHAYS. Can you say your name into the mic?

Mr. CALOMO. Samuel Calomo. Thank you.

Mr. SHAYS. Thank you, sir.

Mr. GONZALEZ. Good morning, Mr. Chairman and Congressman

Tierney. My name is Salvatore Gonzalez and I am from Chapter

3240, the name of it is General John S. Patton, Jr. from Beverly

and I am here to request information from you, if I may.

We have a member of our chapter who has been very sick and

lives on the second floor and he needs assistance because he cannot

negotiate the stairs. He has to sit down two to three times before

he can out to the second floor.

I went to make an initial contact in Jamaica Plain about what

we could do to help him out as far as getting an electric chair. The

doctor had to recommend then to the Rehab Medicine in the fourth

floor so that they could approve the recommendation before he

could be eligible to receive an electric chair. By the way, this veteran is 50 percent service connected for the Second World War.

I made the initial contact in March and the closest I could get

a doctor to see him at the VA, it is May 17th, so the guy is still

trying to get off the second floor which is very hard for him.

My question is this, what does a person like that have to do

when he has to go out and get help? Where does he go from here?

Mr. SHAYS. We are not going to take any questions right now,

but we are going to have your question on the record and we have

staff here that can respond to the question.

Mr. GONZALEZ. Thank you, sir.

Mr. SHAYS. Thank you.

STATEMENT OF NEIL F. RESTANI, DIRECTOR OF VETERANS

SERVICES, TOWN OF LYNNFIELD

Mr. RESTANI. Mr. Chairman, my name is Neil Restani. I am the

director of Veterans Services for the town of Lynnfield. I have a

statement that I would like to read. Also, I served from 1942 to

1946.

Regarding health care at the local level. Our office in Lynnfield

is very satisfied with the treatment and care that our veterans receive at the Bedford health facility. They receive excellent care and

the cases are handled in a professional manner.

Also, the veterans walk-in clinic at Lynn also provides our veterans with much needed assistance. Just last week at our American

Legion meeting, one of our members was very grateful to the treatVerDate 11-MAY-2000 10:29 May 23, 2001 Jkt 000000 PO 00000 Frm 00088 Fmt 6633 Sfmt 6633 C:\DOCS\70278.TXT HGOVREF1 PsN: HGOVREF1
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ment that he receives from the Jamaica Plain facility regarding his

prostate condition.

I have one concern. My office has this concern. I do receive many

referrals from veterans who are not eligible for many services only

because they do not qualify. They do not receive any disability.

These are veterans of World War II and Korea and they are getting

up there in years and now they feel that they would like some kind

of assistance, but they are not qualified. I wonder if that matter

could be looked into. Thank you.

[The prepared statement of Mr. Restani follows:]

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87

Mr. SHAYS. Thank you very much. I am going to try to get an

assessment of how many more speakers we have, if you would raise

your hand. Those are the eight speakers, so we are going to have

to move along. If you can be closer to 2 minutes, it would be great,

but we will live with 3.

Yes sir.

Mr. OUELLETTE. Mr. Chairman and panel, my name is Joseph

Ouellette. I am a disabled combat veteran having served with the

U.S. Army in Vietnam with 173rd Airborne Brigade.

I am here to represent the Essex County Correctional Facility. I

am the veterans outreach coordinator and I also do the HIV coordination with the hepatitis C virus. So there is a link between veterans and the hepatitis C/HIV and there is also a tremendous link

because 90 percent of the incarcerated people are in there because

of substance abuse.

So what I have found for 10 percent being the veterans’ population, I have approximately 120, 130 veterans. Most of them do

not know that they have any veterans’ benefits at all and the

crimes committed are because they have a substance abuse issue.

Most of my connections have been with the Bedford VA, the homeless shelter in Boston, and the veterans mansion in Haverhill

which has been a tremendous asset to help out.

My question or my concern is in the future let us not forget

about the incarcerated veteran. OK? Thank you.

Mr. SHAYS. Thank you, sir. I am struck, sir, by the fact that your

comments are very well taken, I mean as are all the others, but

sometimes that group does get overlooked.

Mr. SMITH. Good afternoon, Mr. Chairman.

My name is Arthur Smith. I am the past department commander

for the State of Massachusetts, the American Legion and I would

ask your indulgence because I have a statement here projecting

what the American Legion feels about this——

Mr. SHAYS. Let me just say though if it is longer than 3 minutes,

it needs to be submitted and you need to summarize.

Mr. SMITH. This is from past national commander, John P.J.

Komer and past national commander, Anthony T. Jordan. Mr.

Chairman and members of the subcommittee, the American Legion

continues to follow the changes in health care delivery in New England with great interest.

The American Legion appreciates the opportunity to submit its

observations and concerns regarding the impact and restructuring

and the resource allocation of delivery of quality VA health services

on the national, regional and local level. The American Legion will

address the specific issues identified in the invitation to submit testimony, the VA budget for fiscal year 2001 and the VISN 1 budget

for fiscal year 2001 and access care for the veterans infected with

hepatitis C.

The American Legion has previously acknowledged the administration’s request of $20.3 billion to veterans’ health care as reasonable, although the American Legion believes that the President’s

budget requests falls short of the required spending level for several reasons. The American Legion recommends that the VA health

care receive $20.5 billion appropriation for fiscal year 2001. First,

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the American Legion questions the VA projections of medical care

collection fund, called MCCF and sharing other collections.

The President’s fiscal year 2001 budget request is based, in part, on the availability of a cost of $600 million from MCCF and another $115 billion from sharing in other collections. The revenue

sources that compromise these funds include veterans co-pays,

third party insurance and contracts with the Department of Defense and Tricare.

Since the enactment of legislation allowing VHA to transfer revenues from MCCF fund, the administration projections have been off

in each of the past 2 years. National projection fell nearly $100 billion short of projections to the fiscal year 1999. In VISN 1 alone, the overestimate was $14 million, just under

2 percent of its total VERA budget. VHA has made adjustments to

its formula in projecting collections. Despite these adjustments

however, the American Legion is not fully convinced that the projected collections for fiscal years 2000 and 2001 by VHA are accurate. This lack of confidence is not due to the lack of consideration

of VHA’s effort, rather it is attributed to the unknown ramifications for similar changes in policies and operations.

Mr. SHAYS. Can I ask you if you could summarize the conclusion

and we will submit the whole thing?

Mr. SMITH. OK, sir.

Mr. SHAYS. Thank you sir, I appreciate your cooperation. We are

just trying to make sure we get to votes this afternoon, there are

votes on the floor of the House. That is our challenge.

Mr. SMITH. Finally, the American Legion is committed to the

issues of the best care to veterans with hepatitis C virus, HCV. The

American Legion has indicated strong support for VA programs

geared toward increasing education among both veterans and providers that involve treatment of HCV, expanding VA treatment and

research.

The national field services of the American Legion continues to

monitor access to HCV treatment as well as other aspects of the

HCV issue and a special focus within its oversight program.

Mr. Chairman, if I might be allowed to say on behalf of myself,

when I entered the U.S. Air Force I raised my right hand. The government did not say if you were 10 percent, 20 percent or 30 percent service connected with a disability that we would take care of

you.

The government said that if you needed health care, we will take

of you and I know earlier this morning they were talking about

lowering the requirements from 70 percent to 50 percent. I do not

think that is fair enough to my fellow veterans that fought in

World War II or my fellow veterans that fought in Korea. I think

the limit should be down to 30 percent. Thank you, Mr. Chairman.

Mr. SHAYS. Thank you, sir. Yes sir.

[Applause.]

Mr. KOONTZ. Ron Koontz. I am the director of Veterans’ Service

for Amesbury. I am also a combat veteran from Vietnam, 1968,

25th Division and you can stop me after 1 minute.

What I would like to discuss is with the first panel was the disability claim process. I believe it was Dr. Murphy talked about the

turnaround time for the initial claims. The 180 days does sound

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good, but it is once that decision has been made, once it goes into

the appeal process, there is definitely a long term wait on this, anywhere from 18 months to 3 years to 7 years and probably beyond.

The other issue would be I have gone through Boston JFK Building and I have seen stacks of claims on the floor at least 3 foot high

and I hope this is not indicative of throughout the United States,

but there does seem to be a backlog on the claims process. Thank

you.

Mr. SHAYS. Thank you very much, appreciate it.

Ms. TROUBETARIS. My name is Maureen Troubetaris, I come here

on behalf of my brother, John Day, served 1967 to 1971, United

States Air Force Staff Sergeant, served in Vietnam, war veteran,

served in Bangkok, Thailand as a crash fire fighter. My brother

has been hospitalized for the past 14 months in the veterans hospital and cannot speak for himself. My family are his eyes and his

ears and his mouthpiece. My greatest concern is the money available. You fund it for the veterans who have long term health care,

health indeed necessities.

Two weeks ago today I got a call at work out of the clear blue

sky from the veterans in Jamaica Plain and was told my brother

ran out of benefits and where do I want him. It is 100 percent service connected, Vietnam War veteran and this was a shock to our

family. Where would we place him?

Once they placed him in a nursing home and they almost killed

him there. I guess my answer today is quality health care for all

veterans, quality of where you place your veterans. There is no followup after you place your veterans in places that you contract out

to. Some of these places that you have contracted to have great violations. You need to have a followup. There needs to be continuity

in health care with the doctors. With long term health care, you

do not have continuity in medical health care. Every month there

is a new team of doctors. The only continuity is in the nursing

staff. You need to have that for a family to understand.

I ask that the committee and I thank Congressman Tierney for

all the help his office has given our family. It is a scary thing that

my brother cannot speak for himself, but I do ask for help that you

continue to finance all the veterans programs and look at the millennium bill as soon as possible. You cannot leave a generation of

people, totally unprepared for long term health care at the mercy

of this kind of treatment. Thank you.

Mr. SHAYS. Thank you for being a supportive sister on behalf of

your brother, ma’am.

[Applause.]

Mr. TIERNEY. I want to note that Maureen is not only a good

voice for her brother and family and veterans, but is a counselor

in the city of Beverly.

Mr. PASSERI. Mr. Chairman, Representative Tierney, Angelo

Passeri. I am a VA/VS deputy representative for the Vicotira Rocky

Post and Beverly, a membership of 600 plus. I want to thank the

panel. They covered every question that was presented to me by

my membership. You did a fantastic job. You covered everything I

wanted to cover.

I just want to augment one thing. When I heard one of the objectives that they had was to downsize the in-patient complement at

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the Bedford Hospital. I got a little nervous because most of my recourse are to help gain access to that facility for our Alzheimer’s

and no doubt it is probably the best institution we have in the Nation.

I work very close with the first line staff and it is a showpiece

and it hurts to see that we cannot gain admittance to that particular unit. And I just want to hope that you people will just keep in

mind when we are talking about downsizing in-patient, that this

facility and others like it are definitely needed. Please give this a

lot of consideration. Thank you very much.

Mr. SHAYS. Thank you very much.

[Applause.]

Mr. SHAYS. Yes sir.

Mr. BOUCHER. Yes, my name is Gerard Boucher. I entered the

Marine Corps December 15, 1966 when I was 19. Wounded October

11, 1967. I am an advocate for the blind and all disabled, veterans

in quotation. First of all, I want to come up here and thank you

all for a day like this. The Congressman, the Chairperson, all the

dignitaries, everybody that had anything to do with this assembly.

I am just sorry that there are not enough veterans here to stick

up for themselves.

I came up here to mention two—one thing I got off my e-mail the

Johnson amendment that just went through the Senate for the

$500 million, I heard the gentleman mention that earlier, I would

like to see the House support that, if I could, and also this young

lady that was up here earlier, just before me mentioned about her

brother not knowing where to put him.

Now all this space after downsizing these medical facilities, Jamaica Plain, Brockton, Broadsbury, what are they going to do with

all that empty space? Are they going to utilize it or sell it or whatever? Would that not be a nice place for a nursing home for veterans? That is my suggestion.

There are a lot of things I would like to say, but I do not want

the chairman to throw me out. This is what I really want to say,

it is all in here, but I do not think you are going to give me the

time.

Mr. SHAYS. Let me just say, sir, I would never throw you out and

it is an honor to have you testify before this committee and it is

an honor to know you have served so well for your country.

Mr. BOUCHER. And I want to thank you all again. Today like this

here is what we need the most. You more you have of this, the better. And it is up to us to get the rest——

Mr. SHAYS. I have a feeling that when Mr. Tierney asked this

committee to come up here he was thinking of you.

Mr. TIERNEY. This gentleman does a good job and he writes to

my office at least once a month, always with pertinent information

and insight and so we thank you very much for that.

Mr. BOUCHER. Thank you, sir. Thank you all.

Mr. SHAYS. Thank you. Sir.

Mr. LYONS. Thank you, Mr. Chairman. My name is Tom Lyons.

I am the executive director of the New England Shelter for Homeless Veterans. I want to thank you for being here today and also

thank my good friend, Congressman Tierney, for allowing me to be

here today.

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I am a former Marine. I served in 1967 to 1970 with a tour of

duty in Vietnam in 1968.

Mr. Chairman, I run probably one of the largest homeless shelters in New England, 320-bed facility for men and women. We are

unique, Mr. Chairman, because we are drug and alcohol free and

our programs are based on structure and discipline, structure and

discipline that these men and women had when they were in the

miliary, we use it as a way of building them back to self-sufficiency.

We have emergency shelter, temporary housing and we also have

permanent housing right inside our facility. We built a new medical clinic with the help of the VA. We are now not only providing

basic medical care, but we are providing complete eye exams as

well as dental care.

We have a training program that over the last 3 years have put

over 1,100 men and women back into the work force in Massachusetts at an average wage of $12. So as you can see, Mr. Chairman,

we are a program that works and I am proud to say that we have

been a player within the veterans community over the last number

of years.

But the concern I have today, Mr. Chairman, is that the VA is

talking about doing away with detox programs and are leaning toward out-patient detox. As someone who sees 85 percent of our clients at our facility who are drug and alcohol dependent, to think

of an outpatient kind of a detox program scares the hell out of me

to be quite honest because we have men and women in our program 8 months to a year or to a year and a half who are drug and

alcohol free.

They were able to do it because of the structure and the discipline and the counseling services that we have in our facility.

I ask you, Mr. Chairman, and I ask your committee to look at

whatever the VA has in terms of surveys, whatever, to outpatient

clinics and see if they actually work or is this just another way of

creating another out source within the VA system. Thank you, Mr.

Chairman.

Mr. SHAYS. Thank you very much. I would just like to note for

the record, it is 1:18, so I think we are almost done with our speakers. We have one gentleman here. We have three speakers all on

this side and I do need to limit it to that so we have three speakers

left.

I am going to just before you speak, I just want to take note that

Dr. Frances Murphy has been here the entire time. She could have

left and she stayed and I appreciate that very much as well as Dr.

Jeannette Post and I appreciate you staying here as a well, Doctor,

as well as Mr. William Conte. It is important that you hear what

the veterans say and I did not need to tell you that because you

know that. You might be able to interact with one or two, but we

need to make sure the record is straight, particularly on one issue

dealing with counseling for women and also whether services are

available throughout wherever you go.

We have three speakers left. I am also going to allow our gentlemen, the panel up here to just make a closing comment if they

would like if they are short. I think maybe what we will do, Dr.

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Murphy, I am going to have you respond to those two questions before we leave so that they are part of the record, afterwards.

Yes sir.

Mr. HINDS. Good afternoon, Mr. Chairman. My name is John

Hinds and I would like to put a face behind some of what you have

been talking about today. I am a disabled Vietnam veteran, a career employee in the Veterans Administration and a veteran who

is suffering from hepatitis.

I would like to thank Dr. Murphy, Dr. Post, Mr. Conte, Mr.

Martineau and Mr. Hogan this morning because they were kind

enough to show me something that I have never seen as a VA employee. I am taking annual today from my job in order to come here

and to thank personally Congressman Tierney for the work he does

not only on behalf of disabled veterans, but also particularly my

district. I live in Georgetown.

Since 1988 I have been an employee of the Veterans Administration and I have worked at the VA Regional Office and the Kennedy

Building in Boston. I have worked at the VA Medical Center and

Jamaica Plain and I have worked at the outpatient clinic in Boston

and for the last 9 years I have worked on the staff at the Med Center in Boston.

I have never had anything lower than an outstanding performance appraisal on an annual basis and yet I have been frustrated

in every attempt, despite my education which includes a Bachelor

of Arts degree and several completions of several courses on a master’s degree level. I have been frustrated because I see what is

being given to the veterans on the front line basis.

Thank you, Mr. Martineau for your comments. They are very appropriate. I have been thrwarted in my attempts to improve myself

as a VA employee. I have gone from a grade 5 to a grade 6 in the

11 years that I have been with Veterans Administration and I have

been labeled, despite being chosen as 1 of the 12 VA employees to

give performance training and individual customer relations training to fellow employees as angry, troubled and frustrated in my attempts to improve myself and improve the care of service to veterans.

So I am the face behind which you have been talking about

today. I just wanted to thank you for this hearing and I wanted

to thank you for your help, but I would like to say if you do one

thing today, please make an attempt to recognize the front line employees who are there for the veterans every day and yes, they are

frustrated because of the inability to improve ourselves and to improve the system. Thank you.

Mr. SHAYS. Thank you very much, sir. Our second to last speaker.

Mr. THEMES. Good afternoon, gentlemen. I am Charles Themes,

22 years military service. I am retired military. Three major battle

scars. I spent 26 months in Korea. There is 1,500 lost in Korea. We

do not know where they are. We do not know if they are prisoners

of war. I know Korea better than most of the students know this

high school. I spent 26 months in Vietnam. I was in combat section

in Vietnam. I jumped out of helicopters, 2nd, 3rd, 4th, 5th Corps,

Laos and Cambodia borders.

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And so I think a lot of my friends were lost over there. What I

am saying is that military retirees and some of the veterans who

were combat veterans have a lot of disabilities. I cannot get my

teeth cleaned at the Veterans Administration with 22 years of military service, five honorable discharges and 6 years reserve. I cannot get my teeth cleaned. When I go to Veterans Administration to

have my teeth cleaned they say head on down the road, that has

been gone, Jack. I said that is there it was. That is where my helicopter is, taking me to Laos and Cambodia.

But I speak for a lot of men, not only retirees, but the veterans.

But if they want to know about North Africa, I spent 31⁄2 years in

North Africa, if they want to know about Cuba, I spent 11 months

in Cuba. I spent 11 months in the South Pole. I spent a lot of

places in a lot of other areas. Islands in the Indian Ocean and

when they look for a demo technician, we need you to do the work,

you go out and do your job. We came back.

When I was relieved from the military service they said you are

all set. I came to VA and they said there is a dental office down

the street, get going. Thank you very much for your time and patience. Have a very nice day.

Mr. SHAYS. Thank you, you too, sir, and our final speaker from

the floor. I am sorry, we have two speakers left.

Mr. CLARK. Good morning, Mr. Chairman, and Congressman

Tierney. Thank you for giving me the opportunity to speak. My

name is Larry Clark. I am a disabled Vietnam veteran. I was in

the U.S. Air Force from 1965 to 1969. For the last 20 years I have

worked with the veterans an employment specialist in the disabled

veteran outreach program.

My statement to you is when we were talking about having

enough drivers to bring the veterans to and from the hospitals it

might be appropriate if possibly in the budget you could appropriate some funding for van drivers because we do have a good

CBO program that is coming out of the shelter and that would be

appropriate, if you could fund that in the budget.

Mr. SHAYS. Thank you, sir. Ma’am? You are our final speaker.

Ms. ZUBEREK. My name is Eleanor Zuberek. I am not a veteran.

I am here speaking for my father who is not well enough to be here

today. Congressman Tierney was kind enough to let me know

about this in spite of the fact that I am frequently consorting with

known Republicans.

I wanted to address the problem of transportation and waiting

times at the VA hospitals too. I get my dad in and out of there myself. I have elected to work part-time so I can be there for him. I

do not know how many veterans have somebody who is willing or

able to do that or who is married to a saint who is willing to put

up with that.

I want to tell you about 1 day last December, I just decided to

summarize this into one experience we had. My dad called me in

the morning and said he was not feeling well so I went flying over

there and he is 82. He has service connected disabilities from

World War II. He was having chest pains and his lips and his fingernails were turning blue.

I said let us go to Beverly Hospital. He said no because there had

been an incident 2 years ago when we had called the VA in the

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middle of the night and they said he is too sick, you cannot bring

him here from Danvers, it is a 40-mile trip. Take him to Beverly,

we give you permission. Well, the next day they did not know

about that.

And my father got stuck with the bill, so he insisted this time

that we call Roxbury and I take him down there. We got there

probably 8:30 and 9 a.m. and we sat in the emergency room with

a lot of people who were very, very sick until 6 p.m. when he could

be seen. He had very bad pneumonia and he had been released

from the hospital the previous week.

One of the men in the emergency room waiting with him had had

bypass surgery 8 days before that. He waited longer than my father did, at least I think he did. They got there before we did. And

I do not think this is unusual. We have been in there, I was waiting outside in the hall for my Dad to have chest x-rays and I met

two men.

One came down from Togas to have some simple tests done and

another one came down from White River Junction. This is to West

Roxbury. With the distance reversed, my father would not have

made it up there. He is too fragile to travel that far. Never mind,

you are providing transportation. And I just want to say anything

you can do for these guys, when you called them to serve their

country they did not say let us study it for 60 days and we will

see if it is affordable before we go.

Mr. SHAYS. Thank you very much for speaking for your Dad.

[Applause.]

Mr. SHAYS. In one way it is regretful to have our last speaker

have such a negative message, but it is an important message to

hear so I appreciate you sharing your remarks.

I would like to make sure I do not forget this, so I am going to

do this now before I just ask for closing comments and thank David

Rapallo who is the minority staff member who I appreciate his

presence and always his participation as an equal in this committee, with Larry Halloran, the staff counsel and also Christine

McElroy who I said I would identify as ultimately responding, Mr.

Welsh, to your suggestion about a briefing on VA benefits by DOD

before you are discharged.

She is going to give a card to you today and then we will give

you the correspondence that we are going to have back and forth.

It is something that we can easily deal with right away. And Gary

Batt from Mr. Tierney’s staff and Cara Siegel and Tony Cooper, as

well as from my staff, Karen Shirest and from the subcommittee

staff as well, Jason Chung and Suzanne French, Apex Reporting

and also to Richard Carey who is in, fact, and Patrick O’Shay the

student who has made our sound system work quite well.

Some of the problem was external and we appreciate how they

have gotten the system to work so nicely. And it is a lot of hard

work. We appreciate both of your participation. And also to Peabody Veteran Memorial High School. Mr. Tierney leaves nothing

out. He saw the name veteran and he said this is the place it had

to be.

I would just encourage, I realize, Dr. Murphy that the answer to

the sexual trauma answer may be a little more complex, but if you

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do not mind getting to the mike and just putting on the record, in

general terms, to be followed by more extensive remark in writing.

Dr. MURPHY. Congress would pass legislation to make all veterans who sustained sexual trauma, whether men or women, eligible

for counseling and treatment for that in the Department of Veterans’ Affairs and we work closely with DOD and make sure we identify those individuals and get them into counseling.

The general eligibility rules after eligibility reform are that any

veteran who served honorably and has an honorable discharge for

90 days or more can enroll for VA health care. They would undergo

a means test, but all priority levels one through seven, are eligible

to enroll in the VA at this time.

Mr. SHAYS. Any area of the country?

Dr. MURPHY. Any area of the country. This is nationwide.

Mr. SHAYS. So sometimes the policy may not be followed, but

that is the rules, so one suggestion is to contact your local Congressman or woman to make sure that that service is provided and

also as well, we are happy to assist, Mr. Tierney, as well in any

of the work that he has done with his veterans.

Dr. MURPHY. And I am sure the network staff or headquarters

staff would be happy to help us.

Mr. SHAYS. Right. To be aware of that problem and to be able

to step in. Thank you very much. And gentlemen, I would just, very

brief comments, I literally need to get a plane soon and Mr.

Tierney, actually he needs to get on his way because you have a

meeting on census before you get on the plane.

Mr. TIERNEY. And in fact, if you gentlemen might excuse me because we are good enough friends that we can talk to each other

at any time. I am due over in Lynn where the issue of census is

very important to us and we are taking some efforts today to make

sure that we get a count so that all of the services to all of our citizens will, in fact, reflect our population.

So let me just thank all of our witnesses from the first panel very

much for not only testifying but for staying and listening; to all of

our members of the second panel, for all the good work that you

do day in and day out as well as your testimony here today and

to all of the veterans who both asked questions and made testimony and those that cared enough to show up or who were able

to show up today and the representation that you made for all of

those who were unable to attend. I look forward to working with

all of you. I thank you, Mr. Chairman, and staff very much for having the meeting held here today.

Thank you.

[Applause.]

Mr. SHAYS. And I would be very remiss because everybody in this

room knows one individual on my staff who does a tremendous

amount of work with veterans, is himself a retired veteran and

that is Harry Hoffmander and I want to thank him.

[Applause.]

Mr. SHAYS. We have not yet adjourned yet. If there is any comment that the four of you would like to make, if there is not, that

is fine.

Mr. Welsh.

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Mr. WELSH. Thank you, Mr. Chairman. I am from Connecticut,

like you and if you ask me the question about party affiliation, you

would like the answer, but I have and always will vote for Congressman Tierney.

Mr. SHAYS. You know what, in this committee we are Americans

first and Republicans and Democrats second, just as you are when

you risked your life for your country.

I thank all of you. This hearing is adjourned. I will be running

out very quickly. I hope I do not appear to be rude, but I need to

get to that plane. Thank you very much.

[Whereupon, the hearing was adjourned.]

[Additional information submitted for the hearing record follows:]

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