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[Senate Hearing 107-454]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 107-454

               ACCESS TO VA HEALTH CARE IN WEST VIRGINIA

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

                             FIELD HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                               __________

                     JULY 16, 2001--HUNTINGTON, WV

                               __________

      Printed for the use of the Committee on Veterans' Affairs 

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                            WASHINGTON : 2002
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                     COMMITTEE ON VETERANS' AFFAIRS

            JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida                  ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS, Vermont           STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii              FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota            BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington             LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia                 TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska         KAY BAILEY HUTCHISON, Texas

                     William E. Brew, Chief Counsel

      William F. Tuerk, Minority Chief Counsel and Staff Director

                                  (ii)

  

                            C O N T E N T S

                              ----------                              

                             July 16, 2001

                                SENATORS

                                                                   Page
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia, 
  prepared statement.............................................     4

                               WITNESSES

Dandridge, John, Jr., Director, VA MidSouth Health Care Network, 
  Department of Veterans Affairs, Nashville, TN..................    30
    Prepared statement of........................................    31
England, Luther T., Vietnam veteran and military retiree, Welch, 
  WV.............................................................    11
Fox, Rebecca, Clinical Support Manager, Mid-Atlantic Health Care 
  Network, Department of Veterans Affairs, Durham, NC............    34
    Prepared statement of........................................    36
Looney, John, Team Leader, Wheeling Vet Center, Department of 
  Veterans Affairs, Wheeling, WV.................................    25
    Prepared statement of........................................    25
Pennington, David, Director, Huntington VA Medical Center, 
  Department of Veterans Affairs, Huntington, WV.................    26
    Prepared statement of........................................    27
Pleva, Randy, President, West Virginia Paralyzed Veterans of 
  America (PVA), and National PVA Vice President, Charleston, WV.     6
Sims, Randall, Vietnam veteran and member of Parkersburg Disabled 
  American Veterans (DAV) Chapter 32 (testifying for his father, 
  World War II ex-prisoner of war PauL Sims), Belpre, OH.........    13
Stafford, Jacob, Chairman, State Veterans' Coalition, Legislative 
  Officer, West Virginia Disabled American Veterans (DAV), and 
  National DAV Executive Committee Member, Oceana, WV............     7
    Prepared statement of........................................    10

                                 (iii)

  

 
               ACCESS TO VA HEALTH CARE IN WEST VIRGINIA

                              ----------                              

                         MONDAY, JULY 16, 2001

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:43 a.m., in 
Shawkey Dining Room, Memorial Student Center, Marshall 
University, Huntington, WV, Hon. John J. Rockefeller IV 
(chairman of the committee) presiding.
    Present: Senator Rockefeller.
    Chairman Rockefeller. The hearing will come to order. I am 
very pleased that you are all here. I have a short statement 
that I am going to give. That is the penalty for your 
attendance--you get a short statement. But a statement is 
useful in that it sets the tone for what we are talking about 
and why we are talking about it and why we are asking these 
particular types of questions.
    We had a hearing in 1993 and we discussed some of these 
same things. It is interesting to me now, 8 years later, back 
when I am again chairman of Veterans', that I can do this again 
and get at some of these issues. The whole question of access 
to health care obviously is crucial to me, because if you don't 
have access to health care, you don't get it. Access equals 
health care. That has always been a problem, and it is 
particularly a problem in a rural State. It will always be that 
way and I have a variety of things I want to say about that.
    So anyway, I am very happy that we have a panel of veterans 
and they are going to talk about what needs to be done to 
improve the access to good health care for veterans in West 
Virginia, in particular--in rural areas generically but West 
Virginia in particular. The rural problem is always different, 
always more complicated, always less well served, and so that 
is of interest to me.
    We also have VA officials who are here and are going to 
talk to us about what some of their plans are, about what they 
hear in the first panel and also some other questions I will 
have for them.
    I think it is a little ironic that when we met in 1993, I 
commented that at that time, we were one of the very few areas 
that were not being devastated by floods. The country was 
suffering many floods back then; I don't particularly remember 
where they were, but we weren't having them here. For some 
reason, I chose to make a comment about that. I am not quite 
sure why I did, but it is a little different today, isn't it?
    I had a lot of things I was scheduled to do today and just 
canceled them because I want to get down again into the flooded 
territories. Floods are something that people don't understand 
until they get into the middle of them, and into the minds of 
people that have been affected by them. The devastation they 
cause is so much more than pictures or cameras can catch 
because they last. Flood victims can get PTSD, just like those 
who were in Vietnam, Korea, World War II, the Persian Gulf, and 
other places.
    So today, we have some of the worst floods in years. I 
don't compare floods because I don't see any advantage. All 
floods are awful in my view, so I don't compare floods of this 
decade to floods of another decade. They are all terrible.
    I want to commend the VA, and especially the VA Medical 
Center in Beckley. They have helped out a great deal in this, 
and I appreciate that.
    In 1993, when former VA Secretary Brown joined us in 
Beckley, he wanted to talk about the challenges that the VA 
faced then: the reorganization of the VA health care system and 
how to decide who should be eligible for VA care. So today, I 
turn to you to learn how these changes which have taken place 
in VA health care delivery--the rapid increase in community 
clinics, eligibility reform, the network organization, which is 
an interesting phenomenon--how these have affected veterans' 
access to basic as well as to specialized health care.
    Unfortunately, many of the problems discussed 8 years ago 
remain with us, and that is the way it often is with health 
care. You don't just solve the problem. It is too big. It is 
too far-reaching. It is too deep.
    We still have with us the fight for an adequate budget, and 
I will have a word to say about that. We have long waiting 
times for health care, for attention. I want to talk about 
that. We have too few VA staff providing specialized care. 
Some, including Randy, will be talking about that. We have a 
lack of long-term care, even though we passed a bill 2 years 
ago to mandate that for certain groups of veterans. That has 
not yet taken shape. We have transportation obstacles for 
veterans traveling to and between VA centers. That was a 
problem then and still is. We want to hear about that.
    In 1993, veterans voiced their concerns about access to and 
copayments for prescription drugs. I want to hear a little bit 
about that. Our veterans population obviously is not getting 
younger, and we have not enacted a prescription drug coverage 
bill under Medicare in Congress. I think we have got a shot at 
doing it this year, a good one, a good one, but we are 
constrained by the tax cut to only doing--it will sound huge, 
but it isn't when you look at the whole country--$300 billion 
over a period of 10 years. That is not the kind of prescription 
drug benefit plan that we need. It ought to be closer to $400 
billion, but because of the tax cut, some veterans won't be 
getting anything; some won't be getting prescription drugs 
while others enjoy tax cuts. It is a question of tradeoffs. I 
mean, how much do we value our veterans, what do we owe them, 
et cetera. To me, the answer is very clear.
    I want to repeat again that I really do believe a lot in 
outpatient clinics. I think they are a special benefit for 
States like West Virginia. Every time that we have placed one, 
and we have a lot of them now with more coming, it seems to me 
that they become real points of access, not just physically, 
but psychologically. People feel, ``Oh, that is pretty close. I 
will just go there,'' as opposed to if they have to go to a 
center or some other place where they might just say, ``Well, 
you know, I could go there, but it is a long way. I don't think 
I will.'' And that ``I don't think I will go'' for health care 
can be a very dangerous decision to make. So it is a good 
thing, having those outpatient clinics, in my judgment.
    With eligibility reform, we increased the number of 
veterans who receive primary care, but this must not come at 
the cost of the specialized programs. These are the two 
critical areas to balance, the basic and the specialized. We 
have more of the basic now than we do the specialized. That is 
a problem, because the VA generally has excelled at specialized 
programs, doctors, and their services, and it is something that 
veterans particularly need, so we need to talk about that.
    VA is now organized into 22 different service networks. 
Obviously, that has clearly changed VA health care delivery. We 
are in an amazing position in West Virginia in that we have 
four different VA centers and they belong to four different, as 
we say, VISN's. How do people feel about that? It is not 
something we are going to change, so it is a question of how do 
we make it work, and it is one of the important areas where 
oversight, which is what the Veterans' Committee does, can be 
very helpful.
    It is impossible to expect that every West Virginia veteran 
can get access to every kind of specialized care close to home. 
That probably isn't something which is going to happen. That is 
too good of a world. So you get to transfers. You transfer to 
people where they can get the best possible specialized care, 
and the question is how can those transfers happen as 
efficiently and humanely and rapidly as possible. VA's network 
and hospital directors have to, I think, make sure that there 
are not any barriers to these forms of transfer, getting people 
where they need to go as quickly as possible, and I want to 
talk about that.
    I am going to end on a cautionary note. After the tax cut 
bill, which you, I hope, know that I worked against, talked 
against, voted against, and still do talk against and will 
continue until something happens, there is not going to be 
enough money available. The Congress made a decision--in my 
judgment, a wrong one, a very, very wrong one, a profoundly 
wrong one--in which they said that we are going to pretty much 
guarantee that veterans don't get the health care that they 
need, that we don't get the kind of services that we in West 
Virginia need sometimes more than other people in other States 
because we are so mountainous and water and sewer become so 
important, highways become so important, transportation becomes 
so important, health care becomes so important. All of these 
things, Medicare and Medicaid, veterans' care, all of them come 
out of Federal funds. They don't come out of the private 
sector. They just don't. They come out of something called 
Federal funds.
    After that budget resolution was adopted by the Congress, I 
just have to tell you, I have no choice but to tell you that 
there is not going to be enough money to do veterans' care the 
way we should. And until and unless we come to our senses and 
do something about that bill--and I am not sure that we are 
going to, because there was such a rush and a mania to return 
money to people--which I am for, but if I had done that, I 
would have made a cut in the payroll taxes, not in the income 
taxes. The income taxes often go to people that don't need it 
nearly as much, and payroll taxes, by definition, goes to 
anybody who is working.
    But, nevertheless, that tax cut was adopted. It passed the 
Congress. We have to deal with it. So the budget increase for 
both health care and benefits administration is not enough as 
it is, and it is not going to be even enough now to keep pace 
with inflation. I have a duty to tell you that, because it is 
true. Again, it is a decision that others in the Congress made, 
not me, and it is something that I feel will do serious damage 
to our country, our educational system, and a lot of other 
important parts of our national future. But the Congress made 
that decision and the President made that decision and that 
decision was passed and signed, so it is now a fact of life.
    So we are not going to have what we need. I think the 
chances of getting it back are not good right now. I will do 
everything I can to fight to change that. I don't know what 
that means right now. I don't expect much result from that, 
certainly now. But I have to be candid with you and I have to 
note that the prospects are not good.
    With that said, we fight on. We always fight on and we do 
the best we can. In West Virginia, doing the best we can 
sometimes is pretty good. Human effort and care and love can 
make up for a lot.
    [The prepared statement of Chairman Rockefeller follows:]

 Prepared Statement of Hon. John D. Rockefeller IV, U.S. Senator From 
                             West Virginia

    Good morning. I welcome all of you here.
    It is good to be back in West Virginia for a Senate 
Veterans' Affairs Committee field hearing--and I like it all 
the better as the new Chairman. I know that a few of you in 
this room remember a hearing that the Committee held in 1993 on 
this very subject--access to VA health care in West Virginia, 
which remains a priority for me.
    I am pleased today that we are joined by a panel of 
veterans who can describe what needs to be done to improve 
access to high quality VA health care for veterans in rural 
areas, especially in West Virginia. Later, we will hear from VA 
officials who will help us understand how they propose to solve 
these problems.
    It is ironic that when we met in 1993, I commented that it 
was one of the few times that other parts of the country were 
devastated by floods while West Virginia remained safe. Today, 
West Virginians--including some here today--are contending with 
the aftermath of the worst floods in twenty years. I commend 
VA, especially the Beckley VA medical center, for rising to the 
occasion to help veterans in need during this disaster.
    In 1993, former VA Secretary Brown joined us in Beckley to 
talk about the challenges that VA faced then--the 
reorganization of VA's health care system, and how to decide 
who should be eligible for VA care. Today, I turn to you to 
learn how these changes in VA's healthcare delivery--the rapid 
increase in community clinics, eligibility reform, and the 
network organization--have affected veterans' access to basic 
and specialized medical care.
    Unfortunately, many of the problems discussed eight years 
ago remain with us: the fight for an adequate budget, long 
waiting times for care, too few VA staff providing specialized 
care, a lack of long-term care services, and transportation for 
veterans traveling to or between VA medical centers. In 1993, 
veterans voiced their concerns about access to, and co-payments 
for, prescription drugs. As our veterans population ages, and 
Congress continues to fail to enact prescription drug coverage 
under Medicare, these concerns grow even more pressing.
    Over recent years, VA has increased access to primary 
health care by opening community based outpatient clinics. I 
have worked closely with VA to open many of these clinics in 
West Virginia. Community outpatient clinics are enormously 
important to veterans who might otherwise have to travel for 
hours for the most basic primary health care. However, it is 
not just enough to increase the points of access--veterans who 
use these clinics should be able to expect and receive the 
highest quality healthcare possible.
    With eligibility reform, VA increased the number of 
veterans who receive primary care, but this must not come at 
the cost of the specialized programs at which VA has excelled--
and that some veterans so desperately need.
    The reorganization of VA into twenty-two service networks 
has clearly changed VA health care delivery. We are in a unique 
position in West Virginia in that our four VA medical centers 
are each in a different VA network. While this may create some 
problems for us, it also presents a wonderful oversight 
opportunity.
    Although it is impossible to expect that every West 
Virginia veteran can access every kind of specialized care 
close to home, it is essential that--should they need services 
only available at distant VA or private facilities--their 
transfers happen as simply and efficiently as possible. VA's 
network and hospital directors must ensure that no barriers 
exist to coordinating and managing care between medical centers 
or between networks.
    Let me end on a cautionary note: after the tax cut, there 
is simply not enough money available--either in the President's 
budget or the Budget Resolution adopted by the Congress--for 
veterans' health care. The budget increase for both health care 
and benefits administration is not even enough to keep pace 
with inflation. I will continue to fight for more funding in 
the appropriations process, but I must be candid and note that 
the prospects are not good.
    That said, we must try to identify the problems in access 
to rural health care, and how we will solve these problems, 
with the resources that we have. I look forward to hearing from 
our witnesses.

    Chairman Rockefeller. Now let us go on to our first panel, 
which has been patiently waiting right here before me. Randy 
Pleva, a longtime friend of mine, lives in Charleston, and is 
President of the West Virginia Chapter of the Paralyzed 
Veterans of America, one of five national PVA Vice Presidents. 
Randy was with Secretary Principi and myself as we were in 
various places and Randy has a variety of things that affect 
him personally and that affect him professionally.
    I am going to introduce each of you, and then I am going to 
ask you to go ahead and make comments and statements.
    Jake Stafford is Chairman of the State Veterans' Coalition, 
Legislative Officer of West Virginia Disabled American 
Veterans, DAV, and National DAV Executive Committee member, so 
he is thoroughly involved and he is living in Oceana. I won't 
be going there this afternoon, but I will be going close by, 
particularly to Mullens. Jake comes every year to DC to meet 
with me to make sure that I am abreast of veterans' concerns in 
West Virginia. He is going to talk about waiting times and 
anything else he wants to, as well as the specialty treatment.
    Randy Sims is a member of the Parkersburg DAV Chapter 32, 
and Randy lives in Belpre, but was born in Parkersburg and grew 
up in Williamstown, WV. I have always felt that people go back 
and forth on both sides of the river and we are all family in 
that sense, so we don't make a big distinction between whether 
you live in Belpre or whether you live in Williamstown. You are 
part of our area of concern. With Randy is his wife, Beth, and 
also his father, Paul Sims, who is an ex-POW who spent a year 
in a German prison camp in World War II, and Vera Hill, one of 
the health care workers that they have hired to help with 
Paul's care. Paul is a 100 percent service-connected disabled 
veteran, and with him, we want to get to the question, and with 
you, Randy, to the question of long-term care.
    Luther, I didn't pass you by. You are a Vietnam veteran. 
You retired with 23 years in the Army and you have a number of 
health care problems, which I won't go into. You are 100 
percent service-connected for a variety of reasons, you live in 
Welch, and you are very active in local veterans' service 
organizations. I think that you are going to focus on a recent 
hospitalization in Huntington, and you may have some other 
comments--you were running short of breath one time and you 
called our office, and you may want to comment on that. You 
were told that you couldn't have surgery done, you had to go to 
St. Mary's. You had surgery done in St. Mary's because you 
didn't want to wait, because you didn't think you could wait. 
The VA said no, St. Mary's said yes, and you went ahead. You 
probably did the right thing.
    So with that in mind, Randy, why don't we start with you. 
Make yourself available to the microphone, since this is all on 
the record and part of official congressional testimony. I 
welcome you very much and am very happy to see you.

 STATEMENT OF RANDY PLEVA, PRESIDENT, WEST VIRGINIA PARALYZED 
  VETERANS OF AMERICA (PVA), AND NATIONAL PVA VICE PRESIDENT, 
                         CHARLESTON, WV

    Mr. Pleva. Yes, Mr. Chairman. Thank you and the members of 
the committee. Paralyzed Veterans of America appreciates this 
opportunity to express our views on spinal cord injury health 
care in the State of West Virginia.
    Mr. Chairman, as I look back at the testimony that I gave 8 
years ago, just to see, if in fact, health care has improved. I 
found, and I am glad to report, that it has with the SCI 
primary care teams in all four VA Hospitals with more nurses 
and physicians receiving training and certification in the SCI 
field. In addition, more of the SCI population is using the VA 
system than they were 8 years ago due to the trust SCI veterans 
have in the primary care team members.
    One thing that took longer to change than anything else is 
going to the SCI center itself. Transfers, until 3 months ago, 
not only were a nightmare for the veteran, but also for the 
person in the VA trying to get someone transferred. Mr. 
Chairman, as you are well aware, we contacted Ms. Moreland on a 
number of occasions when this situation occurred. Then and only 
then, did these transfers become reality. Somewhere someone was 
not doing their job. As of March of this year, all four VA 
hospitals in the State have reported no trouble at all when it 
comes to transferring an SCI patient. Let me reassure this 
committee, WV-PVA will be in contact with each SCI coordinator 
to make sure transfers are no longer a problem.
    As I stated before, more SCI veterans are using the VA 
system but are not going to the SCI centers for their annual 
checkups for various reasons. Some reasons would shock this 
committee, as it did me when I sat and listened to not only the 
veteran, but to also family members. Out of 225 members, only 8 
percent went for annual checkups at an SCI Center inpatient 
care. Just as it was 8 years ago, bowel care in still a 
concern. I have been told that this concern is being addressed 
and that is due to the turnover of nurses on the ward. That the 
new nurses will be trained soon. However, to the SCI patient 
soon is not fast enough. Today is the time. Mr. Chairman, we 
are not asking for a magic wand to fix everything at one time, 
but if the SCI primary care team can be trained, why can't the 
nurses and aides on the wards be trained also? I don't mean to 
sound like the author of doom, good has come to the SCI health 
care in West Virginia and for the first time in years, the VA 
is being trusted. But also remember, it has taken 8 years to 
get this far, and we are only a few feet from the starting line 
when it comes to quality health care for the catastrophically 
disabled veteran.
    Mr. Chairman, this concludes my testimony and I will be 
happy to respond to any questions you may have, sir.
    Chairman Rockefeller. I will give you one right now, 
although this is out of order. You say that most of them don't 
go for regular check-ups, by which you are saying that they go 
if there is a crisis, but they don't go for a regular status 
check-up?
    Mr. Pleva. Right. They don't go for annual check-ups, no, 
sir.
    Chairman Rockefeller. But they do go for----
    Mr. Pleva. No, sir, they don't even go--I mean, they were--
--
    Chairman Rockefeller. No, but when they do go.
    Mr. Pleva. Oh, yes. Well, when they do go, yes, their skin 
ulcer has gone to a stage four or something of this nature 
before they will even go into the VA, before they even think 
about going to an SCI center, due to reasons. I wish I could 
tell you, I mean, and I will, but I think it is something that 
should be privately done, sir.
    Chairman Rockefeller. OK. I appreciate it.
    Jake?

    STATEMENT OF JACOB STAFFORD, CHAIRMAN, STATE VETERANS' 
COALITION, LEGISLATIVE OFFICER, WEST VIRGINIA DISABLED AMERICAN 
 VETERANS (DAV), AND NATIONAL DAV EXECUTIVE COMMITTEE MEMBER, 
                           OCEANA, WV

    Mr. Stafford. On behalf of West Virginia Disabled American 
Veterans and their auxiliary, I am pleased to be here before 
this committee. We would like to thank you at the outset for 
your many endeavors and commend you and the committee for what 
you have done for the veterans in the State of West Virginia 
and across the Nation in the last few years.
    I would like to talk just a little bit about an adequate 
budget. I know you have touched on it, but our problems in West 
Virginia and across this country started with 3 years of flat-
line budgets. We have had a couple of years that are pretty 
good and helped us get back on our feet a little bit. Right 
now, I am tremendously worried about the fundings that we have 
got coming.
    I know the Independent Budget, with the AMVETS, the DAV, 
the VFW, and Paralyzed Veterans, they are calling for $3.5 
billion, $2.66 billion of that for health care. The President's 
proposal is $1 billion for all discretionary spending, and 
basically, that is what we need just for the ``other than'' VHA 
health care.
    Chairman Rockefeller. Actually, it doesn't even do that. It 
doesn't even keep us where we were last year.
    Mr. Stafford. Right. And the reason that we need these 
funds is because of the cost-of-living increases, unfunded 
mandates that were passed by you guys last year. If we could 
get something similar to this, it wouldn't have the adverse 
effect to America's sick and disabled veterans.
    Most of the health care problems we have had in the last 4 
years have been because of underfunding, and hopefully, we will 
not see this again, but it doesn't seem that we won't have it.
    I would like to touch on all four VA hospitals and the 
problems on the specialized service. Beckley, the veterans 
receive specialized care in Richmond, Salem, and Durham. You 
have a 2.5- to 4-month waiting period for the first-time visit 
and specialty clinics at these facilities. This is a very 
serious problem when the veteran has a life-threatening health 
care issue. If they get into the system, the appointments come 
as needed. Non-life-threatening treatment can take 6 months to 
a year, and in some cases longer for an appointment.
    Transportation problems at Beckley for underprivileged 
veterans trying to get to Richmond. Richmond, Durham is about 
5.5 hours away, Salem about 2.5 hours, and this has created 
great problems for veterans getting to the facilities and back 
home. Most have low income and can't afford the cost of long-
distance travel and food costs.
    At Beckley, the VA furnishes transportation to Richmond 
VAMC. Everyone has to stay overnight for appointments. You get 
in there around noon, having to wait until 7 or 8 at night for 
someplace to stay. If the veterans are lucky, they will receive 
at least probably one meal down there. The next morning, at 7, 
they have got to give up their bed, and these guys that have 
got cancer or other severe disabilities are left sitting down 
in the lobby the biggest part of the time that they are down 
there, other than when they are in the appointments, in a 
straight-back chair.
    There needs to be something done, and the VA, if they are 
going to take them out there, they need to take care of them 
and feed them. A lot of them can't afford, and I have talked to 
a lot of veterans that come back, that the only meal they have 
gotten is the one, if they were lucky, that they got while they 
were out there, and this is not right. The VA takes them down 
and they should take care of them. If they are going to take 
them from Beckley to Richmond, they should take care of them 
until they get back to Beckley.
    The transportation to Salem and Durham does, DAV does and 
we don't really have that much problem that we do with the 
veterans going to Richmond.
    Clarksburg, on the specialized treatment, you have got 2- 
to 3-months' wait. After getting into the hospital system, the 
appointments usually come as needed. Life-threatening treatment 
at the VAMC's that they go to, like Pittsburgh and the others, 
you have got anywhere from 6 months to a year-and-a-half wait.
    The biggest problem is that if you haven't finished your 
appointment at Pittsburgh VAMC, then they have two buses going 
up there, one in the morning and the last one leaves at 2. If 
the veterans that ride the bus up, the VA bus, if they are not 
finished at 2 with their doctor's appointment or seen their 
doctor's appointment, then they have got to leave in order to 
get a ride back home, because if they missed their bus, they 
have got no place to stay that night, nothing, and they have 
got to wait until the next day, either sitting around the lobby 
or whatever, in order to get back to Clarksburg.
    This has been brought up several times in the last few 
years by service officers to Clarksburg and Pittsburgh, and up 
to right now, they haven't had any correction to this. They 
need to get a bus that maybe leaves at 4 in the evening or 5 in 
the evening coming back to Clarksburg. I know the cost of VA 
going to Richmond and to Clarksburg, or to Pittsburgh and these 
other places is high because they are using VA employees and 
having to pay overtime, and that is one of the reasons that we 
are having this problem up there.
    Huntington VAMC, on specialty care, you have got 2 to 3 
months for the first time. Specialized appointments and life-
threatening, you have got anywhere from 6 months to a year.
    The transportation problem, they actually don't have many 
at Huntington because the DAV transportation network are 
hauling the veterans out to the different VAMC's around and 
just don't have that. That is like meals. The DAV, while they 
are out on the road, and usually, they don't have to stay 
overnight because the van takes them that morning, stays there 
until their doctor's appointment is complete, and brings them 
back home. Now, travel, meals, and stuff like that, the DAV is 
paying for them.
    The Martinsburg VAMC has got a period of 1 to 2 months, 
probably the best we have got in the State, for specialized 
treatment. Non-life-threatening problems, they have got 6 to 9 
months.
    I would like to talk about new veterans entering the VA 
health care system, the first time. It seems pretty well even 
around the State. You are looking at 4 to 6 months. If you have 
got an emergency, they will see you, but any followup 
treatments that you have got, you may have 4 to 6 months' wait 
period before you actually get in the VA system.
    I would like to talk about the effects on the family 
members and the veterans for specialized health care. For most 
veterans, it is a 3- to 6-hour trip to other VAMC's to receive 
specialized health care and is a burden on the family and 
veterans physically, mentally, and financially. In most cases, 
it takes the family out of the picture of the veteran with no 
family support and family care and encouragement to help the 
veteran and family meet the crisis of a long stay, even a few 
days up to several weeks.
    In most cases, the veteran goes for his first appointment. 
Afterwards, they will be sent back home, making up to six or 
more trips to the VAMC for testing and other treatment. After 
an operation that is needed, then another six to eight trips 
followup treatments or visits. Most veterans will make an 
average of 12 to 20 trips back and forth to that VAMC for 
specialized treatment. These trips can and should be cut down. 
The cost to VA health care is much greater and also to the 
veterans. They can't afford it.
    Most of the facts on this here are my travel around the 
State, and that is fairly regular, talking to veterans, service 
officers, and other veterans' organization service officers. 
These are the facts as the veterans around this State and the 
service officers encounter with specialized treatment and 
services out at the VAMC's within this system. Thank you. I am 
available for questions.
    Chairman Rockefeller. Thank you very much.
    [The prepared statement of Mr. Stafford follows:]
    Prepared Statement of Jacob Stafford, Chairman, State Veterans' 
    Coalition, Legislative Officer, West Virginia Disabled American 
Veterans (DAV), and National DAV Executive Committee Member, Oceana, WV
    Mr. Chairman and members of the Committee:
    On behalf of the West Virginia Disabled American Veterans and its 
Auxiliary. I am pleased to appear before you to discuss the Department 
of Veterans Affairs (VA) Health Care System. A system that has had many 
improvements made during the past few years, but with some 
imperfections relating to waiting time for specialized treatment at 
facility other than their home VA medical Centers and transportation 
problems getting to and from these VA facilities. With flat line 
budgets, not helping our veterans population of West Virginia and the 
nation.
    Mr. Chairman, at the outset, I would like to commend you for your 
many years of dedicated service to West Virginia veterans and those of 
the nation. We appreciate and deeply value the advocacy that this 
committee has demonstrated on behalf of America's disabled wartime 
veterans'.
            adequate budget for va health care and benefits
    The President's budget for fiscal year (2002) recommends only $1 
billion increase for all discretionary spending, that includes health 
care, and related programs under the Department of Veterans Affairs. 
The Independent Budget by the AMVETS, DAV, VFW and PVA is calling for 
an increase of at least $3.5 billion for discretionary spending, with a 
$2.66 billion increase for the Veterans Health Administration, to cover 
inflationary cost, wages increases, un-funded mandates of expanded 
service in last year's legislative session. The increase would restore 
certain services to acceptable levels. Without the additional funding, 
health care would be adversely effected for America's sick and disabled 
veterans.
    Most problems in the VA Health Care System were created because of 
the 3 Years of a Flat Line Budget the VA suffered. The Veterans of 
America doesn't need this to happen again.
              long waiting periods for specialized service
    Beckley VAMC: Veterans that received specialized care at Richmond, 
Salem and Durham VAMC's have 2\1/2\ up to 4 months waiting period for 
first time visits in specialty clinics at these facilities. This is a 
very serious problem when the veteran has a life threatening health 
care issue. After they get into the system at that VAMC they come as 
needed. Non-life threatening treatment can take up to 6 months to 1 
year for an appointment.
    Transportation problems: With Richmond and Durham 5 or more hour 
away, and Salem 2\1/2\ hours has created great problem for veterans 
getting to these facilities and back home. Most have low income and 
can't afford the extra cost of long distance travel and food cost. At 
Beckley the VA furnishes transportation to Richmond VAMC. Everyone has 
to stay overnight for appointments getting there around noon, having to 
wait until 7:00 or 8:00 PM that night for some place to stay. With them 
having to give up the room and bed at 7:00 AM. Some of these Veterans 
are very sick, some with cancer and other severe disabilities, left to 
set in a chair all day. If the veterans are lucky they will get one 
meal during that stay. Leaving Richmond VAMC at 1:00 PM for Beckley 
VAMC, arriving 6:00 to 7:00 PM that night without eating. The VA at 
Richmond should furnish a bag lunch for these patients. These problem 
didn't exist when DAV did the transportation for veterans, because the 
van waited for veterans to complete their appointment.
    Transportation to Durham VAMC and Salem VAMC is furnished by DAV 
Transportation Network without most of these problems.
    Clarksbure VAMC: Veterans has some of the same problems, Again long 
waiting periods for first Specialized appointments. 2 to 3 months wait. 
After getting in that hospital system, appointments come as needed. 
Non-life threatening treatments can take six (6) months and in some 
case up to 1\1/2\ Years.
    Transportation Problems: Two (2) to three (3) hour travel time to 
other VAMCs The VA furnishes transportation to Pittsburgh VAMC. They 
have two (2) buses a day going and coming back to Clarksburg. The 
biggest problem is if you haven't finished with your appointment when 
the last bus leaves at 2 PM and you miss it. You have no place to stay 
that night. So most veterans, a lot of the time will not get to see 
their Doctor with fear of missing their ride home. Our Service Officers 
have informed Clarksburg and Pittsburgh many times during the last few 
years about this problem, with no correction.
    Huntington VAMC: Waiting time take two (2) to three (3) months for 
first time specialized appointments. Non-life threatening appointments 
can take up to one (1) year.
    Transportation Problems: Most transportation is made by the DAV 
Transportation Network for those veterans that do not have 
transportation or can't drive long distance's. Many of these problems 
are not encountered with food or having to stay over night. The DAV 
gives or pays for food while out on the road. Veterans are taken to the 
different VAMCs with the DAV vans waiting until their appointments are 
over before returning back to Huntington VAMC. Much less cost to VA and 
veterans patients!
    Martinsburg VAMC: Waiting time one (1) to two (2) months for 
specialized appointments. Non-life threatening appointments six (6) to 
nine (9) months.
    Transportation Problems: Most transportation is furnished by the 
DAV Transportation Network with few or no problems encountered at the 
other VAMCs. Again the DAV van waits for appointments to be completed 
before returning to Martinsburg VAMC.
          new veterans entering va health care for first time
    All four (4) VAMCs in West Virginia will have a four (4) to six (6) 
month waiting for VA health Care in most cases, some longer. Emergency 
care is taken care of, with three to six months on follow up 
appointments.
      effects on veterans and families for specialized health care
    For most veterans the three (3) to six (6) hour trip to other VAMCs 
to receive specialized health care is a burden on the veteran and 
family members, physically, mentally and financially.
    In most cases it takes the family out of the picture for the 
veteran, with no family support and family care and encouragement to 
help the family and veteran meet the crisis of a long hospital stay, of 
a few days or weeks.
    Most cases the veteran goes for his first appointment. Afterwards, 
they will be sent back home. Making up to six or more trips back to 
that VAMC for test and other treatment, before an operation that is 
needed. Then another six or more trips for follow up treatments or 
visits. Most veterans will make an average of 12 to 20 trips back and 
forth to that VAMC for specialized care per medical issue.
    These trips can and should be cut down. The cost to the VA health 
care system is much greater and also for the veterans.
    The biggest problems with going to Richmond VAMC and I speak on my 
own case. The Doctors that you see, only stay at Richmond for six (6) 
months at a time for their rotation. If that doctor doesn't finish your 
treatment, the next doctor almost has to start over getting you the 
treatment you need. Again causing extra visits! I am not trying to down 
the Doctors I have only good things to say about them, because of the 
help they gave me. But way to many trip to Richmond VAMC and ten (10) 
months to get the operation that we all knew I needed to start with.
                            summary of facts
    In my travel around the state, talking to veterans and DAV Service 
Officer and other Veterans Service Organizations, Service Officers 
these are the facts others and myself have come up with. I have 
personal knowledge of veterans from each VAMC. More so at Beckley VAMC 
than others hospitals.

    Chairman Rockefeller. Luther?

 STATEMENT OF LUTHER T. ENGLAND, VIETNAM VETERAN AND MILITARY 
                       RETIREE, WELCH, WV

    Mr. England. Mr. Chairman, on or about the first or second 
of March, I went to the VA hospital in Huntington. When I got 
there, I was having chest pains. So Scott, the doctor's 
assistant, sent me to the emergency room. The doctor in 
emergency sent me upstairs to the cardiac unit. There, I was 
under the care of Dr. Trainor and his team.
    Dr. Trainor said I needed a heart catheterization, so Dr. 
Epling performed the cardiac catheterization on March 5. After 
the catheterization was performed, it was determined I had an 
80 percent blockage and would need a stint or a heart operation 
as soon as possible.
    Dr. Pellecchia, he came to my room and said that this 
operation could be delayed, but to me, I needed it right then 
because I was going on 12 years with the operation I had done 
in Pittsburgh. I had a triple bypass, so it was getting pretty 
close.
    Dr. Pellecchia said it could be delayed. He said he could 
schedule the surgeon at Cleveland VA hospital in 2 months and 
at Lexington VA hospital in 8 weeks. This is after Dr. Epling 
said it should be done as soon as possible.
    On March 5-6, I called Charlotte Moreland and talked with 
her. She said she would try to get the VA to help me. This is 
when Dr. Pellecchia said he would send me to Cleveland or 
Lexington. I then said I would get the surgery done under 
Medicare and CHAMPUS.
    Then on the 7th or 8th, Dr. Trainor came into my room and 
said I was discharged to go home, but Dr. Epling had already 
scheduled me to go to St. Mary's to have the surgery done by 
Dr. Mark Stuany. Donna Childers brought in some papers to sign 
saying the veterans' hospital would not be responsible for the 
bill. The VA transported me to St. Mary's on the 9th of March 
and I was released on the 12th of March. All followups were to 
be performed at the veterans' hospital.
    I feel I was fortunate. Because of my retirement from the 
military, I had to go to the VA hospital and also have CHAMPUS 
insurance or Medicare Part A. There are some veterans who 
cannot afford it and they have to depend solely on the VA. The 
VA hospital does not have enough medical personnel and nurses 
and other personnel they need. But that was the problem I was 
having.
    There was another man in my room with me. He had to have 
surgery done on his head. He had a brain tumor, a brain cancer, 
named Medford, and he went ahead and did the same thing I did, 
but now he tells me that followups were done at St. Mary's and 
he has a $1,800 he has got to pay out of his own pocket. So 
far, all I have spent is $297, but I got a bill from St. Mary's 
that says I owe them $1,005, so I am waiting on the results of 
that.
    I don't know, but I think we need more nurses, just like I 
read in the paper where you wrote up about it. It was a very 
good article. That's all I have, sir.
    Chairman Rockefeller. Luther, thank you. That is very 
helpful. We do need more nurses.
    Mr. England. Yes, you wrote a good article on that. That 
was a very--you said the VA has the highest nurse in the United 
States and you said we are losing them and you said we need to 
get more nurses.
    Chairman Rockefeller. Right. That is true.
    Is it Randall or Randy?
    Mr. Sims. Either one, Senator.
    Chairman Rockefeller. No, sir, it is either one or the 
other.
    Mr. Sims. Call me Randy, if you like.
    Chairman Rockefeller. Randy, OK.

   STATEMENT OF RANDALL SIMS, VIETNAM VETERAN AND MEMBER OF 
    PARKERSBURG DISABLED AMERICAN VETERANS (DAV) CHAPTER 32 
  (TESTIFYING FOR HIS FATHER, WORLD WAR II EX-PRISONER OF WAR 
                     PAUL SIMS), BELPRE, OH

    Mr. Sims. I never really prepared a statement, but I 
appreciate you letting me testify on the elderly care of 
veterans. It has been a big concern of mine with my father, 
with his memory loss and his wartime post-traumatic stress, and 
I think a lot of these nursing facilities and stuff don't quite 
understand the veterans' issues. So what they would do when 
they start acting up is they are drugging them heavier and 
letting them go dirty, basically, and that is what has 
happened.
    I have found that the best solution was to bring my father 
home, where I had some kind of control over his health care, to 
make sure that he was clean and when he had these outbursts 
from the post-traumatic stress, of the beatings of being a POW 
and stuff, they could be controlled.
    I was going to bring documentation from the nursing home, 
where we thought we had it in a file cabinet, but we have it 
locked up in a safe deposit box in the bank.
    But not all of us want to put our parents in a nursing 
home. We would like to take care of them at home, and it is 
very hard to do. I do have to thank Huntington. They have done 
a real good job on Dad. Dad is a West Virginia veteran. They 
have helped me tremendously with him. It has taken some time, 
but it has worked.
    The issues of getting the health care is getting to be a 
problem. It has been timely. Dad does not travel very well 
anymore. He doesn't like to travel, but we did make this trip. 
I have talked to them at Clarksburg and we have switched his 
medical care down to the Parkersburg clinic, which has done an 
extremely good job for him. We actually live approximately 5 
miles from the Parkersburg clinic, so that is a lot easier on 
him than traveling 84 miles to Clarksburg. So I do think that 
the clinics are working, but we need more nurses in them.
    Chairman Rockefeller. And the difficulty with traveling 
comes just from a reluctance to do it?
    Mr. Sims. That, and the age and Alzheimer's. With 
Alzheimer's, you have to remember, they start losing their 
short-term memory. Now, he has worked all of his life, 
controlled it, and when the short-term memory is gone, then he 
goes back to the wartime stuff, and sometimes it does get hairy 
around the house. But thanks to Ms. Hill here and my wife, we 
have been able to contain it.
    But one of the problems, even him at 100 percent, is we 
have to pay taxes, you have got to pay unemployment taxes, you 
have got to pay workman's comp, they have got to pay city taxes 
and stuff, and it is tough.
    Now, I spoke to Clarksburg. They said they would furnish a 
nurse and they would pay--in Washington County, a high, they 
would pay $12.88 an hour, I believe it was, providing I went 
through one of two agencies. I called the agencies to see what 
they paid the girls and one was $6 and the other one was $6.50, 
I believe. Now, where is that other money going? That is my 
question. I mean, I am sure they have to pay workman's comp and 
stuff, too. But for somebody that has worked all their life and 
saved their money for health care and then has to spend it on 
it, to spend taxes on it, they have already been taxed on it 
once.
    Chairman Rockefeller. Could you describe for the record and 
for the audience and for me what happens when somebody who is a 
POW prisoner in World War II, when he has a flashback, to the 
extent that you feel comfortable doing so. You said it kind of 
gets----
    Mr. Sims. Sometimes it can be comical and sometimes it can 
be bad. I have been shot at. I have had him in a nursing 
facility for, I believe it was around 15 months, where they had 
little buttons around the doors that they would program him for 
alarms. He is programmed to escape. He would stand back and 
watch them and then push those buttons and get out, and he was 
walking up and down Route 47 four different times after dark, 
and that scared me. I was really alarmed about that. One time, 
the Wood County sheriff did pick him up.
    Chairman Rockefeller. So, in other words, what he was----
    Mr. Sims. He was programmed to escape.
    Chairman Rockefeller. What he trained himself to do, so to 
speak, back then came back to him and he tried to do it under 
these circumstances.
    Mr. Sims. Right. Also, he would pound on the desk, the 
nurse's station and say, ``I'm not a POW no more.'' He has done 
that a lot of times, and that is all documented in the medical 
files he has.
    Chairman Rockefeller. What do you do or does his nurse do 
in a situation like that?
    Mr. Sims. The best thing to do is to redirect him, is to 
just start talking about another subject and redirect him and 
get their attention on something else. Ms. Hill here, it is 
just a shame that everybody couldn't have somebody like her. 
She has had my father laughing harder than I think I have ever 
heard him laugh in my life. So things like this is the best 
medicine, in my book, for these people.
    And not all these guys are getting good care. There is an 
article in this latest edition of Disabled American Veterans. A 
gentleman that served 32 years, 6 months, and 3 days, was a POW 
for 15 months and can't get any benefits. See, now these things 
shouldn't be happening.
    I am a disabled veteran myself. If we cannot take care of 
the POW's, I am scared what is going to happen to me. I cannot 
even get insurance, health insurance, life insurance to bury me 
with. So we have got a problem.
    And our younger generation is seeing this problem, Senator, 
and they do not want to go in service. My son is an Eagle 
Scout. He is in college now and he just said, ``Dad, I just see 
what has happened to you and I see what happened to Grandpa and 
I don't want to go in service,'' and I really couldn't blame 
him, because of these cutbacks, and this current 
administration, it is going to ruin us.
    Chairman Rockefeller. Well, I don't know if it is going to 
ruin people, but the VA budget, as everybody here knows, unlike 
a regular non-VA budget, limits true national health care--you 
cannot go above the budget, none of the divisions of the health 
care system can go above the budget--so the budget defines the 
total system. In the non-VA health care system, the cost of 
health care can rise up and people still go ahead, or insurance 
companies pay for it, in part. But in the VA, you can't do 
that.
    It is interesting to sit and watch the VA system work along 
with the non-VA system, or the private health care system, 
whatever you want to call it. They both have problems. One is 
under a budget and one technically isn't, in the same way, but 
they both have problems. Health care is tough. But in the VA, 
if you don't have the budget, it gets a lot tougher real fast.
    We discussed a little bit waiting times. Jake, I think it 
is probably fair to say that a number of the VA facilities 
don't have the personnel. They just don't have the people.
    Mr. Stafford. Well, the problem you have got, like going to 
Richmond or Durham or any of these outlying specialty clinics, 
the thing of it is, they try to take care of their veterans 
there and most of them are overworked to start with. So what 
they have got to do is try to work this particular veteran 
within their health care system. Now, once that veteran gets 
into that clinic, then, well, your appointments come as needed.
    The only thing, a lot of these people are traveling a long, 
long distance, OK, and if they could take, once they do their 
initial appointment with the guy or gal and let them--to where 
they know their problems, and all these tests, instead of 
running backward and forwards, backward and forwards, I know 
myself, when I was going to Richmond with my back problem, it 
is a terrible, terrible pain when you can't walk and you have 
got to sit in a pickup truck or a car, trying to get down there 
and back. I probably made 40 trips between Wyoming County and 
Richmond.
    A lot of these veterans cannot do that. You have got 
veterans maybe with cancer, all this type stuff, and taking 
treatments, radiation treatments, and it is hard to go down 
there on those guys, especially the ones riding the VA 
transportation, and sit all day waiting until the next morning 
and they have done rode 4 or 5 or 6 hours, and wait until 6 at 
night, or 7, and sometimes until 8 to get a place to lay down. 
If they get in there early, sometimes they get a meal. But if 
they have to wait until 8, they have got nothing to eat unless 
they have got the extra money.
    That is just like these veterans that we pick up with the 
DAV transportation program. A lot of times, we go out and pick 
up five, six, seven people and leave the house at 3 in the 
morning to get them to the hospital for the first appointment. 
Then all day long, you have got different ones who have got 
different appointments. And that is something we have tried to 
get them to do, is schedule their appointments for early in the 
morning, maybe 9 or 10. I know a lot of the clinics don't come 
in until evening. But those guys that are coming in the evening 
should be set up to start those evenings appointments because 
they know the ones that are riding the vans.
    Most of these guys that are riding the vans, they can drive 
a little bit around home, maybe to run to the store or get 
groceries or what have you, but they just are not able to drive 
the distance to Beckley, and if they have to hire somebody to 
take them, they want a miner's wages or whatever and it takes 
away from food or paying the electric bill or something like 
that that they may have.
    The last 3 years, the transportation program in West 
Virginia is probably the best in the Nation, with the help of 
the State legislature. We have gone over a million miles and 
something like nearly 50,000 volunteer hours and hauling 
27,000, 28,000 veterans a year. I shouldn't say veterans, I 
should say appointments because some of them, more than one.
    Chairman Rockefeller. Do any of the others of you have 
comments on that question of transportation? Of course, if 
there isn't an outpatient clinic or if the outpatient clinic 
doesn't provide the care for that particular problem, you have 
to travel. Randy, I know you have been down to Salem a lot and 
other places. In other words, you could argue that that is the 
only way you are going to get the specialty care, but if you 
have to get to someplace where the care is offered, you have to 
take transportation. You are saying that transportation is hard 
on people, and some kinds of people in particular because of 
their health problems. But is there a way around that? I don't 
know the way around that right now.
    Mr. Pleva. You know, to be honest with you, Senator, I 
don't see a way around it, just like if our people, if we don't 
drive ourselves or a family member takes us, unless the VA 
would pay for the transportation down to Richmond and back.
    Another concern that we had, also, when I was in Clarksburg 
talking about these CBOC's, these clinics, when an SCI person 
goes in and doesn't have the transportation to get to 
Clarksburg or to one of the four main hospitals, what type of 
transportation needs do you have there, just as the DAV does 
not have lifts in their vans for wheelchair people. So they are 
either going for a family member or a friend to drive them or 
they sit at home, and this is one of our great concerns.
    Chairman Rockefeller. And that is not taking the chance to 
go to where you need to go.
    Mr. Pleva. Right.
    Chairman Rockefeller. So, on the one hand, you have an 
uncomfortable transportation situation, more so for some than 
for others, but on a net basis, it is more important to get to 
that care, isn't it?
    Mr. Pleva. Yes, it is, but there is not a middle-of-the-
road here. It is either it happens or it doesn't, and a lot of 
times, sir, it doesn't happen.
    Chairman Rockefeller. Does that tie into what you said 
before about people not getting checkups, or is it that people 
in West Virginia sometimes just don't want to travel to another 
State or long distances, they just don't want to do that but 
they do have a need to do it?
    Mr. Pleva. Yes. Yes. And honestly, now that we have the SCI 
primary care teams, and probably if you would ask Mr. 
Pennington or people like this, directors of these hospitals, 
these guys are so used of getting their SCI care at the 
hospitals here in Huntington, Martinsburg, Beckley, Clarksburg, 
that they feel like these hospitals should provide this 
service, which some of them may be able to provide the whole 
service, but some of them cannot and they don't want to leave 
Huntington. They don't want to leave the State. They say, 
``Well, why can't you do it here? You have people who know 
about spinal cord injury health care,'' and so on. But some 
things need to be done in Richmond and they just refuse to go.
    Chairman Rockefeller. That is interesting. You are talking 
about human nature, aren't you?
    Mr. Pleva. Oh, absolutely.
    Chairman Rockefeller. If you have a really good specialty 
spinal cord injury physician or health care team in a place 
which is not near, you have got to go to it.
    Mr. Pleva. Yes, you do.
    Chairman Rockefeller. But you are saying that they won't go 
to it even when they get that level four or five, or that is 
the only time they do go to it?
    Mr. Pleva. That is when they will go to it.
    Chairman Rockefeller. That is when they will do it.
    Mr. Pleva. When everything else has stopped, you know, when 
everything has gave up, then yes, you know, you had better go 
or you are going to lose your life, just that simple.
    Chairman Rockefeller. Can you give me an example, Randy, of 
a time when it doesn't reach that level of drama but when you 
would say to somebody who is very familiar with this that they 
ought to go, even if it is not that convenient?
    Mr. Pleva. Oh, well, we deal with that every day.
    Chairman Rockefeller. Give me an example.
    Mr. Pleva. We have people that need to get tests done on 
their bladder, things of this nature, and we will even work 
with the SCI coordinator at the different hospitals and we will 
get calls, ``Hey, I want you to talk to this person and see if 
they won't go to Richmond.'' And as soon as you go in the room, 
they say, ``Why do I have to go to Richmond when they can do it 
right here?'' But if they can't do it here, you need to go.
    Like I said, this is an every day--not every day, but it is 
something that we deal with constantly, trying to get them to 
go--and also, it is also not only for transportation problems 
but due to the care that they receive in these SCI centers is 
not the best care in the world. That is something else that 
needs to be looked at, also, which I discussed a little bit, to 
your attention.
    So, yes, they are here in the State of West Virginia, and 
no, they don't want to leave Huntington or whatever, but even 
though the director or the SCI coordinator or doctor goes and 
tells them they have to go to Richmond, some of them just plumb 
refuse to go.
    Chairman Rockefeller. Yes. It is a little bit like flood 
insurance, isn't it?
    Mr. Pleva. Really. [Laughter.]
    Chairman Rockefeller. I mean, somebody can be flooded out 
five times, but they will go right back and they won't get 
flood insurance. You would think it would be pretty obvious 
that people want to get flood insurance, but they don't. What 
you are dealing with is human nature.
    Mr. Pleva. Right. And the other side of the coin is this. 
This is why they are trusting the VA now, because now you get 
them into Huntington, where before, they would not even go to 
the VA. But now you are getting them into these four VA 
hospitals or into the clinic, so it is going to take time to 
get them to go into the SCI centers.
    Chairman Rockefeller. OK. Randy, another question for you, 
since I have just got you on the list here. You have fought for 
a long time for veterans with spinal cord injuries, I mean, for 
years and years and years that you and I have known each other. 
There have been some eligibility reform changes. The network 
system has changed. Community clinics have changed. Transfers, 
we have already talked about, have increased. But what has been 
the effect of some of these other changes on veterans with 
spinal cord injuries?
    Mr. Pleva. Again, as I stated earlier, the trust in the VA 
system, once again, like I said, these primary teams, these SCI 
primary care teams. At least they can go in and someone knows 
what they are talking about, where 8 years ago, they didn't 
unless they were at an SCI center somewhere. But here in the 
State of West Virginia, all four SCI primary care teams are up 
and running. People know what their problems are, and that is 
one of the big breaks that this State got, I will be quite 
honest with you. Along with eligibility, all different 
categories now, we are not in this five or six or seven. The 
non-service-connected is treated the same as the service-
connected. There is no ifs, ands any longer when you go to 
these teams.
    So there is a plus here for that. Like I said, is it one 
that is going to come back and bite us on the rear end later 
on? I really don't think so, because you have good men and 
women at the VA that are dedicated. But like Jake said, you 
know, and everyone on this panel, these people are worked to 
death. They are wearing, like, six different hats. So they may 
be SCI coordinator one day, which they will be, but they may be 
over another department the next day.
    That is why, again, I go with the training on the floor for 
nurses and aides, that whole thing with the turnover, where 
nurses are on the floor for so long and then they are off the 
floor, they are working somewhere else, so you have whole brand 
new nurses come on and they don't have the foggiest idea about 
how care is done.
    But, yes, I really honestly believe that the primary care 
teams have boosted. I believe it has saved a lot of lives in 
this State.
    Chairman Rockefeller. I appreciate that.
    Jake, on the transfer situation, we really discussed that, 
but is there anything that we can do that makes transfers work 
better, easier, something?
    Mr. Stafford. Yes. The biggest thing is the number of trips 
that they have got to make between their own VAMC and one of 
the specialty clinics. They could take--I know that the VA went 
from inpatient to outpatient. I think it saved a lot of money 
and it was good.
    But on these specialty clinics, like going to Richmond, 
they can take those people, and that is their initial 
appointment down there, and the doctors know basically what 
needs to be done or maybe should be done, instead of making 8 
or 10, 12, or 15 trips back and forth between that VAMC, they 
can put them in the hospital for a couple days and do these 
tests. Now, it may be depending on the condition of the 
veteran, but it could happen, and that would save the VA a lot 
of cost. It would save a lot of cost to the veterans and all 
the way around make it better and not have near as much painful 
sitting in those vans.
    That is just like if you go from Beckley to Richmond as a 
wheelchair patient, you sit in your wheelchair the 5-hours 
going to Richmond. Then you have got to stay down there all 
night, and then there again, you are sitting all day, and you 
done traveled those 5 or 6 hours. They need to do something to 
take care of these, because what they do, the van goes down. It 
gets there about 12, and at 1, it leaves to come back to 
Beckley. So that means everybody has got to stay overnight.
    When the DAV did the transportation between Beckley and 
Richmond, they took them down that morning, they go to their 
doctor's appointment, and when everybody finished up, then they 
brought them back to Beckley. But right now, the cost of paying 
the overtime and the employees there at Beckley, we have had a 
lot of problems about the cost of the van program.
    Well, I mean, if you do things to increase it, and that is 
not counting the extra cost that Richmond has got of keeping 
these guys overnight, and the reason they don't furnish more 
meals than they do is because they are looking at costs, and 
they shouldn't be looking at costs. They should be looking at 
what is best for that veteran.
    But that is just like I said on getting from home to there. 
I mean, these volunteer drivers, and it is not just DAV people, 
it is VFW, American Legion, and a lot of them come in there and 
help with that program, and they should be commended because, 
like I say, some of them are up at 3 in the morning, get 
everybody there maybe by 7, and at 4 in the evening, you get 
finished up and you are until 7 or 8 at night getting back 
home.
    Chairman Rockefeller. Randy--Luther, I am not skipping over 
you again--Randy, you were talking about that you weren't 
necessarily in favor of putting your father in a community 
nursing home, that you would rather take care of him at home. 
Now, I know about taking care of somebody at home. My mother 
died from Alzheimer's. Actually, you don't die from 
Alzheimer's, you die from your lungs filling up, but it is a 
result of that. We had her at home because we could afford to 
do that and to get her the kind of care that Vera provides. But 
talk to me a little bit about why the community nursing home 
isn't the kind of solution that you want to see.
    Mr. Sims. Mr. Chairman, the community nursing home, they 
are out to make a profit like everybody else. You may have one 
girl trying to take care of 20 patients in an 8-hour shift or 
something, and they are just running around. They can hardly 
keep up with their work. They don't have the time to invest in 
that patient to take the proper care of him, so they end up 
over-medicating them, having a house doctor come in and over-
medicating them just to keep them quiet and down.
    Chairman Rockefeller. One hears about that, right, over-
medicating just for the sake of not having a problem?
    Mr. Sims. To keep them out of trouble, yes, sir. The first 
thing I did, we cut my father's medication in half, and then I 
would have to ask my wife on this. I believe the doctor down in 
Parkersburg cut it again, didn't he, and things have been 
manageable at the house with just redirection.
    Chairman Rockefeller. So you are just more in control of 
the situation?
    Mr. Sims. Right.
    Chairman Rockefeller. You feel better--as a son, you feel 
better psychologically, having your father right at home.
    Mr. Sims. Yes. You can't just put him in there and go see 
him and see him the way they take care of him. It is terrible. 
And it is not just one. I am not depicting on one personal care 
home or nursing home, because I checked around to several of 
them and they are pretty much all the same. They hire young 
girls that don't have much experience. They are learning.
    Chairman Rockefeller. Yes, and it is hard to blame them, 
because if you have got 20 patients to take care of, it is 
difficult. We had some VA nurses up in Washington describing 
what it was like after 16 or 17 hours straight on duty. You 
just sort of begin to lose that edge, and in some cases, that 
sense of compassion or concern. I mean, again, it is a matter 
of human nature.
    Mr. Sims. Exactly. You have got to do best for your 
parents, you know. You just try to do what you can do.
    Chairman Rockefeller. Isn't there also something in your 
father knowing Vera, that he sees her on a constant basis, the 
same person?
    Mr. Sims. We got Dad out of the home January 27, and that 
is when, I believe, we hired Vera, the same day. She has been 
with us since then.
    Chairman Rockefeller. Yes, and that continuity helps, 
doesn't it?
    Mr. Sims. Yes, the continuity really helps.
    Chairman Rockefeller. It calms your father down?
    Mr. Sims. Yes. It makes it easier for her to redirect him, 
and if you have different girls coming in all the time, it is 
more confusion for somebody with the memory loss.
    Chairman Rockefeller. Yes. Yes. I appreciate that.
    Luther, you faced a lot of frustration and, I would guess, 
a lot of anxiety in getting that referral for your heart 
surgery.
    Mr. England. Right.
    Chairman Rockefeller. There really wasn't anybody who was 
going to tell you what to do on that occasion, were they? I 
mean, you were determined. You had been through it before. You 
weren't going to mess around and you weren't going to wait, and 
when you had an opportunity not to wait, you took it. Now, how 
does this happen in a VA hospital? They might not have told you 
that you could wait--I don't know this, as I said--but they 
might not have told you that they could wait because they felt 
that you should wait, but because they couldn't really do 
anything about it right then, because the caseload had stacked 
up. What is your analysis of that?
    Mr. England. Well, that is what I got, is that they 
couldn't get me in Cleveland or down to Lexington. They 
couldn't get me into the operating room or to get it done. In 
other words, I am going to have to wait at least 8 weeks before 
they could get me there.
    Chairman Rockefeller. So you did not really need a lot of 
analysis. It was just the words ``8 weeks.'' That is about all 
you had to hear.
    Mr. England. In 1988, I had my operation, same time, same 
period about it. It was the first of March. Brenda Peter, she 
was the doctor for me at that time. She wanted to send me right 
up to Pittsburgh to get my triple bypass, but, you know, I was 
kind of scared, so I told her, ``Let me go home,'' and she let 
me go home. But she called me every day in the morning, in the 
evening. She would either have the nurse call me or Cathy, I 
think it was Kay, and told me, ``Get back to the hospital.''
    So I got back there on the 10th of March and she sent me 
straight up to the hospital. I mean, there wasn't no waiting 
about it. And I got up there in Pittsburgh and I thought, well, 
there will be waiting around. I was there 3 days. On the 17th 
of March, I think it was, or somewhere around there, they 
operated on me. The doctor comes in and says, ``We are going to 
operate on you,'' 1 day, and the next day, I am in the 
operating room. That is how fast it was.
    And here it is, the same time, the same period, and I am 
thinking, hey, are they going to let me just hang around here 
and die or something? It is on your mind. So I decided I would 
go ahead and go to St. Mary's.
    Chairman Rockefeller. Now, back in the 1980's when you had 
care, the VA did transfer you, didn't they?
    Mr. England. Right, but I went home and then they brought 
me back. I came back. The doctor kept insisting I come from my 
house back to the VA. When I got here, they were sitting there 
with my records and put me in a car and they didn't wait. They 
just drove me straight to Pittsburgh. And when I got to 
Pittsburgh, I thought it would be a few minutes. I was in the 
room in less than an hour.
    Chairman Rockefeller. You know, one of the things that this 
panel tells me again is that so much is the way you are 
treated. Waiting times get turned into ``how much do they 
care''-type situations. In other words, a great deal of it is, 
as I keep saying, just human nature. If you are waiting, and if 
you think you need something and you are not getting it, you 
just start worrying. And once you start worrying, there is not 
much that is going to get you off that track until something 
happens.
    I think this is going to be one of the great challenges of 
these next couple of years without adequate funding: how are we 
going to make up for this and how we are going to handle this? 
We had a hearing in Washington, as I said on VA nurses. They 
came in and they testified that they were working 15, 16, 17 
hours on mandatory overtime. It raised very interesting 
questions. They wanted us to take away the mandatory overtime, 
and I am somewhat sympathetic with that.
    But if you are the veteran that is being looked at and 
there is either going to be a nurse or there isn't, you have to 
have a nurse. And if there is a nursing shortage and if it is 
going to get worse, this is critical, isn't it? That nurse 
often, as much or more than the doctor--maybe usually more than 
the doctor--is the person who gives you a sense of, ``I am on 
my way to getting some help,'' or ``I am not on my way to 
getting some help.'' Isn't that right?
    Mr. England. That is right. Just like you wrote in the 
article about nursing, we are going to lose a lot of nursing. 
In fact, I think I had a friend, she just retired from the VA 
up there and she went to Florida. She ran two of these 
outpatient clinics and she was really good. Now that she is 
gone, I don't know who is taking her place, but we have got to 
have people to take her place.
    Chairman Rockefeller. What was interesting, and I will 
conclude on this with this panel, and I will thank you in a 
minute, was that VA nurses actually have a longer duration of 
service than do nurses in general. I think they said they 
averaged 27 years of service, which is really a long time under 
a tremendous amount of pressure, and a tremendous amount of 
emotional wear and tear on them.
    But we have got to face it. Nurses are like teachers. They 
can go off to a private hospital and make more. And you can 
say, well, they ought to stay with Randy or Jake or Luther or 
Randy's father, but when somebody gets offered $10,000, 
$15,000, $20,000 more per year and they have got children, that 
is a tough call for them to make, right? Obviously, a lot of 
them are making the call to stay in the VA system. But the 
question comes, when they retire, about what the next 
generation of nurses is going to do. That is what I think we 
have got to worry about, and that is where pay comes in, which 
is where money comes in.
    You can wish that a nurse were on a corridor, but unless 
you have got the money to pay that nurse to be on a corridor, 
that isn't going to happen. So people can say, well, the 
Federal Government, they just take money and throw it away. If 
you are paying a nurse, you are not throwing money away. You 
are giving a whole series of veterans a sense of continuity and 
trust and care that you can't do any other way.
    The Red Cross doesn't come in or the Salvation Army doesn't 
come in and say, ``We are going to supply you with nurses.'' 
Either the government is going to do it or nobody is going to 
do it, so the money has got to be there.
    Yes, sir?
    Mr. Stafford. I have got one more thing I would like to 
talk about and that is a lot of your rural VA hospitals like 
Beckley, and the others we have got in West Virginia, they are 
trying to replace doctors with physicians' assistants. I am not 
trying to put the physicians' assistants down. They have got a 
4-year bachelor's degree. They have got 2 years of regular 
academics and 2 years of practicing.
    If I had to go to a VA hospital, I would rather have a 4-
year-trained RN than I would. Now, I am not saying that in the 
future, they are not going to get better. But their anatomy 
studies is not near what a doctor is. You know, you are looking 
at 6 years of schooling to be a doctor. But they try to make 
doctors out of these physicians' assistants, and why? In order 
to save money. They would rather give them $50,000 or $60,000 a 
year as $120,000 a year to a doctor. That is the biggest 
problem we have got in a rural-type settings with the VAMC's.
    Chairman Rockefeller. Well, you have got that, and let me 
give a little bit of the other side of it, and that is that we 
have got to find out a way--I have said this many times before. 
I can remember going to the Yale Medical School back in the 
late 1980's, just because I wanted to. I had a friend up there 
who was the Chairman of Psychiatry and I said, I want to get 
everybody in medical care, everybody who is training to be 
something--doctor, nurse, physician's assistant, whatever--I 
want to get them in this room and talk with them. The 
administration is OK, but they have got to sit at the back. I 
don't want to see them. I want to talk to these others. And he 
did it.
    And what was amazing to me then--and, of course, that was 
then--was that the doctors who were trained to be doctors never 
interacted or crossed paths with the nurses who were trained to 
be nurses. Those two groups were obviously going to be working 
together for the rest of their lives. Everybody was kind of 
just on their own track.
    And I think one of the things that is going to be part of 
our health care future in this country is that there is going 
to be more of a cross-relationship in a constructive way 
between various parts of the health care community because 
there is going to have to be. I understand what you are saying 
about the physicians' assistants, and I remember there were 
some people, including myself at one point when I was Governor, 
who were not sure about them. We had three medical schools in 
West Virginia, one of them here, one at WVU, and then the 
osteopathic, and I didn't think we could afford three.
    Well, we can't afford three, and so I made a move to do 
something with the osteopathic school, which I now regard as 
one of the larger mistakes of my life. Those folks may not be 
everything everybody wants, but they are turning up in little 
towns and communities all over Southern West Virginia and the 
rest of West Virginia and I really like that. In other words, 
they go to these rural places and they stay there and they stay 
in our State. I am not saying that Marshall and WVU graduates 
don't. They do, too.
    But this is part, I think, of our health care future, where 
you are going to get these mixes of people working together to 
solve a problem because there just aren't enough staff. My 21-
year-old--well, he is 22 now, actually, as of a couple of days 
ago--he wanted to be a doctor at one point and he spent 2 weeks 
at Georgetown Hospital in Washington. That was really a 
program. They locked him in. He couldn't step outside 
Georgetown, and he got to see everything. I mean, he went into 
OR and to ER. He saw the whole thing for 2 weeks.
    What was amazing to me was that half the doctors informally 
counseled him not to go into medicine because, they said, the 
pressures are so tough. It kills your family life and 
everything else.
    When you have really good times, like we did in the past 8 
or 10 years or so, then people get siphoned off into other 
areas. Now we are maybe not going to have as good a time for a 
few years economically so people will stay where they are more, 
but it is a problem. It is just a problem.
    Those nurses who are working 16 hours a day can't keep 
doing that. You just can't do that and provide the service, and 
keep yourself on track. You can't do it.
    So there is a lot we have got to figure out about how to 
make health care work both in the VA system and outside of it, 
and I want to really thank each one of you because you are each 
facing different kinds of problems and situations and you have 
all been fighters for veterans and I really, really appreciate 
your taking the time to come here this morning. Thank you very, 
very much.
    If panel two could come forward, that would be David 
Pennington, John Dandridge, John Looney, and Becky Fox.
    You have heard about people who go by the book. I am going 
to go by the book, so John, I am not going to start with you 
because you are not first on my list here, so you have to wait 
until you turn up on my list. I am going to start with David 
Pennington, who is Director of the Huntington VA Medical 
Center. David, I am really glad that you are here.
    What I guess I will do is I will introduce each of you and 
then I will have a series of questions for you. Now, we didn't 
use those lights for the veterans. I have never much liked 
those lights because they are kind of rude because they sit 
right in your face. They probably ought to be sitting here 
instead. But, nevertheless, that is just to kind of make sure 
we get to ask questions and that kind of thing and that you get 
to say what you want to say after the testimony. Your testimony 
is always included.
    Incidentally, in your case, we will also have some followup 
questions because we did not get some of the testimony until 
late. So we will have more questions than the ones that I ask.
    The second witness is John Dandridge, Jr., who is Director 
of the MidSouth Health Care Network, which is otherwise called 
VISN 9. That means you direct medical centers in Huntington, 
Lexington, Louisville, Memphis, Mountain Home--where is that?
    Mr. Dandridge. That is in Johnson City, TN.
    Chairman Rockefeller. Johnson City, TN, Murfreesboro, and 
Nashville.
    Mr. Dandridge. Correct.
    Chairman Rockefeller. So you have got a bunch of hospitals.
    Mr. Dandridge. That, I do.
    Chairman Rockefeller. And this is your first job with the 
VA, isn't it?
    Mr. Dandridge. That is correct. I have been with the VA--it 
was 3 years in June.
    Chairman Rockefeller. That is good. And you had how many 
years of experience before that?
    Mr. Dandridge. Twenty years.
    Chairman Rockefeller. Twenty years of non-VA health care 
experience before that.
    Mr. Dandridge. Correct.
    Chairman Rockefeller. The next fellow here is named John 
Looney, who I have known for a couple of years. John is the 
Team Leader up at the Wheeling Vet Center. John, you also 
testified in 1993.
    Mr. Looney. Yes.
    Chairman Rockefeller. 1993--that seems like a long time 
ago, but you testified and I appreciate that, and you have been 
a friend a long time. You talked about the role of the Wheeling 
Vet Center then. It seems to me like we didn't open that up 
until after 1993, but we obviously did.
    Mr. Looney. It was 1990.
    Chairman Rockefeller. It just doesn't seem that long ago to 
me, but you are right. And you are going to talk a little bit 
about what you hear from veterans in terms of the Northern 
Panhandle and the vet center, also Pittsburgh, because you use 
Pittsburgh. That is your----
    Mr. Dandridge. Right. That is our hospital.
    Chairman Rockefeller. That is your hospital.
    Becky Fox, more formally known as Rebecca, is the Clinical 
Support Manager for the Mid-Atlantic Network, VISN 6, and that 
is made up of eight VA centers and that is Beckley, Ashville, 
Durham, Fayetteville, and Salisbury in North Carolina, and 
Hampton, Richmond, and Salem in Virginia.
    Ms. Fox. Correct.
    Chairman Rockefeller. So you move around some.
    Ms. Fox. We sure do.
    Chairman Rockefeller. One of the reasons, obviously, that 
we got the both of you was this question of people going back 
and forth and spinal cord injury and all the rest of it.
    But now let me be quiet, and John, why don't we start with 
you.

  STATEMENT OF JOHN LOONEY, TEAM LEADER, WHEELING VET CENTER, 
          DEPARTMENT OF VETERANS AFFAIRS, WHEELING, WV

    Mr. Dandridge. In the interest of time, I would like to 
submit my statement in writing----
    Chairman Rockefeller. All your submissions are accepted, 
for everybody.
    Mr. Dandridge [continuing]. And just highlight a couple 
things.
    One, I see the vet center as the front door to the VA. We 
get questions from veterans concerning their claims, as well as 
health care, and also the tele-psychiatry which we worked so 
hard to get. Your office was instrumental in getting that set 
up for us. It is very successful. We have 8 to 12 different 
veterans using that facility each month and we are real pleased 
with how well it works. We also had dermatology working on it. 
It has really helped the veterans become medication compliant 
and it has done very well. We really appreciate that.
    Chairman Rockefeller. And you do PTSD over there, too, 
don't you?
    Mr. Looney. Correct.
    Chairman Rockefeller. When we get to questions, I am going 
to ask you about that because that interests me, what kind of 
setting, how important is the setting for doing correct PTSD, 
No. 1, and second, how important is it to treat a number of 
veterans together for PTSD as opposed to working with one or 
two individual veterans. Do veterans leverage each other to let 
it come out some?
    [The prepared statement of Mr. Looney follows:]

 Prepared Statement of John Looney, Team Leader, Wheeling Vet Center, 
              Department of Veterans Affairs, Wheeling, WV

    Mr. Chairman and members of the Committee:
    I am pleased to appear today at this field hearing of the 
Senate Committee on Veterans' Affairs. Readjustment Counseling 
Services (RCS), or Vet Centers, are community-based operations 
of the Department of Veterans Affairs (VA). As part of the 
Veterans Health Administration's mission, the Vet Center 
program provides psychotherapy to combat traumatized veterans. 
Vet Centers also refer and coordinate veterans' care with VA 
medical centers (VAMCs). I like to refer to Vet Centers as VA's 
front door. Vet Center staff members both explain hospital 
procedures to the veteran and relay the veteran's concerns to 
the hospital staff. RCS sees this as part of our mission.
    I believe it inevitable that misunderstandings will happen 
between client and staff of any medical system. I feel a great 
sense of accomplishment when a combat veteran in his seventies 
or eighties comes back to me and says: ``That fellow you told 
me to call at the VA Hospital did a wonderful job for me''.
    The Wheeling Vet Center is only a three-person team, yet we 
have provided 1,311 veteran contact hours since January. 
Between the other therapist, Jay Teacoach, and myself, we see 
12 veterans per workday. We refer over 80 veterans annually to 
the VAMCs for inpatient services. The Wheeling Vet Center has 
received a grant from the Retired Non-Commission Officer 
Association to work with the Wheeling area Soup Kitchen to 
serve homeless veterans a special meal on the 4th of July and 
Veterans' Day. We have also received a gift of money from a 
local Martial Art Tournament allowing us to sponsor a 2-bus 
pilgrimage of veterans to the Korean, Vietnam, and Women's 
Memorials in Washington, DC. This one-day trip will be 
comprised of several generations sharing their remembrances of 
friends and sacrifices made to ensure freedom and democracy. VA 
headquarters is exploring documenting this pilgrimage of Upper 
Ohio Valley veterans.
    Mr. Chairman, I know that you are an advocate of 
coordinating care through tele-psychiatry for veterans living a 
2- to 3-hour drive from the VA Hospital. Currently 8 to 12 
different veterans are seen monthly at our Vet Center for 
medication checks with their psychiatrist via tele-health.
    Mr. Chairman, this concludes my statement. I will now be 
happy to respond to any questions you may have.

    Chairman Rockefeller. David, you have got actually 2 extra 
minutes from John. [Laughter.]

STATEMENT OF DAVID PENNINGTON, DIRECTOR, HUNTINGTON VA MEDICAL 
     CENTER, DEPARTMENT OF VETERANS AFFAIRS, HUNTINGTON, WV

    Mr. Pennington. In the interest of brevity, Senator, I will 
take only a few minutes. Since testimony has been submitted, I 
would just like to highlight a few things on behalf of 
Huntington and its system of clinics and say how pleased I am 
to be here today to have the opportunity to chat with you and 
others.
    There have been a number of important topics here already 
presented, issues that both John and I have worked diligently 
with, and I am sure Becky, as well, in her Network. But I would 
just like to highlight a few things in regards to Huntington.
    We have a very proud history of serving veterans with a 
little over 700 employees and 80 inpatient beds. We are 
following the trend of health care and have moved most 
certainly into the outpatient arena. We are a little different 
than the other three sites within the State in that we have a 
little more depth in regards to our sub-specialty care, and 
working with Joan C. Edwards School of Medicine at Marshall, 
have been very fortunate in our recruitment efforts. We have, 
in addition to our cardiology, the opportunity to do diagnostic 
caths as well as electro-physiology studies. We have some depth 
in orthopedics, pulmonology and gastroenterology, chronic pain 
management, acute dialysis, neurology, and some other areas. 
Most of this is reflective of our working relationship with 
Marshall, and, of course, as you well know, Marshall's basic 
science building sits on the campus with the VA.
    Chairman Rockefeller. And that is the reason, you think the 
basic reason, that you are able to get these specialties and 
sub-specialties?
    Mr. Pennington. I think that has a lot to do with it, as 
well as a tremendous working relationship with the Dean, 
Charlie McKown. Charlie and I meet on a weekly basis, and he 
and I are both very interested in regards to what we can do 
collectively in serving veterans.
    Last year, we provided care for almost 23,000 veterans. You 
made mention of the fact that the river is an artificial 
boundary, and we take care of veterans in Southwestern West 
Virginia, Eastern Kentucky, and Southern Ohio. For the last 5 
years, we have seen tremendous growth, from approximately 
17,675 veterans to a projection of 23,000 for this year. That 
certainly comes with its challenges, and as you well know, in 
Appalachia, there are many challenges in regards to providing 
healthcare services.
    We have been very fortunate in our support from the Network 
in regards to opening community-based clinics. Of course, we 
have one in Charleston which is VA staffed and operated, as 
well as Prestonsburg, KY. A contract clinic just opened last 
week in Whitesburg, KY. We are working diligently on one in 
Mingo County, in addition to our one in Logan, which is in 
operation.
    Indeed, we do depend on other medical facilities for our 
tertiary-level care, primarily Lexington and Cleveland VAMC's. 
Last year, we transferred 196 patients to other facilities for 
care. Some of those services that we do not provide locally at 
Huntington are inpatient psychiatric care, open heart surgery, 
and some orthopedic surgery--joint replacement. We work with 
VISN 6 in regards to Richmond VAMC for spinal cord injury and 
traumatic brain injury, but most of our referrals go to 
Lexington or Cleveland. Occasionally, we do use Nashville in 
regards to some very sophisticated care needs. Our objective is 
to get the veteran to the best place that they can be treated 
in a timely manner.
    We do a number of things in relationship----
    Chairman Rockefeller. How long does it take? I have never 
driven to either Cleveland or Nashville.
    Mr. Pennington. Nashville--I hate to tell you how fast I 
can drive it, Senator, but it is about a 6-hour trip from 
Huntington.
    Chairman Rockefeller. And what about Cleveland?
    Mr. Pennington. Cleveland is about a 4\1/2\- to 5-hour 
drive.
    Cleveland has provided our veterans excellent service and 
quality service, and we are a part of their major teaching 
program in cardiac care. Lexington, being the closer facility 
to us for tertiary-level care, is the facility we try most to 
get folks to when needed.
    Senator that will conclude my comments and I would be happy 
to answer any questions you may have.
    Chairman Rockefeller. OK. David, I appreciate that very 
much.
    [The prepared statement of Mr. Pennington follows:]

Prepared Statement of David Pennington, Director, Huntington VA Medical 
         Center, Department of Veterans Affairs, Huntington, WV

    Mr. Chairman:
    It is a pleasure to be here today to speak to the Senate 
Veterans Affairs Committee regarding issues of access to, and 
quality of VA health care in a rural setting. As Director for 
the Huntington VA Medical Center (VAMC), it is truly an honor 
to provide you and the Committee with a brief outline of the 
Huntington VA Medical Center and the services provided our 
patients.
    The medical center has a proud history of serving veterans. 
With a dedicated staff of just over 700 employees and an 
operating budget over $78 million, the Huntington VAMC operates 
80 medical and surgical beds, an inpatient and outpatient 
surgery program, and an expanding outpatient treatment program. 
Huntington VAMC has the good fortune of being able to recruit 
quality subspecialists, in part due to our close affiliation 
with the Joan C. Edwards School of Medicine at Marshall 
University. Medical subspecialty care provided at the medical 
center includes cardiology (including heart catheterization), 
electrophysiology studies, orthopedics, pulmonology, 
gastroenterology, oncology, ENT, nuclear medicine, neurology, 
acute dialysis, chronic pain management and many other 
subspecialties.
    Huntington VAMC has undergone not only a physical 
transformation but also a clinical one, which has improved the 
quality of care for more veterans. Working with the Joan C. 
Edwards School of Medicine, the VAMC has increased clinical 
services, expanded access, and improved the overall quality of 
care to veterans. We are striving to be a customer-focused 
organization with a goal of being the veterans' provider of 
choice.
    Medical students and residents train in an atmosphere of 
modern medicine. What was once a 250-bed facility with limited 
subspecialty care and outpatient services is now an 80-bed 
facility with a much larger outpatient program, designed to 
treat patients in a comfortable and friendly environment. 
During fiscal year 2000, there were over 181,000 outpatient 
visits for Huntington VAMC.
    Huntington VAMC provides quality medical care for almost 
23,000 patients in southwestern West Virginia, eastern 
Kentucky, and southern Ohio. The number of veterans choosing 
the Huntington VAMC as their primary healthcare provider has 
increased significantly over the last 5 years, from 17,675 in 
FY 1997 to a projected 23,000 in FY 2001. This increase can be 
attributed to our quality of care, customer service, expanded 
range of services, and greater access.
    Convenient access to healthcare for veterans in Appalachia 
has been a critical issue, and the VAMC and Network 9 have 
worked diligently to address this need. The DAV transportation 
program has filled a tremendous void for many veterans by 
building a network of volunteer drivers and a fleet of 
vehicles. The establishment of community-based outpatient 
clinics (CBOCs) is another initiative for improving access. In 
1998 Huntington VAMC opened a VA-staffed CBOC in Charleston. 
This clinic provides improved access for many veterans, 
including those in surrounding counties such as Boone and 
Jackson. This year, we opened a contract CBOC in Logan County, 
and before the end of the year we expect to open another 
contract CBOC in Mingo County. We also operate a VA-staffed 
clinic in Prestonsburg, KY and have just opened a contract 
clinic in Whitesburg, KY. During the 3-year evaluation and 
study period, each contract clinic will have a limited 
enrollment of 600 patients.
    VA health care relies on a system of support from other 
VAMCs. We utilize other medical centers within our Network for 
services unavailable at Huntington VAMC and have transferred 
196 patients to other VAMCs for care. Examples of cases that 
are transferred to other facilities include inpatient 
psychiatric care, open-heart surgery, placement of stints, and 
some orthopedic surgery. We utilize Richmond VAMC for specialty 
care in Spinal Cord Injury (SCI) and Traumatic Brain Injury 
JBI). This fiscal year, we also have transferred 58 patients to 
community hospitals and received transfers of 150 patients from 
community hospitals.
    Local inpatient and medical subspecialty care is purchased 
within the community when the patient's medical condition 
warrants emergent access to care we can not provide at the 
Huntington VAMC and it is not practical to transfer the patient 
to a tertiary VAMC that supports us. In FY 2000, 154 patients 
were admitted to community hospitals at a cost exceeding $1.1 
million. As we expanded primary care services to Charleston, WV 
and Prestonsburg, KY, we have seen an increase of community 
hospital care in those localities. With further expansion to 
Logan, Williamson, and other communities, we anticipate that 
reliance on local community hospitals will increase for 
veterans who have emergent needs.
    We have emphasized in our planning the provision of 
consistent standards as part of the expansion of community 
based primary care services. In order to ensure that providers 
at each CBOC have ready access to a patient's medical 
information, we have expanded our computerized patient record 
system to all clinic sites. Providers, whether at a VA staffed 
or a contract CBOC, have access to the entire medical document 
and can order subspecialty consults, lab tests, and radiology 
procedures as if they were at the VAMC. A physician, nurse, and 
quality management officer conduct periodic site reviews to 
ensure the standard of care is equal to the standards set at 
the medical center. Through the electronic medical record, 
provider-specific data are obtained to monitor adherence to 
quality performance measures. In addition to our own extensive 
quality management program, outside reviews by the West 
Virginia Medical Institute (which is under national contract 
with VA) are conducted monthly, reviewing current medical 
records against approximately 32 standard of care criteria.
    The VA Regional Office in Huntington, the Vet Centers, and 
each of the four West Virginia VAMCs have an excellent working 
relationship, combining planning efforts to address issues 
within the state. Though organizationally each of the VAMCs are 
aligned with a different Network, the senior management teams 
of each medical center meet periodically. They maintain a good 
working relationship and work closely to meet the needs of our 
patients. For example, Huntington utilizes the PTSID inpatient 
program at Clarksburg VAMC to minimize travel distance for 
patients and their families. Huntington VAMC has provided 
surgical support for patients from Beckley in the past, and the 
medical center, regional office, and Vet Center have jointly 
coordinated a number of veteran standdowns and participated in 
many veteran organization programs.
    Long-term care is clearly a significant issue for our 
patients. The West Virginia Veterans Home in Barboursville, 
which provides domiciliary care, and Huntington VAMC have 
worked together to foster an excellent relationship geared 
towards meeting the needs veterans. In fiscal year 2000 there 
were 106 admissions to the State Veterans Home in 
Barboursville.
    Similar to other VAMCs, we utilize community-based nursing 
home care services. In fiscal year 2000, 207 patients were 
discharged to or placed in a community nursing home from 
Huntington VAMC. This allows the veterans to stay closer to 
their homes, and closer to their families and friends. 
Contracting in the community has proven to be the best means of 
providing these services. As the veteran population increases 
in age, the demand for long-term care services, including 
geriatric psychiatric care, will increase.
    Mental health services for our patients are provided on an 
outpatient basis at the medical center. When inpatient mental 
health services are required, patient care is coordinated 
through our system of VA facilities. Lexington, Chillicothe, 
and Clarksburg VAMCs are 3 nearby facilities providing 
inpatient mental health care. To ensure continuity of care, the 
Huntington staff addresses follow-up care for patients as they 
are discharged from the inpatient facility.
    Huntington VAMC was the first facility in the nation to 
develop a program with our Vet Centers to conduct telemedicine 
for mental health counseling. Through this initiative, patients 
in Charleston and Logan, WV, have quicker and more convenient 
access to services. We have now expanded telemedicine 
capability and conduct subspecialty consults for neurosurgery 
with Lexington VAMC and will expand the system further in the 
very near future to include linkage with our Prestonsburg CBOC.
    The VAMC provides services for homeless veterans through 
the Health Care for Homeless Veterans (HCHV) Program. The 
program was reviewed by the Commission on Accreditation of 
Rehabilitation Facilities (CARF), a national accreditation 
program, in April 2000 and was given a three-year accreditation 
with no recommendations, which was an outstanding achievement 
by our program. Two outreach social workers, a clerk, and a 
Team Leader, staff the program.
    The homeless outreach social workers are physically located 
in the homeless shelters in both Huntington and Charleston and 
are actively involved in the Huntington Homeless Coalition and 
the Charleston Area Coalition. The outreach social workers 
provide homeless veterans access to VA and Mental Health 
services, eligibility services, and surplus clothing from the 
Department of Defense such as boots, fatigues, winter coats, 
sleeping bags, etc. The veterans also have access to 
Laurelwood, a transitional residential care facility located in 
Huntington, WV. The veterans can stay up to a maximum of 180 
days when placed at Laurelwood and receive extended VA 
substance abuse treatment and non-VA substance abuse related 
services. The goal of the Laurelwood program is to facilitate 
veteran's reintegration back into the community.
    Another program that will soon be available to homeless 
veterans is the Guthrie Project. Work is continuing through the 
Charleston Homeless Coalition to reconstruct and redevelop 18 
houses at the old Guthrie Air Force Base located near 
Charleston, WV. A total of $3,000,000 in grants has been 
awarded with six of the reconstructed houses to be developed to 
provide for homeless veterans' specific needs. One of those six 
houses is being completely rebuilt to meet the needs of SCI and 
other wheelchair bound veterans. Guthrie graduates will have 
been trained, will maintain competitive employment while living 
at Guthrie with supportive services, and will ultimately be 
able to move into their own homes. Supportive services will 
continue as needed to ensure success.
    Mr. Chairman, Huntington VAMC is proud to serve our 
veterans in a caring and compassionate manner. We are most 
appreciative of your interest in the needs of the nation's 
veterans and the support you have shown them as well as us. 
This concludes my statement, and I will be happy to answer any 
questions you or other Committee members may have.

    Chairman Rockefeller. John Dandridge, we are happy to have 
you. Incidentally, we thank both of you for coming here, unless 
you both live in Huntington, which I don't think you do, so 
thanks for coming.

STATEMENT OF JOHN DANDRIDGE, JR., DIRECTOR, VA MIDSOUTH HEALTH 
  CARE NETWORK, DEPARTMENT OF VETERANS' AFFAIRS, NASHVILLE, TN

    Mr. Dandridge. Thank you, Mr. Chairman, members of the 
committee, distinguished veterans, and guests. It is my 
pleasure to have this opportunity to be here today to talk 
about VISN 9's efforts to address issues of access and quality 
for veterans in rural settings.
    I would also like to express our appreciation to you and 
your dedication and commitment to veterans' health service 
issues and to the VA in your capacity as Senator for the State 
of West Virginia, as well as both member and now chair of the 
committee. We have been very fortunate over the years to have 
been the beneficiary of your interest and look forward to its 
continuation.
    Like yourself, I am personally committed, as well as 
professionally committed, to the service of veterans and their 
needs as a Network Director in the VA. The mission of our 
network is to provide comprehensive, appropriate health care to 
our veterans with the emphasis on improving quality, improving 
access, as well as the efficiency in which we provide care, and 
certainly with a mind to being as cost effective as we can.
    Our network is comprised of six core hospitals in the 
States of West Virginia, Tennessee, and Kentucky. Our service 
area covers approximately 150 square miles. We service 262 
counties. We have as part of our service configuration 26 
outpatient centers, three of which are core satellites, 
comprehensive centers, and 23 CBOC's.
    Our direction over the past couple of years has been to 
focus on ways in which we can improve access. Last year, we 
engaged an outside consultant. We utilized the benefit of that 
expertise to assist us in trying to determine ways in which we 
can improve access to our veterans with a focus on trying to 
reach at least 80 percent of our population such that they 
would have access to a primary care setting within 30 minutes.
    We were very inclusive in that we called upon our three 
State commissioners and other stakeholders to participate both 
in the planning as well as in the siting of centers as we began 
to roll them out over the last year-and-a-half. We believe that 
that has been very, very helpful in enabling us to make the 
best possible decisions in terms of where to locate our 
centers, and we have developed at least seven centers a year 
over the past several years.
    In terms of continuity and quality, we rely very heavily on 
CPRS as a tool which we use within the VA and within our 
network specifically. What CPRS enables us to do, both in our 
contract sites----
    Chairman Rockefeller. CPRS?
    Mr. Dandridge. Yes, that is the computerized patient record 
system.
    Chairman Rockefeller. OK. You have got to tell me that, 
then. [Laughter.]
    Mr. Dandridge. Because what it enables us to do is to look 
at and profile just how care is being conducted at each of our 
sites. Our contract sites will not be renewed unless they 
actually include CPRS as part of their capability, as well.
    Mental health is an area that we are very interested in. We 
have recently selected a physician by the name of Dr. Godleski, 
who is at Louisville. She is our mental health product line 
manager. She and her team are currently working on a plan that 
will enable us to define how we can best improve mental health 
services within our network. We are looking at such things as 
having psychiatrists rotate between the various sites, wherever 
feasible, looking at community placement, and assigning 
additional social workers where that makes sense. We are 
looking at opportunities to improve mental health.
    As you know and as you have indicated, all of us have had 
budget challenges. Network 9 was one of the first networks to 
go into headquarters for a supplemental in, I guess it was 
1999. We received a loan and we were able to pay back that loan 
from the reserves that we were able to carry forward that year. 
Last year, our reserve was approximately $11.8 million. We paid 
the loan, as well as used remaining funds to address outreach 
initiatives for our network.
    The next year coming is going to be very challenging for 
us. We----
    Chairman Rockefeller. How do you pay back a loan? I mean, 
you have got to pay back a loan----
    Mr. Dandridge. Well, it was a lot of hard work on the part 
of the facility directors, looking at ways to be as cost 
efficient as possible. And with the increased budget for the 
year 2000, it enabled us to use some of those funds to pay back 
the $5 million which we borrowed. We also converted some of our 
NRM dollars, which was money----
    Chairman Rockefeller. What is that?
    Mr. Dandridge. Non-reoccurring maintenance dollars, which 
are funds that we use to address infrastructure needs in our 
facilities. In fact, we will do that this year, as well, to the 
tune of about $1 million.
    That will conclude my comments. Certainly, you have my 
testimony for the record----
    Chairman Rockefeller. Right.
    Mr. Dandridge [continuing]. And I am available to be 
responsive to any questions that you might have as a part of 
these proceedings.
    Chairman Rockefeller. Yes. Deferring maintenance is tough.
    [The prepared statement of Mr. Dandridge follows:]
Prepared Statement of John Dandridge, Jr., Director, VA MidSouth Health 
      Care Network, Department of Veterans Affairs, Nashville, TN
    Mr. Chairman, members of the committee, distinguished veterans, and 
guests:
    Thank you for this opportunity to appear before you today to 
address VISN 9's efforts to provide access and quality of care for 
veterans in rural settings. I am committed to our veterans, personally 
and professionally. Our mission is to provide comprehensive, 
appropriate health care services to veterans consistent with mandated 
benefits, and to manage the provision of services in the optimal 
setting in order to provide high quality, accessible, cost-efficient 
care. Our guiding principles are to enhance quality, improve access and 
customer service as well as reduce costs.

                                OVERVIEW

    The MidSouth Healthcare Network provides healthcare services to 
over a million veterans in Tennessee, Kentucky, West Virginia, 
Mississippi, Arkansas, Virginia, Georgia, Indiana and Ohio. There are 
262 counties--over 150,000 square miles--within the MidSouth Healthcare 
Network service area. The Network is comprised of six core medical 
centers, three nursing home care facilities, one domiciliary, three 
long-standing satellite outpatient clinics and 23 community-based 
clinics. We have strategically located these clinics to improve 
veterans' access to care.
    Twenty percent of the veterans residing in the VISN 9 geographic 
area live in three urban areas around Louisville, Memphis and 
Nashville.
    Healthcare responsibility for West Virginia veterans is shared 
among four networks. VISN 9 is responsible for provision of services to 
10 of the 55 counties in West Virginia. The VISN 9's geographic service 
area accounts for approximately 59,000 of the states 200,000 veterans. 
Almost half of the West Virginia veterans in our service area reside in 
one county--Kanawha County.

                                 ACCESS

    Our Network realized early the need to address rural health issues 
among veterans residing in underserved areas as well as the need to 
develop strong working relationships with non-VA area healthcare 
providers. A core strategy of the Network is to provide 80% of eligible 
veterans access to primary care within 30 minutes of their homes. 
During FY 1999 we engaged an outside consultant to help us identify a 
strategic direction for VISN 9 as well as opportunities to improve 
access. The result of our planning was a conceptual methodology to aid 
in the identification and siting of future community based outpatients 
clinics (CBOCs). We included our affiliates and other stakeholder 
groups early in development of this methodology as well as our annual 
CBOC site selection process. We organized a workgroup comprised of the 
State Commissioners from three states, consumer representatives and 
VISN staff to provide input and recommendations for locating community 
clinics and for addressing access issues including access to long-term 
care and mental health services. This has provided us a sound and 
inclusive process for establishing future community based clinics. This 
collaborative is serving our veterans and the Network well.
    As a Network, we have developed six to seven clinics per year over 
the past three years. Currently, we have CBOCs located in seven states. 
There are eight clinics in Tennessee, seven in Kentucky, three in West 
Virginia, two each in Mississippi and Virginia, and one each in Indiana 
and Arkansas.
    We target locations based on access needs, geographic and 
topographic challenges and opportunities in order to decompress 
workloads at the VA main campuses, thus improving access to care and 
decreasing hospital wait times.
    Throughout VISN 9 there has been an increase in outpatient visits 
and decrease in admissions to inpatient care. We have seen our acute 
bed days of care drop from around 2,600 per 1000 unique veterans served 
in FY 1996 to a current level of around 800 per 1000 and our Average 
daily census drop from 2,605 to 1,470. Concurrently, due in large part 
to the accessibility of care in the outpatient/ambulatory setting, we 
have experienced an increase of more than 700,000 outpatient encounters 
between FY 1996 and FY 2000. This movement from inpatient based care to 
outpatient based care is not endemic to VISN 9, but throughout the 
system. We have to manage and coordinate care among our VISN 9 
facilities, other VA centers outside of our VISN and among resources 
available in the community.

                    CONTINUITY/COORDINATION OF CARE

    A key part of quality is continuity and coordination of care. 
Within VISN 9 we decided to ensure continuity of care by mandating that 
the VHA's Computerized Patient Records System (CPRS) be utilized in all 
our CBOCs, staffed as well as contract. This decision was made a number 
of years ago. Full implementation was pending the development of an 
internal Wide Area Network as well as implementation of CPRS standards 
within VISN 9. I am glad to say that both of these elements have been 
accomplished. We use CPRS to review and monitor clinical documentation 
and conduct chart reviews at each site. By mandating CPRS, the patient 
record and services provided are always available.
    The recently staffed and contract sites will all be functional 
users of CPRS. We have informed existing contract sites that contract 
renewal will require their implementation of CPRS. Each of our VA-
staffed sites has implemented CPRS. The importance of this is not only 
to ensure that there is continuity of care received by our veteran 
patients but also to have an electronic mechanism to review services 
provided and monitor the actual services, their documentation and 
eventually the quality of care. Implementation of the computerized 
patient record is only one technological advancement we have pursued. 
We are also actively piloting the use of telemedicine/tele-psychiatry 
at the Huntington VAMC. Mr. David Pennington will address that in more 
detail.

                             MENTAL HEALTH

    Recognizing the significant role psychiatric care plays in the 
health of our veterans, we established a Network-level Mental Health 
service line headed by a psychiatrist who is proving to be a strong 
advocate for mental health care. She has already spent a considerable 
amount of time reviewing mental health programs within our Network and 
has initiated a plan to address access to care for veterans needing 
psychiatric care. Mental health follow-up has shown overall improvement 
since the Network appointment of Dr. Linda Godleski. At our VA staffed 
clinic sites, mental health screening is routinely conducted. We then 
rely upon referrals from the clinics for treatment at our main 
facilities. We are considering options for further enhancement:
     Enlist a `traveling psychiatrist' to visit the CBOCs 
rotating appointment days
     Utilize a social worker to more aggressively focus on 
mental health issues
     Contract for services with area resources
     Widely use tele-psychiatry
    We are committed to the provision of appropriate Mental Health 
Services at each of our locations.

                             LONG TERM CARE

    In an effort to conform to the terms of the Millennium Act, VISN 9 
will re-establish additional long term care beds in order to achieve an 
Average Daily Census (ADC) level of 411 beds--an increase of 122 ADC 
over current levels. As a network, we must assess where the 122 beds 
will be located. VISN 9 is addressing the long-term care needs of our 
veterans and maintaining necessary facilities. Our current planning 
includes assessing what capacity we have within our existing Medical 
Centers particularly at Murfreesboro, Mountain Home, Lexington and 
Memphis. We also must remain cognizant of the culture and environment 
in which care is delivered and respond to the desires of our veterans 
and their family members.

                                 BUDGET

    I appreciate the strong support you have given VA in your past role 
as Ranking Member of the Senate Committee on Veterans' Affairs, as a 
West Virginia Senator, and now as Chairman of the Veterans' Affairs 
Committee. This has meant a great deal to us as leaders and managers in 
VA healthcare and to our veterans.
    We carried over $11.8 million from FY 2000 to our FY 2001 budget. 
The prior year, (FY 1999), in order to avoid a projected $16 million 
dollar shortfall, we converted equipment dollars as well as requested a 
$5 million dollar loan from VA Headquarters. With the $11.8 million 
carryover, we were able to repay the prior year's loan, and establish 5 
CBOCs within the Network. Additionally, we earmarked remaining funds to 
address waiting times for access to primary and specialty care.
    This year we have to address significant increases in costs 
resulting from greater utilization of pharmaceuticals, increase demand 
for services, continued growth in prosthetics utilization, higher 
utility cost and Millennium Act program costs.
    While we do expect to meet our budget this year we will not have 
any significant carry over of funds and currently have converted $1 
million in minor construction dollars.
    We are currently in the process of budget and workload projections 
for FY 2002 and while I am unable to comment on what our financial 
condition for next year will be, I will note that preliminary 
indications are that we will not be in a position to continue to expand 
community based clinic access. We will focus on expansion of community 
based mental health services; reinstitution of facility based long term 
care beds, decreasing waiting times and improving access to specialty 
services.
    Overall, we attempt to retain some flexibility with our resources. 
It is generally prudent to maintain a reasonable allotment of funds to 
support new initiatives and be able to address unanticipated needs. 
This is how we are able to sustain new initiatives and unanticipated 
requirements until funding is received. As a Network we are always 
challenged to address the many competing needs and interests. We have 
to make choices and set priorities within the scope of available 
resources, however, we do this with input from our stakeholders.

                               CONCLUSION

    I hope the information I have shared with you is helpful. Thank you 
for your continued support of our Nation's veterans. I, along with 
members of my staff, am available to address any questions you may have 
at this time.

    Chairman Rockefeller. Charlie, before you go out, I want to 
thank you for being here. It is important symbolically, and 
typical of you in all the years I have known you. You have got 
the head man at the Marshall Medical School sitting right here. 
It is what we need to see as much as possible for the future of 
our veterans' health care because you are right here listening, 
and I really do appreciate it, so I want to thank you for that.
    Dr. McKown. Thank you. Thank you for being here.
    Chairman Rockefeller. Becky, please.

    STATEMENT OF REBECCA FOX, CLINICAL SUPPORT MANAGER, MID-
 ATLANTIC HEALTH CARE NETWORK, DEPARTMENT OF VETERANS AFFAIRS, 
                           DURHAM, NC

    Ms. Fox. Thank you for the opportunity to be here this 
morning to talk about VISN 6's efforts to provide the right 
care and the right setting at the right time for the veterans 
of West Virginia, particularly those served by Beckley. As we 
have already talked about this morning, a lack of a tertiary 
care VA medical center in West Virginia results in inherent 
challenges to coordination of care.
    In fiscal year 2000, VISN 6 facilities, including Ashville, 
Durham, Richmond, and Salem, treated 1,793 West Virginia 
veterans. In fiscal year 2001 to date, Richmond and Salem alone 
have treated 2,103 West Virginia veterans. This includes 123 
inpatient transfers from Beckley plus 13 other transfers from 
VA medical centers in West Virginia or from the private sector 
facilities in West Virginia.
    Chairman Rockefeller. Is that separate veterans, or are the 
visits sometimes meaning the same veterans?
    Ms. Fox. They are separate veterans.
    Chairman Rockefeller. Separate veterans, OK.
    Ms. Fox. Separate veterans. Beckley provides primary and 
secondary diagnostic and therapeutic services, outpatient 
mental health services, an array of long-term care services 
from skilled rehab to respite care. Beckley does rely heavily 
on VISN 6's tertiary care medical centers to meet the complex 
care needs of veterans. They often refer medical specialties, 
such as cardiology, rheumatology, endocrinology, and surgery 
specialties, including orthopedics and ENT, to VISN 6 
facilities.
    These services are provided on either an outpatient or an 
inpatient basis. Urgent acute inpatient care is either provided 
at Beckley, or in the community if the patient's condition 
warrants, or at a VISN 6 tertiary care facility, providing the 
clinician has deemed that it is safe to transport the patient. 
The facility routinely contracts for some services in the 
community, including radiation therapy, mammography, contract 
dialysis, neurology, and dermatology.
    Salem is the primary referral site for mental health care. 
They accept Beckley's patients on a 24/7 basis because they 
understand the limited ability at Beckley to provide acute 
mental health care.
    VISN 6 actions that we have taken to try and increase the 
coordination of transfers include the implementation of a VISN-
wide transfer policy and identification of points of contact at 
all of our eight sites on a 24-hour, 7-day-a-week basis. The 
outcomes from this policy have been there has been improved 
communication regarding transfers across all sites, and also a 
reduced time to actually get a patient transferred. We also 
monitor monthly waiting times for specialty appointments and 
facility actions regarding how they are going to reduce waiting 
times.
    Specifically at Beckley----
    Chairman Rockefeller. What does that mean, what you just 
said? You monitor and then----
    Ms. Fox. We monitor the waiting times, how long it takes 
for patients to get appointments for specialty clinics. We look 
at that monthly, and for each month, if the specialty clinic 
waiting time is beyond 45 days, facilities turn in an action 
plan for how they are going to address the waiting times, 
whether it is more space, whether it is more providers, whether 
they are adding Saturday clinics, whether they are adding 
evening hours. All of those things are parts of what is 
included in that monitoring.
    Additionally, we have added, recently constructed and 
activated an audiology suite at Beckley. We have added an 
optometrist to the Beckley VA staff. Funding has been provided 
for additional staffing in primary care and specialty care at 
Beckley. There has recently been approval for a project to add 
an additional floor at Beckley and to renovate existing space 
for more efficient outpatient clinic utilization. This will 
include specialty care clinics.
    We basically have also added staff at the referral sites. 
We have added monitored beds at the Salem VA. We have used 
tele-medicine to improve access to care. Examples of that 
include mental health care between Salem and Beckley, SCI care, 
endocrinology, and pathology care between Beckley and Richmond.
    Despite the above actions, the nursing shortage at Salem 
and at Richmond, as well as difficulty recruiting specialists 
at Beckley, Salem, and Richmond impact the timely transfer and 
delivery of specialty care.
    We look at access to and coordination of care and monitor 
that through inpatient/outpatient satisfaction surveys, 
transfer logs, again, clinic waiting times. We also track the 
scheduling of consults. There is frequently chief-of-staff/
chief-of-staff interaction and followup if there are consults 
that are pending beyond 30 days between facilities to try and 
get those patients seen.
    In addition to that, we try to communicate programmatic 
changes with their VSO's and let them know of planned projects 
and how we are trying to address the access issue and share the 
waiting time information across the VISN with the facilities 
and with the VSO's at the MAC meetings. Veterans and their 
families, if they have questions or concerns about transfers, 
can speak with either their primary care provider, the patient 
advocate at the facility, or the patient transfer coordinator.
    In summary, we are really committed to providing timely 
access for West Virginia veterans through VISN 6 facilities. It 
is our intent and goal that delivery of the care and any 
required coordination be transparent to the veteran and 
seamless.
    Chairman Rockefeller. Thank you, Becky.
    [The prepared statement of Ms. Fox follows:]

   Prepared Statement of Rebecca Fox, Clinical Support Manager, Mid-
 Atlantic Health Care Network, Department of Veterans Affairs, Durham, 
                                   NC

    Mr. Chairman and Members of the Committee:
    I appreciate the opportunity to speak before you today regarding 
VISN 6 efforts to ensure the right care at the right time in the right 
setting to veterans in West Virginia, particularly those served by 
Beckley. The lack of a tertiary referral VA Medical Center (VAMC) in 
West Virginia results in inherent challenges to coordination of care.

                FISCAL YEAR 2000 AND 2001 TRANSFER DATA

    In FY 2000, VISN 6 facilities provided care to 1,793 WV veterans at 
VAMCs Richmond, Salem, Durham, and Asheville. In FY 2001 to date, 
Beckley has facilitated 123 inpatient transfers to other VISN 6 
facilities. VAMC Salem has provided care to a total of 1,050 WV 
veterans; this represents 6,143 clinic visits and 203 veterans treated 
as inpatients. In FY 2001 to date, Richmond has accepted 79 inpatient 
transfers from WV VAMCs. Patients are primarily referred to Richmond 
from VAMCs Huntington and Clarksburg for spinal cord injury care, 
traumatic brain injury care, and cardiac care. Of the WV veterans 
referred to Richmond, thirteen were from non-VISN 6 sites in WV.

                              BECKLEY VAMC

    The Beckley VAMC offers primary and secondary diagnostic and 
therapeutic health services, outpatient mental health services, 
diagnostic services and long-term care from skilled rehabilitative 
services to comfort care and respite services. The medical center 
relies heavily on the other VISN tertiary care medical centers, 
particularly Salem and Richmond to support the complex care needs of 
the Beckley VAMC patients. Beckley routinely refers patients to other 
VISN 6 facilities for acute consultation such as Cardiology, 
Gastroenterology, other medical sub-specialties, Orthopedics, ENT, 
other surgical specialties, and Spinal Cord Injury (SCI) care. These 
consultations occur in either the inpatient or outpatient setting 
depending on the veteran's unique needs. Veterans are routinely 
referred by Beckley to local, private sector facilities for chronic 
dialysis, cancer radiation therapy, mammography, dermatology, neurology 
and all home health services. Veterans requiring Alzheimers special 
care are referred to community long-term care facilities. In urgent 
situations, Beckley also refers veterans with acute care needs to the 
community.
    VAMC Salem serves as the primary referral site for inpatient Mental 
Health services; however, on occasion these veterans are referred 
either to the community in the event of pending legal actions or to 
another VAMC if Salem does not have beds. Mental Health patients have 
also been transferred to Martinsburg and Clarksburg if beds are not 
available at Salem. Salem accepts Mental Health patients on a ``24/7'' 
basis due to Beckley's limited ability to provide this acute care.

                VISN 6 ACTIONS TO IMPROVE ACCESS TO CARE

    VISN 6 has initiated numerous actions to address the issues 
encountered by Beckley in transferring patients for tertiary care to 
improve the timeliness of referrals and transfers and to ensure that 
the appropriate care is provided. VISN 6 actions include:
     Creation of an interdisciplinary VISN team to redesign and 
refine the transfer process to ensure consistent safe transfer of 
patients with an emphasis on improved communication among the 
facilities. The result of this process is a VISN-level transfer policy 
with a consistent approach to transfers and identification of points of 
contact for transfers on a 24 hour, seven-day basis. Indicators 
developed to monitor the effectiveness of the redesign and quarterly 
reviews of the monitor results show that there has been improvement in 
communication between facilities regarding transfers, a decrease in the 
average length of time for transfer, and an increase in patients 
meeting criteria for admission. The frequency of transfers that must 
either be referred to another VA or to the private sector is also 
monitored.
     Identification of a transfer coordinator at each site to 
coordinate both inpatient transfers and outpatient consultations. This 
individual coordinates record transfers and promotes communication 
between clinicians at both facilities.
     Monthly monitoring of waiting times and facility-initiated 
actions to reduce waiting times for specialty clinic appointments and 
primary care. There are mechanisms in place for urgent outpatient 
consultations when there are prolonged waiting times for next available 
appointments. Reduction of waiting times for specialty care is also the 
focus of a new VISN initiative to spread access and efficiency changes 
identified by the Institute for Health Care Improvement.
     Construction and activation of an Audiology suite at 
Beckley VAMC in FY 2000. This service had previously been provided in 
the community at less convenience for veterans.
     Funding of an optometrist on-site at Beckley VAMC.
     Funding of additional staff to support Primary and 
Specialty care services. VAMC Beckley received the largest percentage 
increase in their FY 2001 budget of any VISN 6 facility.
     Support for telemedicine initiatives to improve access to 
care for West Virginia veterans. Examples include use of telemedicine 
in the provision of Mental Health care between Salem and Beckley; SCI 
care through Richmond; pre-transplant care through Richmond; Pathology 
services through Richmond; and endocrinology consultation.
     Increased resources for specialty care delivery at 
referral sites.
     Funding for additional 8 monitored beds at Salem VAMC.
     Approval of a project for an additional floor and 
renovation to add space for specialty care clinics and allow more 
efficient outpatient clinic operations at Beckley.
     Purchase of a bus and funding a driver to transport 
veterans from Beckley to Richmond. This is in addition to the fleet of 
12 vans comprised of DAV and WV state supplied vehicles driven by 
volunteer drivers. All but two vans are outplaced in the various 
counties served by Beckley. The two on site are utilized for both local 
and long distance runs. This has been particularly helpful to veterans 
served by Beckley.
     Additional actions taken by Richmond VAMC to facilitate 
the referral process include: assignment of a lodger coordinator to 
facilitate lodging patients who are receiving outpatient care; an 
outpatient transfer coordinator who receives, forwards, and monitors 
referrals for specialty care from other VAMCs; assignment of a nurse 
administrator in the SCI Service to assist with coordination of SCI 
patient care; development of VISTA software to make special 
transportation needs of patients available to administrative and 
clinical staff; identification of a roster of contacts at other 
facilities involved in transfer of patients; and implementation of 
computer applications that enable physicians at each facility within 
the VISN to access patients' medical records at other VISN 6 VAMCs.
    Difficulties in recruiting nurses and physician specialists at 
Beckley, as well as at Salem and Richmond, are having an impact on 
transfers and referrals for specialty care.

                               MONITORING

    Access to care and coordination of care is monitored through:
     inpatient and outpatient satisfaction surveys and call-
backs;
     inpatient transfer logs;
     monthly clinic waiting times both at the VISN and facility 
level with action plans developed for clinics with excessive delays;
     tracking scheduling of consults and appointments at the 
referral facility;
     VISN inter-facility transfer monitors; and
     SCI patient satisfaction surveys.
    When problems have been identified, actions have been taken. 
Examples include:
     if the specialty is offered at Beckley, making attempts to 
address the access issue locally;
     follow-up on pending consults between the Chiefs of Staff 
of the involved facilities;
     plans in progress for an SCI inpatient room and initiation 
of group education activities at Beckley; and
     redesign of the transfer process at Beckley and the VISN 
level transfer process redesign.

                             COMMUNICATION

    The VISN communicates with veterans and VSOs at the VISN Management 
Assistance Council (MAC), and facilities have regular meetings with 
local VSOs. Problems identified by veterans as well as facility changes 
in services and planned projects are routinely discussed. For example, 
concerns regarding transportation of West Virginia veterans to referral 
sites discussed at the MAC prompted the purchase of a bus by the VISN 
to facilitate transfers. A
    medical center ``update'' is also provided at service officers' 
meetings. Beckley strives to keep SCI veterans informed of SCI services 
through the involvement of IPVA at meetings with the SCI team and at 
bimonthly service line advisory committee meetings. The PVA monthly 
newsletter also contains a section on SCI news at Beckley. This is yet 
another avenue for communicating with veterans and addressing their 
concerns.
    Veterans and their families have ready access to their primary care 
providers as well as facility-level patient advocates and the patient 
transfer coordinator to communicate their questions and concerns.
    VISN 6 is committed to providing timely access to care for West 
Virginia veterans through facilities and local providers and through 
our tertiary and acute care facilities in Virginia and North Carolina. 
It is our intent and goal that delivery of care and any required 
coordination is seamless and transparent to the veterans we serve.
    This concludes my remarks. I will be glad to respond to any 
questions that you have.

    Chairman Rockefeller. I find that when I am listening to a 
panelist and we can talk about things that aren't going right 
as well as things that are going right, it somehow becomes a 
better piece of testimony, and you did mention the nursing 
shortage.
    Ms. Fox. Absolutely.
    Chairman Rockefeller. But pretty much everything else you 
said, we are doing this right. I just say that because life 
doesn't usually work like that. I know there are things that 
you worry about, and I am going to come to you in a little bit 
on that.
    This is to all of you. I think the nursing shortage at 
Huntington is a little bit less severe than it is in some of 
our other West Virginia medical centers. Nevertheless, at our 
hearing in Washington, we had Sandy McMeans--a nurse from the 
VA Medical Center in Martinsburg--testify. She gave a terrific 
view on the whole question about too few nurses taking care of 
too many sick patients and what it does to you in general, how 
it kind of exhausts you, breaks you down, compounded by the 
whole issue of mandatory overtime.
    John, this may affect you less, but maybe I am wrong. Can 
you each give your view on how critical you think that 
situation is and is likely to become--in other words, the trend 
as well as the fact.
    Mr. Dandridge. Yes, Senator. I guess I will start. For me, 
I have been in health care long enough that I have seen this 
come full cycle, repeating itself from the late 1970's and 
early 1980's. Certainly, I would say that there, in my opinion, 
are a number of factors that, over time, may have contributed 
to this, and I think, in part, some of it has even been 
professionally driven in terms of some of the shifts in the 
general expectations that we move more toward a bachelor's 
degree and MSN and rely less on associate degree programs.
    I think, also, it is complicated by the fact that we are 
seeing a change in the makeup of our nurse profile and perhaps 
even the level of interest in nursing as a career, certainly 
acknowledging the fact that, as a society, we have been more 
embracing of the gender that has traditionally gone into 
nursing and they have found opportunities in more professional 
areas. I mean, they are astronauts, they are doctors, and many 
other professions that were traditionally not available to a 
large portion of our female population years ago. I think that 
as we look toward the next 2 years, we are going to see the 
problem become more exacerbated.
    From my vantage point, I think there are some things that 
perhaps we can do maybe better. Certainly one is looking at the 
functions that we currently have our nurses performing in our 
hospitals. We still have some facilities that are functioning 
with virtually all RN staffs and there are other duties that 
could more appropriately be carried out by nursing aides, 
nursing assistants, pharmacy techs, pharmacy attendants, and 
others.
    Chairman Rockefeller. So, how are we addressing that?
    Mr. Dandridge. Well, I think that we have to really look at 
the distribution of work and then make a clear----
    Chairman Rockefeller. Are you free to do what you want?
    Mr. Dandridge. Well, I would not say totally free----
    Chairman Rockefeller. I understand that, but in other 
words, if you come up with a particularly good way of doing a 
mix that provides a net better health care possibility or 
outcome, you could go ahead and do it?
    Mr. Dandridge. I believe that I am, sir. I certainly 
believe that I have a responsibility to work with nursing union 
leadership in that we are communicating, that we are discussing 
and working together on some of these things that could result 
in changes or a necessity to renegotiate contracts. I certainly 
believe that I have the flexibility, as long as I am 
coordinating and communicating with headquarters. That is not 
to say that everything that I might consider or propose would 
get done, but I think there is considerable flexibility.
    Chairman Rockefeller. Do you think that physicians are 
opening up more? Actually, I would be interested to hear also 
on women physicians, of whom there are a great many more these 
days, are they flexible in their openness to nurses taking on 
more responsibility or is that so-called old-time attitude 
still there?
    Mr. Dandridge. I think it has changed and changed for the 
better. I think there has been a lot of emphasis on the team as 
a collaborative approach to supporting and meeting the needs of 
our veterans. I think that is particularly strong in the VA, 
and as I stated, I think that is a positive. So, I mean, 
certainly there are always going to be individual exceptions, 
but I think, overall, there is a strong team spirit that works 
together through the difficult times as well as the good times.
    Chairman Rockefeller. Are there other comments from the 
panel on that shortage?
    Ms. Fox. The nursing shortage is particularly real for VISN 
6 at Richmond and Durham, which are two tertiary care 
facilities, and if you look geographically with Richmond and 
MCV and probably six hospitals within three miles of the 
facility, and the same thing with Durham, with Duke and UNC 
hospitals very close by, it is a really competitive 
environment.
    I think that the facilities have done very well with 
recruiting and retaining the nurses they have. They are really 
focusing on retention versus recruitment and they have been 
given a lot of leeway. Everyone in the network acknowledges the 
looming crisis and the fact that enrollments in the schools of 
nursing have gone down and we are doing what we can, such as 
the VA cadet programs, to try and spread that across the 
network so that we can stimulate an interest in careers in 
nursing.
    I do think that practice is now much more collaborative and 
I think there is definitely a partnership between physicians 
and nurses and a recognition that each has a unique 
contribution to the team.
    Chairman Rockefeller. OK. David, do you agree with that?
    Mr. Pennington. Senator, I would echo both of the comments. 
We have been fortunate here in the tri-State area because we 
have a number of nursing programs. We have more graduates than 
in many other locations.
    Chairman Rockefeller. Right.
    Mr. Pennington. We have hosted----
    Chairman Rockefeller. Marshall helps.
    Mr. Pennington. Marshall certainly helps, and we have 
hosted recruitment fairs to try to help our sister VA's. John 
has encouraged a great deal of flexibility within the sites 
that he manages in respect to multi-function health care techs, 
which we are using in some of our clinics, and to give as much 
flexibility as we can in respect to those duties.
    I think that part of what we are seeing as a challenge 
these days is that the aging curve in regards to the World War 
II veteran requires a much more intense level of need, and I 
think that is where a lot of the challenges come in respect to 
nursing for the VA.
    Chairman Rockefeller. Could I ask and just get a quick 
answer, do VA hospitals have transfer directors or 
coordinators, or how is that done?
    Mr. Pennington. I can say specifically, in regards to 
Huntington, I have a three-RN staff that report directly to the 
Chief of Staff that are involved with all transfers, both in 
and out of the facility, all transplant cases, and any special 
needs that a veteran may require at another VA or in the 
community, plus home health care.
    Chairman Rockefeller. So they will monitor when buses 
leave, when they get there, vans, et cetera?
    Mr. Pennington. Absolutely. I expect that office to report 
to the Chief of Staff and to myself on a daily basis any 
particular needs or crises and I expect them to get the 
veterans where they need to be in a timely manner.
    Chairman Rockefeller. Do they report back problems?
    Mr. Pennington. Absolutely. They are rather vocal RN's, and 
I encourage them to be that way.
    Chairman Rockefeller. Yes. Yes.
    Ms. Fox. That is the case in VISN 6, as well. We have 
designated transfer coordinators. They are a mixture of RNs and 
administrative staff. We have people who can accept transfers 
24/7 and they do a good job of it. Any problems that come up in 
terms of transfers from contract hospitals or from other 
facilities are discussed in the morning meetings, so we do have 
that function in place.
    Chairman Rockefeller. OK. You mentioned the computerized 
patient records. You gave it a different----
    Mr. Dandridge. CPRS is the acronym, yes.
    Chairman Rockefeller. CPRS.
    Mr. Dandridge. We have lots of those.
    Chairman Rockefeller. Now, that is obviously crucial, and 
one of the shocking things in this country is how many of our 
government agencies--I mean, the Senate didn't even have an 
Internet service until 4 or 5 years ago, so getting everything 
computerized is easy to say, but it is hard to do. Of course, 
it is not the only key to care coordination, particularly for 
veterans who require very special kinds of care, including some 
that might only be available in the private sector.
    How do you work that? This is to anybody who wants to 
answer it, but obviously----
    Mr. Dandridge. Well, I think perhaps there is a two-part 
answer to the question, and one is how are we doing it and the 
other is what might still be some of the possibilities or 
opportunities.
    As already responded to, we do have care coordinators in 
our network. It was one of the earlier challenges that I 
undertook as a new network director, taking the lead from 
Huntington here in West Virginia that had been very aggressive 
and proactive in putting such a plan in place and trying to 
make certain that we did not have a Tower of Babel in respect 
to how those functions were organized, or not organized, as the 
case may be, so we can minimize breakdowns in communication.
    I think we have such a system in place. I think it works 
generally well. Certainly from the testimony that has been 
given by the veterans that were in the earlier panel, it is 
obvious that there are things that we need to continue to be 
doing to improve service.
    It troubles me to hear some of the logistical kinds of 
circumstances in which the veterans describe here today, and I 
think there are some things that we need to do more 
aggressively to look at better managing the logistics of 
getting the veterans to and from and situations where----
    Chairman Rockefeller. It sounds like timing is one of the 
answers.
    Mr. Dandridge. Well, I mean, for example, if one says that 
the bus leaves at--basically two departures, a specific time 
going and a specific time coming back, the answer would be, is 
that something that could be changed, and why not change it 
such that it gives them more extended time?
    The comment regarding overnight stay, I am a product of the 
Medical College of Virginia. The Medical College of Virginia is 
a major tertiary hospital. Patients come from all over the 
world for heart transplants, et cetera. They had a facility 
akin to a hospital. It was called Nelson Clinic.
    They would not admit the patient to a hospital bed for a 
work-up, which they might have to undergo maybe once a year or 
once every other year. They had a facility on or near the 
campus. Patients could come in for his or her testing and go 
back for the night have their meals and then go back to the 
hospital the next day for the continuation of tests. And if 
they required 2 days or 3 days of testing, they were 
accommodated accordingly.
    This is not unheard of, or uncommon in health care, people 
trying to make a buck do it all the time. If you have someone 
that needs to come in, you go get them or you see that they get 
there and you treat them like kings and queens because you want 
them to come back. I don't know what is different or why it has 
to be different.
    Chairman Rockefeller. John, I want to get to that PTSD 
question. It is better understood, but there is still so much 
ahead of us, isn't there, on PTSD? I am interested in how you 
do that in a community outreach center, and again, the question 
of a group approach as opposed to a more individual approach or 
do you need both?
    Mr. Looney. Well, you do need both. You spoke of safety. It 
is where the person feels most safe, in individual or in group. 
Certainly, it is hard for an individual to go from individual 
treatment into group. That is just expected. It is normal. But 
once they get into group, they find that it is easier for them 
to relate their experiences and get that acceptance from the 
other folks in the group and also the idea that one incident 
will encourage another incident to come up from another 
person's experience.
    The whole idea of treating trauma is talking about the 
trauma. It is a cleansing process, as you talk about it. I am 
sure the folks you will be seeing this afternoon will want to 
talk about their trauma, and that is the most healthy thing to 
do, so talk about it, talk about their losses. If you don't 
talk about it, then it becomes very powerful in a negative way. 
So talking about it in a safe place is what we want to 
encourage.
    Chairman Rockefeller. As you don't talk about it, the more 
that you don't talk about it, the deeper it sinks in and the 
harder it is to talk about, is that right?
    Mr. Looney. Correct. It is sort of like it develops a scar 
tissue and the scar tissue gets deeper and deeper and it causes 
more life problems as this scar tissue keeps building up.
    Chairman Rockefeller. There are a variety of alternative 
approaches to PTSD, not all of which involve just group 
counseling. Is word about them spreading out there in the 
community? In other words, everybody thought that PTSD was 
Vietnam until they discovered that it went back even to World 
War I. And then even further, we discovered that it spreads to 
many people throughout life, non-veterans just living life. I 
mean, PTSD is everywhere.
    This country has managed to avoid dealing with mental 
health problems for so long, simply saying, well, it is a 
behavioral problem or something of that sort. It just boggled 
my mind. And the only program in the country that deals with it 
is Medicaid, to some extent, and VA. It is not an easy thing 
for Americans to deal with, is it?
    Mr. Looney. No, it hasn't been. One of the things that has 
happened is that, with the Vietnam veterans, when they came 
back, they tend to cling among themselves and they started 
addressing the issue themselves and then advocated, and then 
some of the spin-offs that you see now are groups for domestic 
violence trauma, women and men sexually assaulted. Those are 
all spin-offs, because they are traumatized and the way you 
treat it is the general way you treat post-traumatic stress.
    You also have another spin-off that I believe is real 
important is the working with critical incident debriefings 
with the first responders, your EMT's, police officers. When 
they come up on a particularly bad scene, in order to keep them 
in the service, you want to debrief them quickly. And if you 
don't debrief them quickly, then it becomes an ongoing problem 
to where you will eventually lose them from the service. What 
you want to do is to encourage the experienced people to stay 
in the service.
    You mentioned, or you were talking about access to care. I 
have some access to care facts that relate to the CBOC, if you 
would wish. We have a CBOC--that is a community-based 
outpatient clinic----
    Chairman Rockefeller. I know you change one letter and then 
you become a telephone company. [Laughter.]
    Mr. Looney. We have worked real hard with these folks. They 
are very nice folks. They are very dedicated to the veterans. 
But some of the issues that the veterans come to me with is 
that new patients have to wait three to 4 weeks for an 
appointment.
    Chairman Rockefeller. So if you haven't established a 
problem, in other words----
    Mr. Looney. If I haven't established a problem and I need 
to be treated by VA, then I have got to wait 3 to 4 weeks or go 
up to the VA hospital and go in as a walk-in. The CBOC's aren't 
set up to do walk-ins. We are working with a contract CBOC and 
not a VA-staffed CBOC.
    Urgent care issues, even if I am in the system and I have 
the flu or some illness of that sort and I call the CBOC, I 
have to make sure I talk to the nurse. I just cannot talk to 
the receptionist. I have to talk to the nurse to get scheduled 
for an appointment. There are appointments available at the end 
of the day. They would squeeze me in.
    If you are in the CBOC system and you miss an appointment 
to get your prescriptions renewed, then there is no followup 
for that. I had one veteran that missed his appointments. His 
prescription stopped. We tried to get him back on, turned back 
on. He called and talked to us. We called the hospital 
pharmacy, worked very well to get them out to him. But it 
failed him in that he went into the hospital with a stroke the 
same day that his blood pressure medication came to his house. 
So I would really like to see some way of addressing that issue 
to do some followup with the folks.
    In this particular CBOC, they are scheduling followup 
appointments currently, this week, into February. So that 
raises a question----
    Chairman Rockefeller. Into February next?
    Mr. Looney. Yes.
    Chairman Rockefeller. Really?
    Mr. Looney. And that, to me, raises the question, 
particularly with contracts, is to set up some sort of a 
patient-to-practitioner ratio that is standardized, where we in 
VA can say, OK, we are sure that there are enough people on 
this station to address these issues and they don't have to 
wait until February, or we can make sure that we can followup 
with the fellows that missed their appointment.
    Chairman Rockefeller. Well, I appreciate that.
    Are there any comments that any of you would like to make 
about any other subject or any subject--no, any subject dealing 
with veterans?
    Mr. Dandridge. Senator, one of the things that is included 
in my testimony, and certainly, I think, is consistent with an 
area that you are interested in, is the availability of long-
term care services for our veterans. VISN 9, I am sad to say, 
is one of the networks that did not maintain capacity in 
respect to the 1998 requirements to maintain ADC beds and 
staff. We are currently assessing our current situation with 
the intent of having a plan into headquarters the end of July 
that will address how we intend to reestablish approximately 
122 ADC for our veterans in VISN 9 and we will be looking 
across the network in respect to where we have patient units 
that may not currently be in use, looking at veteran population 
and demographics and other things to make a determination as to 
how best to accomplish this.
    Chairman Rockefeller. Yes. It obviously is not a complete 
program, but it is a beginning. It has just got to happen. It 
has got to happen. You can afford long-term care in this 
country if you are very rich and you can afford it if you are 
practically dead broke. But if you are anywhere in between, you 
can't touch it unless you just spend yourself out.
    I really appreciate this. It is going to be tough for all 
of us in these coming years, I think, because of this budget 
situation. Budgets are considered by people sort of to be 
inanimate objects, but they are highly animate and they have 
everything to do with what kind of care people get or don't or 
whether you can keep people or not. So I really worry so much 
about the budget and the VA, so much about it. If you get $23 
billion 1 year and $24 billion the second year, you can say, 
gee, I got a $1 billion increase. No, you didn't. You got a 
$700 million cut just to keep up with the cost of things.
    I mean, I have already expressed my views on the human 
effect of the tax cut on veterans and others. We are going to 
see it across our Nation. We are going to see it in defense. We 
are going to see it in welfare reform. We are going to see it 
in education, people who stay in teaching and nursing, people 
who don't. But that is not the discussion of the day.
    I want to really thank all of you for taking the time to 
come. You are professionals and you do good work.
    You have your hand up in the back?
    Mr. Mitchell. Can I come forward a little bit?
    Chairman Rockefeller. Sure.
    Mr. Mitchell. I want to say something.
    Chairman Rockefeller. OK. I also want to thank Bill Brew, 
who is our staff director, and I want to thank you, too, 
Jennifer, very much, and Charlotte Moreland, wherever she is, 
and Julie Fischer.
    Yes?
    Mr. Mitchell. I am James A. Mitchell. I am President of the 
Houdaville Retirees Association and I speak for World War II 
veterans because almost all of the men--I, myself, wanted to do 
that, but I am the President of the organization, which are 
almost all veterans of World War II. I gave Charlotte a copy of 
a letter to you that you can read about the payments that the 
men have to make at the VA hospital to the veterans of World 
War II. There is a lot of them can't afford to even pay that, 
so if you would check that over. I just wanted to say hello and 
tell you that I gave Charlotte a letter out there for you.
    Chairman Rockefeller. I appreciate that.
    Mr. Mitchell. Thank you for being here.
    Chairman Rockefeller. Thank you, sir.
    You know, one thing in closing, and I have got to go 
because I want to go look at more of this flood situation 
because I think that everybody concentrates on the physical 
devastation and sometimes what I worry about is the human 
devastation that lasts for years and years and years.
    And that is another thing. I can remember the 1977 flood, 
which pretty much wiped out Matewan and parts of Williamson. We 
went ahead and built a huge wall, flood wall. Well, there may 
be no money to do those kinds of things. We have got 15 natural 
disaster crises going on in the country at this moment, of 
which we are one. Actually, I think there are 16 and we are one 
of them. What happens to all of this? I mean, this is where 
this question of money becomes important.
    But I just wanted to say, John, I watched the night before 
last ``Born on the Fourth of July'' again. It is sort of like 
``October Sky.'' You just keep watching it. Wherever you see 
it, wherever you come into it, you just watch it. I happened to 
catch this one from the very beginning. It was the first time I 
have caught it from the very beginning other than when I saw it 
in the theater. But it is an extraordinary, powerful thing of 
the effect of war and the physical, psychological, emotional 
destruction of people and the incredible courage which they, in 
most cases, summon up to handle that, and in some cases, just 
can't.
    But I was kind of pleased that I ran into that before I 
came down for this hearing, because it reminds you of the 
unbelievable human stakes that are in play here and how deep 
hurt can be and how long it can last and how cruel people can 
be, too, sometimes.
    So with that, I thank everybody very much. I am going to go 
put on something a little bit more suitable to dealing with 
flood victims, and I really do thank you and I thank you 
particularly for coming.
    [Applause.]
    [Whereupon, at 12:06 p.m., the committee was adjourned.]

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