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[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]

      CHALLENGES IN RURAL AMERICA: VA ACCESS AND MENTAL HEALTHCARE

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

                                HEARING

                               before the

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       WEDNESDAY, AUGUST 6, 2014

                               __________

                           Serial No. 113-83

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

         Available via the World Wide Web: http://www.fdsys.gov

                             ______

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                       Wednesday, August 6, 2014

                                                                   Page

Challenges in Rural America: VA Access and Mental Healthcare.....     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman.......................................     1
    Prepared Statement...........................................    32

Hon. Steve Pearce................................................     4

                               WITNESSES

John Taylor, Veteran.............................................     5
    Prepared Statement...........................................    33

Richard Moncrief, Veteran........................................     8
    Prepared Statement...........................................    35

Dawn Tschabrun, Chief Executive Officer, Lovelace Hospital.......    10

Lisa Freeman, Interim Network Director, Veterans Integrated 
  Service Network (VISN) 18, Veterans Health Administration, U.S. 
  Department of Veterans' Affairs................................    19
    Prepared Statement...........................................    35

    Accompanied by:

        James Robbins M.D., Interim Medical Center Director New 
            Mexico VA Healthcare System, Veterans Integrated 
            Service Network (VISN) 18, Veterans Health 
            Administration, U.S. Department of Veterans Affairs;
    And
        Lori Highberger M.D., Deputy Chief Medical Officer and 
            Mental Health Lead, Veterans Integrated Service 
            Network (VISN) 18, Veterans Health Administration, 
            U.S. Department of Veterans Affairs

 
      CHALLENGES IN RURAL AMERICA: VA ACCESS AND MENTAL HEALTHCARE

                              ----------                              

                       Wednesday, August 6, 2014

            Committee on Veterans' Affairs,
                     U.S. House of Representatives,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 11:15 a.m., at 
the Roswell Convention and Civic Center, 912 North Main Street, 
Roswell, New Mexico, Hon. Jeff Miller [chairman of the 
committee] presiding.
    Present:  Representatives Miller and Lamborn.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. The meeting will come to order. Before I 
begin, there's something we need to take care of today. And I 
would ask unanimous consent for our colleague, Steve Pearce, to 
be allowed to sit at the dais today and participate in today's 
proceedings.
    Without objection, so ordered.
    Good morning, everybody. I'm pleased to be back. It was one 
year ago that I had my first opportunity to come to Roswell 
after driving down from Albuquerque with Congressman Steve 
Pearce. So it's a pleasure to be here.
    I'm Jeff Miller, Chairman of the House Committee on 
Veterans' Affairs. I flew in this morning from Pensacola, 
Florida, where we have more water than you do, Steve.
    I'm joined by senior committee member from Colorado, Doug 
Lamborn. I'm pleased to have him here today. And, of course, 
our friend and colleague, Steve Pearce.
    The Chairman. I know I speak for Representative Lamborn 
because we both feel the same way. Our friend, Steve Pearce, is 
a dedicated member of Congress. We actually sit together on the 
floor of the House almost every time we have a series of votes.
    And I know that he is keenly interested in the veteran 
community and the things that are going on not only here, but 
all over the United States of America. So it's a pleasure, 
Steve, to have you joining us today.
    Mr. Pearce. Thank you.
    The Chairman. And I'm grateful to him for inviting us to 
come back and have a chance to listen to some individuals who 
are going to testify today.
    Before we begin, I'd like to just ask, you're a veteran, 
please stand. If you are not able to stand, raise your hand. We 
want to recognize you and say thank you for your service to our 
nation.
    The Chairman. Again thank you so much for your service and 
continuing to help, as do many of you here in Roswell, your 
fellow veterans.
    Ensuring that you and your neighbors and colleagues in New 
Mexico and around the country have timely access to quality 
healthcare through the Department of Veterans Affairs is why 
we're here today. I'm grateful to each of you for joining us 
because it is a very timely topic that we discuss right now.
    As you know our committee has been involved for quite 
sometime, but in a much more diligent fashion, holdings two 
full committee hearings a week through the summer months 
because of the crisis that exists right now within the 
Department of Veterans' Affairs.
    We knew that there were wait times, we knew that there were 
issues. What we did not know until recently, and I say 
recently, late last year, when we actually started 
investigating, was the corruption, the lying, the cheating, and 
the stealing that was going on by some employees within the 
Department of Veterans Affairs as it relates to wait times.
    Because of that, we fashioned a piece of legislation that 
the President will sign tomorrow that I think will go a long 
way to starting the process of fixing VA.
    One thing is you cannot legislate morality, you cannot 
legislate common sense, you cannot legislate people doing the 
right thing. But what we did do was give the Secretary the 
ability to fire individuals who aren't doing their job or who 
find that they forced other people to manipulate the numbers so 
that they can receive bonuses.
    We still think there may be some potential criminal claims 
that may be lodged against some of these supervisors because to 
change numbers at the federal level to get a promotion or a 
bonus of some type is, in fact, a violation of the law. We have 
asked the Department of Justice and the FBI to get involved, 
and they have.
    In the four months since this broke, April 9th was when we 
actually broke the story, CNN has covered it quite ostensibly. 
They didn't even really start covering it until the end of 
April. But we have held as I said about two meetings a week. 
And we have continued our oversight.
    Now, for people all across the country, the media will have 
you believing that we are on a five-week vacation. That's not 
quite what the August recess is supposed to be.
    The August recess is supposed to be an opportunity not only 
for us to go back and reconnect with our constituents, but also 
to travel all across the country as I do as the chairman, as 
Doug Lamborn does, and as Steve will do with me tomorrow when 
we go to El Paso to look at the issues over there as well.
    We are continuing to keep shining a light on VA to make 
sure that they, in fact, are changing the way they do business. 
Unfortunately it's not going to change overnight. You know 
that. It didn't happen overnight, it's not going to change 
overnight.
    But I think the new Secretary has the right attitude. My 
caution to him is don't let the bureaucracy eat you up, because 
that's what happened to Secretary Shinseki. The unfortunate 
thing about the Secretary's departure is that the very people 
that caused the problems are still employed by the Department 
of Veterans Affairs. But the Secretary was lied to and he's 
gone.
    So, you know, the VA's nationwide access audit found 
troubling scheduling practices were in place in Albuquerque at 
the medical center there. And we're going to hear from some of 
our witnesses this morning about issues that they have had to 
confront.
    And, look, it may not all be bad. I'm not here just to hear 
the bad stuff. I want to hear some of the good things, because 
out of the 330,000 VA employees that are out there today, let 
me assure you that there are a lot of good ones that are going 
to work every day at the VA because they want to serve veterans 
and because they want to do the right thing.
    But we've got to fix the problem and get rid of the people 
who are the dead wood inside that system so that you are served 
better and you get the care that you've earned.
    I look forward to our discussion this morning. I thank you 
all for being here. I will now turn to my good friend Mr. 
Lamborn for his opening statement.
    Mr. Lamborn. Very briefly, thank you, Mr. Chairman, for 
having this hearing. It's great to be in Roswell, it's great to 
be among veterans.
    My father was a World War II veteran. He passed away a 
couple of years ago. He fought in 11 campaigns in North Africa, 
Sicily, and Italy. And it changed his life. I mean it made him 
a different person.
    It was something he talked about. He was someone who talked 
about his experiences. And almost every day for the rest of his 
life. And so it was just great to sit at his feet and learn 
about the greatest generation.
    And then my oldest son has served in the Army. And one week 
after high school he was in for three years, serving in support 
of the 82nd Airborne at Fort Bragg. So I'm honored to be part 
of the VA committee.
    And let me just say, Chairman Miller, you may already know 
this. But he is so dedicated to veterans, his care and his 
concern and stewardship of the taxpayer dollars, and the 
clinics and hospitals. He's doing such a great job. But you 
know that. And that's why he's here in Roswell, that's why 
we're having this hearing.
    So it's an honor to serve with him. And it's an honor to 
serve with Steve Pearce. As a veteran himself, he knows these 
issues. But beyond that Steve Pearce is legendary in Congress 
for his dedication to the person, a person off the street 
living in his Congressional district.
    They've written about him in The Wall Street Journal. And I 
don't want to embarrass you, Steve. But he sets a great example 
that many of us appreciate and learn from and have benefited 
from. So it's just great to be here, Mr. Chairman. Thanks for 
having this hearing.
    The Chairman. Thanks very much, Doug. I'm going to 
recognize Congressman Pearce in just a minute and introduce our 
witnesses.
    But first I want to thank them for their presence here 
today and for participating in this hearing and doing all the 
things that you do for the veterans in this local community and 
around this region.
    I would also like to gently remind you, if possible, we do 
have a five-minute opening statement rule. What will happen is 
these little lights will pop up. It will go green. And when you 
get to one minute, it will go to yellow. And then when you get 
to red, that means your time is expired.
    Now, if you go longer than a minute after red, I can't 
promise what will happen. We want to hear your entire 
statement. So they are here certainly to kind of help keep 
people on time with their statements. But we appreciate you 
being here to talk to us.
    At this time let me ask Steve Pearce if he would introduce 
our panelists. Thanks.
    Mr. Pearce. Thank you, Mr. Chairman. Thank you for being 
here. Also thanks, Mr. Lamborn.

             OPENING STATEMENT OF HON. STEVE PEARCE

    Mr. Lamborn last night was going to get on the plane to 
come here. They had thunderstorms that were going to keep him 
from flying. So he and his wife got in the car and drove here. 
So I think we need to recognize the dedication that people have 
when they make commitments in Congress. It's a very serious 
thing.
    The reason we're here today has been amplified in the last 
two days since I've been home. Since being here back in New 
Mexico, I ran across one veteran that was driven from here to 
Albuquerque to receive an injection in the index finger.
    That's the reason we have set this pilot project up here 
today, to stop using those kinds of long trips for things that 
could be done locally.
    Another veteran that we saw just yesterday in Jal had 
hearing loss from cannon fire back in Korea. His hearing aids 
broke. They sent him to the VA in Big Springs.
    Big Springs VA paid him miles to go there. Big Springs sent 
him to Albuquerque the next week. They paid him mileage there. 
They kept him there three days. After assessing him, then they 
returned him back to Big Springs and said he ought to have gone 
there to start with.
    And then he finally got the hearing aids and they didn't 
work so he's still using his old ones. And it's that sort of 
ineffectiveness and inefficiencies that cause veterans 
tremendous problems.
    Then this morning I was on a call-in radio program. The 
young lady carried her 88-year-old father yesterday to the 
Artesia clinic. She had a card in her hand for the appointment 
time. It was made for 31 days later.
    They showed up. And they said they had no record. They were 
three veterans trying to get into the Artesia clinic just 
yesterday all with the same problem. And the arrogance of them 
is what really made people mad.
    The arrogance that you don't have a right to be here, we 
told you, you don't have an appointment, while they're holding 
the cards. These are the things that drive us all.
    Today we have John Taylor. He was a combat sniper in 
Vietnam, a hospital administrator in his private life. He has a 
100 percent disability rating for PTSD. He's been an advocate 
for veterans throughout New Mexico. He's a contributor to the 
Roswell Daily Record on veterans affairs.
    Secondly, we have Richard Moncrief, a veteran living with 
PTSD. He'll talk about services due to limited access to 
physical doctors he declares to be less than viable. He's a 
veteran service officer for New Mexico Veterans Department. He 
works on a daily basis for the betterment of our veterans.
    We have Harry McGraw that was scheduled on this first 
panel. I'm not sure if he's on a later panel. I'll introduce 
him later if he's going to come up. But again we appreciate 
Chairman Miller remembering his promise and coming back here.
    I would like to also acknowledge that the VA in Albuquerque 
has been cordial in two visits since the problems were first 
noted by the chairman and became a national crisis.
    Those meetings have been congenial, they've been 
transparent, they have honored the promise that we would indeed 
set up a pilot project. It's ongoing today and for a couple of 
days where we're actually letting local veterans see local 
providers.
    When the VA's problems erupted nationwide, there was a kind 
of a clamor to take a look at what we might do. And I 
appreciate the fact that Chairman Miller looked back at what's 
called Healthy Vets that we've had filed for the last four 
Congresses, for the last eight years, basically saying, if you 
have to drive more than a certain distance, you can go to your 
local providers.
    So Chairman Miller inserted that as one of the key 
provisions in one of the most dramatic reforms in the VA system 
since its inception. I think that the chairman has done a 
tremendous job in getting this bill through.
    It's approved by the House, Senate, and is set to be signed 
by the President later this week. So I just think, if it's 
approved in committee procedures, I think we ought to give the 
chairman a round of applause for remembering the rural veterans 
of this country.
    Mr. Pearce. The VA has a lot of people who care deeply 
about the veterans. And they serve well and they do their job 
well. But the abuses and the problems have dominated.
    And that's the reason that we're here in Roswell today, to 
hold the first hearing nationwide after the passage of that 
historic legislation. And the chairman will see the pilot 
project in operation here in Roswell today.
    So thank you very much for being here. And I will yield 
back my time, Mr. Chairman.
    The Chairman. Thank you very much, Steve.
    And we will begin with Mr. Taylor. We recognize you for 
your opening statement.

                    STATEMENT OF JOHN TAYLOR

    Mr. Taylor. Chairman Miller, Congressman Lamborn, and 
Congressman Pearce, it is an honor to provide testimony before 
you today.
    My active duty combat military experience was with the 
101st Airborne Rangers in Vietnam. After seeing many of my 
brothers die in heated combat situations within the infamous A 
Shau Valley area of Thua Thien/Hue and being shot twice and 
bayoneted on the same day, dying on the MASH unit surgery 
table, and obviously returned to life, I never imagined any of 
us would come back home to die directly related to post-combat 
medical care in our VA hospitals. Sadly, as you are now aware, 
that has become a painful reality.
    In the interest of saving this committee time, with respect 
to my evaluations and solution recommendations, the last 
committee hearing we held on ``Service should not lead to 
suicide,'' one of my fellow compatriots, Sergeant Josh 
Renschler, had a very good, very detailed analysis. And I would 
put that as a reference to what I have coming up.
    For my side, I would like to look more at the unique 
situation that we have here in our area of Southeastern New 
Mexico, a significant variation that I would term `acute 
rurality'. Being in a rural desert community, systemic problems 
encountered throughout the country are greatly intensified in 
Southeastern New Mexico.
    As a quick example, following the CARES Commission findings 
during President Bush's last term in office, a Director of 
Rural Administration was created to help eliminate our acute 
problems with rural access in our area.
    As it turned out, that rural administrator responsible for 
resolving our problems was none other than our administrator of 
the Albuquerque VA Hospital, obviously the very person 
historically refusing our requests for local fee-based 
services. Ineffectual outcomes are obvious. A fox in the 
henhouse type situation.
    For the last nine years, I've published a weekly Veterans 
Advocate column in our local newspaper, the Roswell Daily 
Record. The column is a volunteered, not compensated, freelance 
work having no allegiance to any person or group except to my 
brother and sister veterans.
    Over the years I've made members of both sides of the aisle 
uncomfortable to say the least. However, the majority of my 
rants have now shown to be true. Like so many of the other 
public forum veterans' advocates, we're asking why did it take 
the recent deaths of so many of us to prove what we have been 
claiming for so many years, over ten as far as myself goes.
    It is important to note that our deaths were majorly not 
due to medical care provided by our VA medical professionals. 
Physicians, nurses, support personnel, and even support 
administrative people are doing a great job. That goes without 
question.
    But the administrative games played by VA administrative 
leaders and by system oversight groups, that's the problem. 
I've made that statement publicly several times over the past 
nine years only to be ignored and politically told either we're 
working on a resolution or you're not correct in your 
accusations.
    Finally, saddest of all, my claims have been validated with 
the many deaths recently uncovered and still being uncovered 
thanks to courageous whistleblowers within the system. 
Veterans' families and friends have continued to not come 
forward due of fear of reprisal. You guys have seen that in 
action also.
    The VA has historically denied this to be true. But as you 
yourself have recently seen, the VA seems to have a problem 
with the truth. I personally can offer proof that this has 
occurred long before the recent awakening.
    I respectfully submitted a few of my VET ADVO columns in 
support of my testimony today, most of which are six to nine 
years old. But it's the same theme coming forward.
    This illustrates real-life catastrophes I have encountered 
over my nine years as advocate, which were literally ignored or 
denied as being accurate by our state VA administrators and 
government officials.
    We all know now how invalid the VA denials were and still 
are. Two specific sets of columns illustrate factually the 
problems and battles we have faced with the Albuquerque VA 
Hospital administrators, consistently denied by the VA as being 
accurate.
    Number one, the first was a series of columns I did on a 
chronic PTSD veteran who over the space of more than one year 
threatened to commit suicide due to his Desert Storm 
nightmares. His wife approached Colonel Ron McKay, USMC 
Retired, and me with horror stories of her lack of effective 
treatment for her husband by the VA.
    Apache, my column name for my brother to respect his 
privacy, had undergone several treatable modalities listing 
from three days to three months inpatient sessions. More than 
once he was sent home in a cab for a two and a half hour drive, 
before which he would ask the driver to swing by the nearest 
Albuquerque liquor store to make his journey easier.
    His primary substance abuse/dependency directly related to 
his PTSD was alcohol. Knowing this his treatment team and/or 
patient discharge planner should have known this was a perfect 
storm doomed to failure. Each time Apache returned home totally 
inebriated, once again threatening suicide.
    He was instructed by his VA treatment clinician to report 
to a local VA social worker for aftercare. During the first 
visit by Apache and his wife, as reported by his wife, the 
counselor asked, ``So what is it you want me to do? You know, 
you could go to the A.A. and get some help.'' So a furious 
Apache and his wife got up and left.
    In my experience as a director of a psychiatric center and 
an inpatient substance abuse center, aftercare for either 
malady requires at a minimum the services of a certified 
psychiatric counselor or certified substance abuse counselor. 
In Texas and New Mexico, this is required for licensure, not a 
social worker.
    Eventually Apache was found dead one night outside his 
house in spite of repeated requests to the VA for help keeping 
him alive. The VA response? He was noncompliant. In other 
words, they gave up.
    The second set of columns dealt with several cases that I 
did through the years. One in particular was an 87-year-old 
veteran who I was proud to two or three times a month drive to 
Albuquerque, a three and a half hour round trip. He had an 
active catheter. And his 87-year-old wife, who was in poor 
health, did the drive. There's the problem.
    His response to me several times was, ``My people don't 
lie.'' I have reliable witnesses to that encounter. This was in 
a situation where I had actual proof that the VA did, in fact, 
lie. Not miscommunicate as politically correct, but lie.
    And when I approached the administrator, he didn't want to 
hear it. He said, ``My people don't lie.'' I said I can give 
you incontrovertible truth. ``My people don't lie. You're 
done.''
    All right. Last week I measured the actual distance from 
our nearest CBOC in Artesia and found it to be about 45 miles. 
We've been excluded from a lot of the improvements because we 
didn't qualify for the ``less than 40 mile'' rule. Obviously 
I'm 45 miles so I'm five miles over that limit.
    I apologize for this lengthy testimony. But after nine 
years of reporting on these issues and warning everyone of the 
obvious, predictable outcomes, I hope this report does not once 
again fall on deaf ears.
    Simply stated, systems monitored by its own department 
members, no matter the claims of independent watchdog status, 
do not and will not work. Paying bonuses to upper echelon 
administrators is a crafty mechanism created by upper 
management to milk the system. I know. I've been there.
    In my many years as a medical administrator my reward, 
bonus, if you please, was continued employment for the next 
year. That was my bonus. The contrived reason for VA bonuses 
reported in other House and Senate committee hearings is to 
entice and retain competent administrators.
    That, Honorable Committee Members, is a fallacy perpetrated 
on those who have not worked in the medical arena. Competence 
in our current VA administration based on this bonus rule has 
been proven grossly lacking among our current VA handpicked 
wonder kids.
    In my experience it's safe to say you would find a 
sufficient queue of qualified applicants for each VA 
administrative position you currently find not up to par. 
Current doctors and medical administrators being RIF'd, which 
is reduction in force, in the administration's military 
drawdown could easily and effectively be placed in certain 
comparable positions recently found lacking in the VA 
administrator network.
    I sincerely hope my testimony and attached resource 
materials will help you with your enormous task of keeping my 
brother and sister veterans alive once they return home after 
surviving death on the battlefield.
    I would be pleased and honored to answer any questions you 
may have of me. God bless you in your efforts, God bless our 
brother and sister veterans, and God bless our nation. Thank 
you.

    [The prepared statement of John Taylor appears in the 
Appendix]

    The Chairman. Thank you very much, Mr. Taylor. And we'll 
ask questions after everybody has already given their 
testimony.
    Mr. Moncrief, you're recognized here. Please go ahead.

                 STATEMENT OF RICHARD MONCRIEF

    Mr. Moncrief. Thank you. I would like to thank the 
committee for giving me the chance to speak out about the lack 
of mental healthcare in the southeast corner of the state.
    I have been using the mental health services in the Artesia 
clinic for several years now. With the loss of Dr. Peter 
Hochla, we are now being forced to use the telemed system, 
which is a very impersonal way of conducting mental health.
    The men and women who suffer from PTSD and TBI need to have 
a live physical being to talk to. Better yet to have group 
therapy with a skilled group leader and a psychologist would 
even be better.
    Having a warm body to talk to in person is better than a 
flat screen for a patient. The talk is more personal and you 
can see the body movement and make better eye contact with the 
person doing the counseling.
    Dr. Hochla, when he would come, he would come every three 
to six months and make appointments for people. Well, I still 
needed somebody to talk to because I had to let my hair down 
and relax every once in a while.
    I ended up hiring my own Licensed Professional Clinical 
Counselor. I tried to use TRICARE since I was retired, but they 
didn't pay enough money. They didn't pay up to Medicare 
standards. So I ended up paying for the counselor myself. And 
there's a great need for some kind of skilled counselor in this 
part of the country.
    There are many more problems that need to be addressed. I 
have been given medication to increase my blood pressure after 
the hospital had already told me I had high blood pressure.
    Is the pharmacy or the doctor supposed to check to see if 
there's a problem or is it my job as a working person without 
medical experience to see if the medication is bad for me. I 
take it it would be up to the medical staff to figure that one 
out.
    I was given a hearing test last year at the VA Medical 
Center. The doctor said my hearing had gotten worse. I didn't 
receive hearing aids. I asked why. He didn't say.
    So here in town this lady invited me to come over to check 
on a hearing test. And after giving me a hearing test, she said 
yes, my hearing was getting worse and it would be best if I got 
hearing aids for both ears before I lose my hearing totally.
    There is a shortage of housing spaces for homeless veterans 
in Southeast New Mexico. I have had to send people to 
Albuquerque to get any help either way or we have to find funds 
to be able to put them up in hotels and money to feed them.
    The major problem of veterans having a nice resting spot 
now has been solved here in the City of Roswell. We now have 
our own veterans cemetery that's been dedicated and it's in use 
as of today.
    I had to call the Hospital Executive Assistant to the 
Director to have my 100 percent total disability and permanent 
disability put in the hospital computer after nine months of 
waiting. The hospital didn't even recognize that I was 100 
percent disabled.
    And now my last question is why do veterans have to drive 
200 miles to get medical attention in Southeast New Mexico? 
Thank you.

    [The prepared statement of Richard Moncrief appears in the 
Appendix]

    The Chairman. Thank you very much, Mr. Moncrief.
    I understand Ms. Tschabrun is a late addition to the 
witness table. We appreciate you being here and willing to 
stand in. Thank you for what you have been doing. If you could 
in your statement tell us a little bit about what Lovelace is 
doing.

                  STATEMENT OF DAWN TSCHABRUN

    Ms. Tschabrun. Thank you, Chairman. Congressman Pearce, 
thank you. My name is Dawn Tschabrun. I am the CEO, chief 
executive officer, of Lovelace Regional Hospital here in 
Roswell.
    I'm coming to you today to say that we've seen some 
improvements. The Demonstration Project is working. As of this 
morning, we've seen five veterans in our clinic and it's been 
very, very successful.
    We will see a balance of nine by the end of the week. And 
it's been a huge satisfier to our veterans who live here in 
Roswell as well as in Southeast New Mexico. So kudos and thank 
you for that.
    My other comment is Lovelace stands ready to come to the 
table and discuss the needs of veterans in Roswell and 
Southeast New Mexico to eliminate travel to Albuquerque so that 
veterans can be seen at home.
    We have qualified, competent care providers from physicians 
to nurse practitioners right here in Roswell that are willing 
and able to serve our veterans. Thank you very much.

    [The prepared statement of Dawn Tschabrun appears in the 
Appendix]

    The Chairman. Thank you very much. What we'll do now is 
we'll start a round of questions. We'll go through one round 
and then we may have a second round.
    And, of course, in the legislation that will be signed 
tomorrow, it does have a 40-mile requirement; if you are 
further than 40 miles, the VA has to allow you to go outside 
the system if you choose. In the past the VA has had the 
ability to do that.
    They've obviously made it very, very difficult. This is 
supposed to open that gate specifically for the rural 
communities, much like Roswell.
    And, look, in the panhandle of Florida, where I live, we 
have more veterans than any Congressional district in the 
country. We do not have a VA Hospital, my veterans have to go 
to Biloxi.
    So they have about a three-hour drive to go to the 
hospital. We have three major medical facilities in Pensacola. 
It just doesn't make sense.
    But let me also tell you that this entire process is in no 
way an attempt to tear the VA apart brick by brick. We're 
trying to help supplement what they already do with local 
providers, local facilities, because it's better for the 
veteran, it's better for the taxpayers.
    They don't have to pay for mileage to Albuquerque and 
putting somebody up only to get there and find out your 
appointment has been cancelled and you have to turn around and 
come back tomorrow or next week, whatever it may be. A lot of 
things are going to change.
    Now, this is a finite program. It was originally designed 
because of the wait list that exists out there today. But the 
intent is that it will carry on. We will have to appropriate 
more money to it.
    There is some fear among veteran service organizations. And 
probably the most vocal is the Disabled American Veterans. The 
Disabled American Veterans, they don't like this at all. They 
think that this is the first step in trying to rip the VA 
apart.
    Again they need to listen to you, the veterans, who have to 
drive hours to access care and understand what you're having to 
go through. And hopefully everybody will come to like this 
program.
    Some will stay in the VA, some will go outside the VA and 
get their healthcare, continuity of care. All of those things 
are issues that we have to watch and provide oversight to. But 
our intent is to get the care quickly and ensure quality of 
care is available to you.
    So to Mr. Taylor and Mr. Moncrief, what I'd like to ask is 
the scheduling issues at Albuquerque, can you kind of go into 
detail a little bit and have you seen any changes in the way 
the scheduling has been done over the last several months?
    Because we're hearing from certain people around the 
country that there are positive changes. And we want those 
changes to be permanent changes, not just temporary.
    Mr. Taylor. Chairman Miller, Congressman Pearce brought 
this up in one of his telephone town meetings, has anything 
changed locally. And I think there are excellent VA hospitals 
in the country, there are some obviously not. I'll give you a 
personal example just last week how things have changed.
    I have to literally, excuse the pun, pull teeth in order to 
get dental fee-based service down here in Roswell. So last week 
I called. And I had a really painful wisdom tooth that was 
going nuts on me.
    So I called the dentist. He said, well, you have to call to 
Albuquerque and get the approvals. So I did. I called in, I got 
the dental clinic. It took 50 minutes going down the line, 
you're the fifth caller. Finally I got to be the next caller. 
So after 50 minutes, I finally get a ring from the phone.
    I get another message saying I'm sorry, sir, the system is 
down. We're sorry, the system is down, please call back. I did 
this morning and evening. And I did it the next morning and 
still the same thing.
    So have things improved? I'm hearing not. Some people have 
said yeah. But certainly in my experience this is an example of 
trying to get into the system.
    The Chairman. Mr. Moncrief.
    Mr. Moncrief. I haven't had as much trouble getting 
appointments. I've been able to clinics. I had to forego an 
appointment this morning to be on this counsel this morning. I 
thank you for that.
    But I've had a lot of people that have come to talk to me 
and ask why they're having a problem getting into the VA 
Hospital, getting into the system. And a lot of people have 
come in with the idea that they're going to be able to get in 
into the healthcare system just because they're a veteran.
    Well, if you're anything other than service connected and 
you make over $30,000 as a husband and wife, you're going to 
have a hard time getting into the VA healthcare system because 
the bar has been set. That's as high as it's going to go. It's 
on welfare.
    So there are a lot of people that I had to turn out and say 
I'm sorry, we're just not going to be able to get you anything. 
So, of course, they're not going to be able to get 
appointments.
    There's been a few people that have had a lot of problems 
with appointments. But I have been able to contact one very 
important person at the hospital. And she's sitting right 
behind me back here, Kara Catton. And she is super at taking 
care of a lot of the problems that I've had to deal with 
veterans.
    The Chairman. Mr. Lamborn.
    Mr. Lamborn. Thank you, Mr. Chairman, Ms. Tschabrun, I hope 
I pronounce your name correctly.
    Ms. Tschabrun. Close enough.
    Mr. Lamborn. Okay. One of the issues that we need to be 
really careful about when we start using more fee basis, which 
is the private sector providing healthcare, is the custody and 
the chain of custody of medical records.
    Because someone may have been going to a VA clinic or 
hospital for decades and now they're going to like maybe your 
facility. And it just is important that the medical records 
have continuity.
    So how is the best way to address that?
    Ms. Tschabrun. There's a couple of ways to address that, 
sir. What we've demonstrated today and through this week is the 
VA worked very collaboratively with us and sent those records 
electronically to us so that our providers here could review 
the history so that we were not starting from a zero playing 
field.
    Our providers have the opportunity to review that. And 
then, as we transition that care, you speak of continuity of 
care. That's essential. Not only for veterans but for everyone.
    So as we see those veterans today through the week, we will 
then put that electronic record back to the VA so they can see 
what happened in their visit here. So absolutely we can do hard 
paper, we can fax, we can download to disks, we can transfer 
electronically through HIPAA secure mechanisms so that we keep 
that data safe.
    Mr. Lamborn. And it could be a two-way street?
    Ms. Tschabrun. Absolutely.
    Mr. Lamborn. So after receiving care in your facility, they 
go back to the VA, it will be returned to them?
    Ms. Tschabrun. Yes, sir. That's imperative, because the 
bottom line is patient care, assuring that whoever the patient 
is, through that continuum of care, that the providers are 
knowledgeable about what occurred. And if either side fails to 
do that, then we've let the patient down from my perspective.
    Mr. Lamborn. Well, I think that that's such an important 
thing. We're going to have to really stay on top of that 
because there are some IT issues there that may have to be 
addressed.
    Ms. Tschabrun. Sure.
    Mr. Lamborn. Also I would like to ask about telemedicine. 
And, Mr. Moncrief, you expressed concern that, let's say, for 
counseling or therapy, that there were some things lacking 
through telemedicine.
    We know that telemedicine negates the need for taking a 
long car trip; however, you have pointed to drawbacks. What are 
the pluses and minuses of telemedicine in your opinion? And, 
Ms. Tschabrun, your opinion also.
    Mr. Moncrief. The problem that I see with telemedicine, 
sir, is it's great if you are going to take your blood 
pressure, you are going to do things that surgically you can 
talk to the doctors and things like that.
    But talking to somebody mentally, you need a physical body 
there; somebody to talk to that you know is concerned about 
you. How can a TV set tell you you've got--you can't show it. I 
mean it's a little--it's impersonal.
    As far as I'm concerned, it's the wrong way to be doing 
mental health. You need to have a live human being sitting 
there that can understand you and see and be able--what are 
they going to do, request a TV camera? It's not going to walk 
over and pat you on the back or make you feel better.
    Mr. Lamborn. Ms. Tschabrun.
    Ms. Tschabrun. I think it's a huge challenge. Quite 
honestly there is a deficit of providers in certain fields of 
medicine. So that brought about the telemedicine option.
    In Roswell and Southeast New Mexico, extremely rural, it's 
difficult to recruit some providers in some specialties. And 
medical schools are not producing at the rate that they had 
been.
    So telemedicine offers a different approach to prevent 
travel. I think there are some very good uses of telemedicine. 
Pulmonology, even perhaps cardiology if it's not that initial 
visit. I think initial visits need to be face to face.
    But telemedicine I think can help us bridge that gap. When 
we do not have perhaps the ability to recruit that provider 
into our area, it allows us to link into that provider so that 
we don't have a deficit of care for our community.
    Mr. Lamborn. I want to thank you all for being here. Mr. 
Chairman, thank you.
    The Chairman. Mr. Pearce.
    Mr. Pearce. Thank you, Mr. Chairman.
    Mr. Moncrief, you mentioned in your testimony that you pay 
for your own counseling service. Where is that counseling 
service located?
    Mr. Moncrief. Right here in town, sir.
    Mr. Pearce. And how much did you pay for a session, if you 
don't mind saying in front of a room?
    Mr. Moncrief. It was 75 to $100.
    Mr. Pearce. How much?
    Mr. Moncrief. Seventy-five to $100.
    Mr. Pearce. Seventy-five to $100. In the next panel, I'll 
be talking about how, in a very heated exchange with myself and 
the VA in Albuquerque, one of the senior staff members there 
was declaring he could not get people seen for less than the 
price of gasoline. How much do you get paid to drive for 
gasoline?
    Mr. Moncrief. Over $160 to go up and come back.
    Mr. Pearce. So you get paid $160 in gas money. Then you see 
the psychologist there in Albuquerque and come back. For $75 
and no gas money, you are able to see someone here.
    Mr. Moncrief. And it's very personal, sir.
    Mr. Pearce. Ms. Tschabrun, you said that you're seeing six 
or eight people right now, you're seeing five people a day and 
nine by the end of the week. What's the scope of services 
provided?
    Ms. Tschabrun. This is family practice.
    Mr. Pearce. So just typical stuff?
    Ms. Tschabrun. Just general stuff, general checkups, 
general reviews, ongoing type of things.
    Mr. Pearce. What is the cost that you are going to be 
charging for those visits today? I don't want to get into your 
data. If you don't want to say it, that's fine.
    Ms. Tschabrun. I would prefer not to say it.
    Mr. Pearce. Okay. That would be fine.
    Mr. Chairman, I also notice that the Secretary of Veterans 
Affairs for New Mexico is here, Mr. Hale, if we could recognize 
him. Mr. Hale is of service to his company and country and a 
veteran himself. So thank you for being here.
    Mr. Taylor, you have probably as much experience as dealing 
with the people here in this area. What has been your 
experience in fee-for-service here in the Roswell area?
    Mr. Taylor. Overall I found it to be excellent.
    Mr. Pearce. I mean how easy is it to get fee-for-service 
payment back from the VA? How has the process worked? Can you 
just call up there and say I feel bad, I can't make the drive, 
how does it work?
    Mr. Taylor. Right now the only one that I can use is the 
dental. And in that case, you know, I do the visit. The dentist 
will bill the VA for the services. And it's considerably less 
than what is billed obviously. And then they pay and the 
dentist accepts whatever.
    Mr. Pearce. Does everybody that wants fee-for-service get 
accepted for that or is that 10 percent, 90 percent?
    Mr. Taylor. Well, right now it's 100 percent.
    Mr. Pearce. I'm talking about the last couple of years. If 
you want to get fee-for-service, you can get fee-for-service?
    Mr. Taylor. You have to get the approval. There's a fee-
based director at the hospital.
    Mr. Pearce. Mr. Moncrief, you appear to be wanting to say 
something. Do you want to add anything to that?
    Mr. Moncrief. I'd like to say that, when you go down to the 
Artesia clinic and they have to get an x-ray, they send you 
over to the Artesia Hospital. Well, Artesia ends up billing us. 
And I'd like to know why.
    Because it's the VA sending us there, it's not the Artesia 
Hospital. And the same thing if you get blood work, anything 
like that, done. You end up getting a bill.
    Mr. Pearce. The gentleman in the audience today that talked 
about being required to drive to Albuquerque for blood tests 
and then have to go back to get the results. I mean again you 
all deal with as many veterans in this area.
    When people request to have their blood work done here, 
blood tests taken here, at least a sample are they given that 
permission or is that very difficult to achieve? Is that a 
single, isolated incident?
    Mr. Taylor. For the most part, let's say the physician at 
Artesia needs that done. He can have that done and there's not 
much of a hassle there. Again let me make one statement.
    A large chunk of our problems--there's two areas that, if 
they can be covered locally, it would eliminate a lot of 
problems. One being urgent care and one being emergency care.
    Now, if we can get that done locally, it would be a 
tremendous savings. Plus it's no fun driving with a 102-degree 
temperature even 45 minutes to Artesia. Try it sometime. It's 
not comfortable.
    So if we had a local doc in the box or urgent care center 
and we had the tie-in to an emergency room, that comfortably 
the vet can feel that it will be paid for. I mean we have the 
option now.
    Like I say, if you've got a problem, call 911 or go to the 
hospital. Many of my vets go to the hospital and find out 
they're going to have to pay for it.
    Mr. Pearce. One last question, Mr. Chairman and Ms. 
Tschabrun. One of the things that I hear frequently from 
veterans or providers, when they provide service, many in the 
VA process say you can go see someone because it's an 
emergency. But then there's trouble getting payment. What is 
your experience receiving payment for the services provided?
    Ms. Tschabrun. My experience is that it's very late in 
payments coming back from the VA that extend beyond other 
commercial payers.
    Mr. Pearce. Had you ever not get paid for anything and have 
to go back to the veteran?
    Ms. Tschabrun. Yeah, that occasionally happens. If we do 
not receive payment, then we will circle around back to the 
individual patient and seek payment from them.
    Mr. Pearce. Thank you. I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Pearce.
    Ms. Tschabrun, one of the things as you well know in the 
bill and, of course, most of the hospitals know as well is that 
the language was inserted into the legislation. It mostly was a 
repetition of existing law.
    But it does baffle me that an agency the size of the VA, 
especially when they have approved much of what gets done, have 
a hard time with it.
    I'd like to know, how has your experience been with the VA 
in trying to set up the pilot program and have they reached out 
to you since this legislation passed both houses? Because 
that's the main focus. Folks need to get prepared. They've got 
90 days with which to write the rules in order to implement 
this. Has there been a proactive part on the VA?
    Ms. Tschabrun. Absolutely, sir. Polly from Albuquerque VA 
reached out to our clinic and said I have this list of patients 
that we would like to get care at your facility, can we arrange 
those appointments. So they were done right there.
    But it was proactive on the VA's part giving us a call. We 
were notified that we would be receiving X number. We didn't 
know exactly what X meant. But then Polly was very, very quick 
to give us the phone call and say we want these patients seen 
and I'll be shipping their records to you.
    The Chairman. And how quickly were you able to see the 
patient?
    Ms. Tschabrun. We made the appointments within five days of 
notification.
    The Chairman. Do you do that by telephone or do you do it 
with a letter or a card?
    Ms. Tschabrun. That was by telephone, sir.
    The Chairman. One of the biggest complaints that we heard 
and I don't know if it's been a problem here, is that VA in the 
past has felt like the best way to do it was with the Pony 
Express.
    It definitely was not the time that few chose at the time 
they chose. You may not have been able to make your 
appointment. If you can't make that appointment, then you 
cancelled it and/or you didn't settle in the first place. So 
that's something that we hope VA will be able to rectify as we 
move forward.
    Let me ask, we talked about the bad things and, John, you 
talked about that too. I'd like to hear something good about 
VA. So, John, if you want to follow up with my comment.
    Mr. Taylor. Definitely. There's a lot of good particularly 
with the applied--the actual patient care. As I said the care 
professionals do an excellent job.
    Fortunately we have as Richard mentioned Kara Catton and 
Sonya Brown at the VA Hospital in Albuquerque. They are quick 
to respond when we've got a problem and then they do a fine job 
in getting it done.
    The problem is they're putting out fires. When I was an 
administrator, I didn't want my people running around putting 
out fires. It's just like the next step is a forest fire, which 
is obviously what happened here.
    If you have a forest fire, you find out what caused it. You 
go to the system and systemically you solve the problem. So 
it's good to do firefighting. But that should not be the course 
of business that you take. It's not helpful.
    So several times now I just--at Artesia last week, I spent 
about an hour and a half, which is way over what my physician 
there says to spend. But we've got several problems.
    And after five heart attacks, he needed to do an extended 
workups on me. He took the time with the personnel out there. 
And I've heard some mention, well, they're a little short 
tempered.
    Yeah. I guess, if you are facing a bunch of us old codgers, 
we tend to get on everybody's nerves I'm sure. On the whole 
they're professional and they get the job done.
    So again there are a lot of positives there. It's the 
possible death outcome that has me concerned.
    Again I had a fellow vet that called me. To me he presented 
as having appendicitis. Of course, I couldn't make that 
judgment. But he had all the classic symptoms.
    I called Artesia. They said, well, if he's that bad, we can 
take him in about two weeks. We can't take him today. Call 911 
or go to the emergency room. Well, he was in bad shape.
    Before I could get back to him and tell him, okay, you can 
go, he didn't have the money to pay for it. So he and his wife 
were already driving up to Albuquerque.
    So here's a guy with an almost 102 temperature and acute 
abdominal pain, nausea. He can't be seen by anybody and he 
can't go to the emergency room because he can't afford it. 
These are the real-life problems. It's just you can't use 
firefighting as your course of business.
    If we had an urgent care center here, what we used to call 
doc in the box, they can go over and take care of the immediate 
problem. So you can triage the problem, but you've got to have 
the first step, which is either the urgent care center, a low 
cost way of doing something, or the emergency room for 
critical.
    So yes, they're very positive. But we in total have to get 
on these shortcomings.
    The Chairman. Richard.
    Mr. Moncrief. Since receiving my 100 percent, I've been 
able to use the dental clinic up there. And they have been very 
responsible to me. And I haven't had any problem of getting fee 
basis down here.
    They have gone out of their way to send me down here 
instead of having to go up there to get certain work done. They 
do implants and everything up there. But down here they'll let 
you get local crowns and things like that put on. And I'd like 
to commend them for the job they've done for me. Most of the 
time they're very good.
    I've had people call me from Carlsbad. A gentleman was--his 
wife was on chemotherapy. And he was supposed to go up to the 
dental clinic in Albuquerque to get work done. I called up 
there, got a hold of one of the doctors, and they gave him a 
fee basis to get it all done down there in Carlsbad and he 
wouldn't have to leave his wife on chemotherapy.
    So I haven't had problems with them. Certainly I've had a 
lot more problems using the orthopedics and things like that up 
there.
    The Chairman. Mr. Lamborn.
    Mr. Lamborn. I want to follow up a little bit more on the 
medical records issue. Let's say someone is using fee basis and 
they come to your facility. And they have shipped you the 
medical records of the past history.
    Do you have 100 percent assurance that you are getting the 
complete set of medical records? If something is left out, that 
can, you know, trigger a real problem.
    Ms. Tschabrun. You know, to address that, I can't say with 
certainty. ``I've got all of it''. I have to believe in faith 
that they are sending what is appropriate to send for that 
specific instance in this--in the demonstration that we're in 
right now.
    I would expect on a go-forward basis that we--as the 
project continues, as the veterans have choice, that they can 
then really give that full medical record. And in turn we also 
turn that back, because it's got to be a collaborative 
partnership between the both of us to be successful.
    Mr. Lamborn. I just think, as we go forward, this is 
something to really monitor closely.
    Ms. Tschabrun. Absolutely.
    Mr. Lamborn. So I look forward to what's being developed 
here.
    Mr. Chairman, that's all I have for this time.
    The Chairman. Do you get the physical record or do you have 
the ability to put eyes on the VA record or how does it work?
    Ms. Tschabrun. These records were actually faxed to us. So 
we have the bulk of, you know, a period of time that their 
providers went back and reviewed prior to the meeting with that 
patient today.
    The Chairman. And then your physician or whoever saw them 
makes whatever----
    Ms. Tschabrun. Makes their notes.
    The Chairman. Do you destroy then the set of records that 
you have or do you have the ability to keep them?
    Ms. Tschabrun. I don't think that we would destroy those 
records, because they're a permanent part then of a patient 
being seen. So we would create a patient file in this facility 
that we saw them in. And then that would be an ongoing file for 
that patient.
    They may become an inactive patient for us. But they may 
remain active. But we would still maintain that encounter.
    The Chairman. Okay. Mr. Pearce.
    Mr. Pearce. Thank you, Mr. Chairman. I'll just make a 
couple comments and yield back.
    But you were asking for the good things that happen. So as 
I travel around, we hear those stories of people very 
satisfied. So we recently ran a poll of all the veterans in the 
district.
    So the result was--I can't remember the exact numbers. But 
it was a significant number, maybe 45 percent, were extremely 
satisfied with the care. And so I do like to give those 
positive things.
    Also in our first meeting that we had with the VA after the 
scandal broke and the Albuquerque VA actually showed up on the 
list and we had the meeting, we took about six or seven 
veterans in there.
    And I don't remember exactly the records that we made notes 
of at the meeting. But about three or four of the veterans had 
problems. But they expressed that they were content with the 
care when they got there. It was the scheduling or the distance 
they had to drive or whatever.
    And so I like to share those positive things, because there 
are good people working inside the system. It's just the system 
has serious flaws and breaks in that system.
    And the last comment that I'll make in recognition of both 
the Albuquerque and the El Paso VA, when we started seeing 
problems--this is when I was elected in 2002--I kept hearing 
the same problems over and over. So we made a list of those.
    There are about 23 recurring problems. At every meeting, 
every single one of the 23 things would be a problem. So I did 
set up corollary meetings with the lead administrator, the head 
of the Albuquerque VA Hospital.
    And to their credit he would bring his assistant. And he 
would come to different places in this big Second District. 
Every quarter we would address those. And as they started 
working from that list of 23 recurring things, those began to 
improve.
    And they were things like sending people all the way to 
Albuquerque, having cancelled their appointment four days 
before they get there. And one of the big complaints was they 
were being paid $0.11 for gasoline. And that didn't come close 
to even covering it.
    So those meetings have continued and they still continue. 
And we can pay attention to the smaller things. But the big 
systemic problems that your committee has uncovered is what 
we're dealing with and very difficult systemic problems.
    So again I appreciate the hearing here. And I wanted to 
pass along those good things that I do hear along with the 
criticisms and complaints. And I'll yield back.
    The Chairman. Thank you very much. I want to say thank you 
to the first panel. We've got a second panel that we want to 
hear from.
    So with that you're excused. And thank you very much.
    The Chairman. I want to go ahead and call up the second 
panel while they're getting everything set.
    We have Lisa Freeman, acting network director for Veterans 
Integrated Service Network 18. She is accompanied by Dr. James 
Robbins. He's the interim medical center director for the 
Albuquerque VA Medical Center and Dr. Lori Highberger, the 
deputy chief medical officer and mental health lead for VISN 
18. Thank you now for being here.
    You do need to get right up into that microphone. Don't be 
afraid, it's not going to bite you. It's very difficult to 
hear.
    And, Ms. Freeman, you're recognized. Please proceed with 
your testimony.

   STATEMENT OF ELIZABETH FREEMAN, INTERIM NETWORK DIRECTOR 
VETERANS INTEGRATED SERVICE NETWORK (VISN) 18, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY JAMES ROBBINS M.D., INTERIM MEDICAL CENTER 
 DIRECTOR NEW MEXICO VA healthcare SYSTEM, VETERANS INTEGRATED 
SERVICE NETWORK (VISN) 18, VETERANS HEALTH ADMINISTRATION, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; AND LORI HIGHBERGER M.D.,DEPUTY 
    CHIEF MEDICAL OFFICER AND MENTAL HEALTH LEAD, VETERANS 
     INTEGRATED SERVICE NETWORK (VISN) 18, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                 STATEMENT OF ELIZABETH FREEMAN

    Ms. Freeman. Thank you. Good morning, Chairman Miller, 
Congressman Pearce, and Congressman Lamborn. I too want to 
thank all the veterans who are here today for your service to 
this country.
    And I also want to thank the previous panel members. And I 
look forward to addressing together their concerns.
    Thank you for the opportunity to discuss the New Mexico VA 
healthcare system's commitment to providing veterans 
accessible, high-quality, patient-centered care and to 
specifically address rural healthcare and access to mental 
healthcare in New Mexico.
    The New Mexico VA healthcare system serves veterans in New 
Mexico, Southern Colorado, and West Texas. The New Mexico VA 
healthcare system includes the Raymond G. Murphy VA Medical 
Center and 13 community-based outpatient clinics.
    The VA Medical Center is a joint commission accredited 
tertiary care referral center located in the heart of 
Albuquerque. It provides a full range of patient care services 
with state-of-the-art technology as well as education and 
research. It is the only VA medical center in New Mexico.
    Approximately 75,000 New Mexico veterans are enrolled in VA 
healthcare. And 47 percent of those enrolled veterans live in 
rural areas.
    The VHA Office of Rural Health currently supports nine 
projects, for a total of nearly $1.9 million in the State of 
New Mexico. These projects increase rural veteran access to 
mental healthcare, women's healthcare, primary care, pharmacy 
services, and neurology services. Five of these nine projects 
use telehealth to deliver healthcare closer to veterans' homes.
    One currently funded Office of Rural Health initiative is 
home-based primary care for veterans residing in rural areas 
near Santa Fe and Artesia. The home-based primary care program 
provides primary care for frail, chronically ill veterans in 
their own homes.
    There is an increased support for group specialty care 
through the expanded use of clinical video telehealth or CVT 
technology. The use of this technology in homes is on the rise, 
especially aiming to assist American Indian veterans who are 
the most rural, isolated, and transportation challenged.
    In fiscal year 2013, the New Mexico VA healthcare system 
served over 5,000 veterans through telehealth. And 59 percent 
of these veterans lived in rural areas. Of these 1,000 veterans 
accessed mental health services through CVT, 90 percent of whom 
live in rural areas.
    The New Mexico VA healthcare system has a robust expanding 
telehealth program including more than 30 telehealth programs 
offering additional modalities to CVT including home 
telehealth, video to home, storage for telehealth, secure 
messaging, e-consultations, and Specialty Care Access Network-
Extension for Community healthcare Outcomes known as SCAN-ECHO.
    The New Mexico VA healthcare system has been aggressive in 
providing comprehensive mental healthcare for veterans from 
prior wars and conflicts to the current OEF, OAF, O & D 
conflicts.
    This includes primary care, mental health integration, and 
an approach that considers the mental health need of veterans 
with a course that is designed to promote an optimal level of 
social and occupational function and participation in family 
and community life for our veterans.
    We continue to promote early recognition of mental health 
problems. Veterans are routinely screened in primary care for 
PTSD, depression, substance abuse, traumatic brain injury, and 
military sexual trauma. Screening for this array of mental 
health problems helps support effective identification of 
veterans needing mental health services. And it promotes our 
suicide prevention efforts.
    In September of 2013, the New Mexico VA healthcare system 
hosted a mental health summit with over 87 community 
participants. The New Mexico VA healthcare system will be 
hosting another mental health seminar in September of this year 
with a focus on mental health access. And there will also be a 
separate track on homelessness.
    There are four vet centers in New Mexico including 
Albuquerque, Farmington, Santa Fe, and Las Cruces.
    The New Mexico VA healthcare system is committed to 
providing high-quality, safe, and accessible care for our 
veterans. We will continue to focus on improving veterans' 
access to care and have instituted numerous changes that are 
showing positive results.
    Our location presents unique challenges with regard to 
distance, culture, and constrained healthcare markets. Our 
rural health programs are robust. And we will continue to 
strive to meet the needs of veterans in rural areas.
    Mr. Chairman, this concludes my statement. Thank you for 
the opportunity to appear before you today in my 30th day on 
this job. My colleagues and I will be pleased to respond to any 
questions you or other members of the committee have.
    [The prepared statement of Elizabeth Freeman appears in the 
Appendix]
    The Chairman. Thank you very much for your testimony. 
Earlier this year PC3 was initiated. How has PC3 been utilized 
here in the Roswell area?
    Ms. Freeman. Mr. Chairman, I'll ask Dr. Robbins to respond.
    Dr. Robbins. I'm happy to.
    Mr. Chairman, I believe it's actually been utilized--it's 
been utilized to some degree. But not as much as would be 
optimal. And one of the--although there is fee basis in this 
area to the tune of about $300,000 or more, PC3 has been not 
utilized very well.
    That's one of the reasons we actually had the CEO of 
TRICARE come to the facility and meet with us about issues and 
found that to be a very productive conversation.
    And one reason that we are looking at mental health access 
in the Roswell area is that those individuals go to PC3. So 
we're beginning to lay the tracks and do more interaction with 
them.
    The Chairman. Can you just explain for us a little bit why 
it hasn't been utilized as much. It's my understanding that 
there are ten mental health providers here in the area. And 
that obviously is a key.
    Obviously the older veterans seem to want to have a face-
to-face. Many of the returning Iraq and Afghanistan veterans 
seem to be comfortable with video teleconference, they Skype a 
lot with their families so they're okay skyping with a 
physician. But why do you think you're not utilizing PC3 much 
here?
    Dr. Robbins. Sir, I think the VA model has largely been--we 
provide what we can in-house and send out-of-house as a 
secondary plan. I think that's something that's one of the very 
things we need to reevaluate now. And we're in the process of 
redoing that.
    The Chairman. I hope you do. I think what we found is that 
the VA, although they do provide quality healthcare and many 
veterans are satisfied with the healthcare that they're 
receiving, it has become very apparent to me that the VA wants 
to grow itself to the detriment in many cases of the veteran.
    Even in your comments, Ms. Freeman, you talked about 
testimony, initiatives, where you're recruiting and adding 
mental health specialists, increasing telehealth, and 
reorganizing programs. But you didn't in your testimony talk 
about face-to-face visits in the local communities.
    VA always seems to want to protect its own bureaucracy. 
Veterans need to be able to get the care they need where they 
want to get it and when they want to get it. And we are 
delivering healthcare today, the whole of healthcare.
    But the model is the same model for civilians. Forcing 
people to drive to facilities? Why? Because you have to have 
the patient census in those facilities in order to justify the 
facility being here.
    That's not necessarily in the patients' best interest. So 
why do you think it's--and I'm not going to pick on you really.
    Why do you think it's so hard? Is it just because of the 
way we have been doing it for so long?
    Ms. Freeman. So if you don't mind, Mr. Chairman, my 
comments are from my experience in Palo Alto. We have 
facilities from Palo Alto to Sonora down to Monterey. And we do 
face that same struggle.
    Sometimes it isn't the desire to keep it in-house because 
we do want to treat each unique veteran and give him or her the 
care he or she needs and has earned. Sometimes it's just a 
matter of, as one of the previous panelists had mentioned, just 
finding the right providers; that we know we want to ensure one 
standard of care in having the highest quality of care that we 
can provide to the veterans.
    But I do think that the choice act is going to give us more 
latitude to partner with community providers to provide those 
services closer to home.
    Dr. Highberger. I'd like to speak to that just from a 
mental health standpoint too.
    There are two things that I think are very unique in the VA 
providing care. And I can say that my father was a Korean war 
combat veteran. He unfortunately was not eligible to get VA 
services because of income. And he had his own insurance and 
that's fine.
    I do think it would have been really beneficial to have had 
the primary care services that VA has because it can pick up on 
these things that are very specific to people who have served 
overseas.
    There are things medically that we look for, we hunt for 
these, to make sure they get addressed. I think that's 
something very unique about primary care. And that's why you 
see it close to home. I think it's the same way with mental 
health.
    So I have worked in the community. I know what I see when 
people come in to me and they're diagnosed with bipolar 
disorder. No one has ever asked them if they've served.
    So there's this sense of protectiveness I think that we've 
had. And it's not about the bureaucracy or the agency. It's 
just very frustrating for us, when we feel like we own that 
care and we're responsible for that care and we want the best 
care, that primary care and mental health are so tied to having 
served that we do tend to hold it more than sometimes I think 
we should.
    And I think that this process going forward will push us to 
really help with the community, help them understand what they 
need to be looking for. Because there are other veterans who 
are not eligible for VA care who will benefit them from that 
knowledge.
    The Chairman. And I think that's a great thing, because VA 
does a lot of outreach, trying to get veterans to come into the 
system and be able to use the system.
    But I think you need to have outreach as well to the local 
providers. I think that's a great first step. And mental health 
I think is one of the those things that, VA has to be in charge 
of.
    You can still do some of it on a non-VA care basis. But 
again why force a veteran to go to VA and get a flu shot. Why 
even knee or, hip replacements, those kind of things can be 
done outside VA to allow you to do the things that only you can 
do. So I appreciate that.
    Mr. Lamborn.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Ms. Freeman, you heard Mr. Moncrief earlier talk about 
telehealth in regards to mental health counseling. And he felt 
it was impersonal.
    Is that a drawback that can be overcome or is it unique to 
each individual or how do you respond to that concern?
    Ms. Freeman. So my experience has been that I think, as the 
chairman just mentioned, that with the newer veterans they're 
much more comfortable with the video telehealth. And they even 
say why would you do it any other way. But then you have other 
veterans of other eras.
    And, you know, I think it's incumbent upon us to meet each 
veteran where he or she is and provide the kind of services 
that are going to be effective for them. If telehealth medicine 
is not going to be effective for veterans of other eras, then 
we have to find a way to provide that face-to-face care, we 
have to find the providers that we know, the protocols that we 
know how to treat those symptoms that are unique to servers of 
this country.
    Mr. Lamborn. Okay. Thank you. Now, you said in your 
testimony that you were doing an outreach by going to different 
communities. Could you elaborate on that, especially concerning 
Roswell in particular, where you've sent teams out to meet the 
folks.
    Ms. Freeman. Sure. If you don't mind if I ask Dr. 
Highberger to talk about that.
    Dr. Highberger. Yes. What I would say is that in general 
we're trying to partner a lot more with the community in many 
ways. So, for example, the issue of homelessness was brought up 
and how do we help, you know. You're a service officer here and 
you're trying to help, you know, your colleague and what is 
there.
    And I think there are times where I think as VA we have to 
recognize we aren't the answer in every way, shape, or form, 
that we have to work with the community. There may be times 
where we need to help develop something up.
    One way that I think we've demonstrated that we can do that 
is through the SSVF program, which is supporting veterans and 
their families through national grants.
    If those grants can help a community agency who is 
interested and committed in working with veterans to develop 
that kind of service that the veteran service officers and the 
veterans and other stakeholders are all identifying as a 
definite need, then that's a good way of trying to partner in 
this and get those solutions together.
    So we might not be able from VA to be in every city and 
every county and have our staff there. And I think we just have 
to accept that it's not all about us. It's really about the 
community as well. And they've got great services that can 
assist us.
    We've got several instances of that throughout with 
incredible partnerships that really work as if they all work 
for the same agency. So I think that's really a demonstration 
of success is where you find it.
    Dr. Robbins. I also think that one of the things that 
happens certainly in New Mexico and probably in other locations 
is it's very easy to sit at the home facility and think of that 
as the world. And I think part of what we have to do is make 
specific and conscious efforts to reach out individually and 
personally to locations around the state and set up events 
here.
    I know that we have a plan to begin visiting the different 
parts of the state every month by a member of senior 
management. And we have a homeless stand down coming up in I 
think it's Carlsbad and one other location in the Southeast.
    So part of it is a conscious effort to reach out, 
understand the problems, and be on the ground in places like 
Roswell, Artesia, and others.
    Mr. Lamborn. Ms. Freeman, what do you think the Patient 
Centered Community Care program, PC3 in shorthand, what do you 
think about that program?
    Ms. Freeman. So I think any vehicle that we have where we 
can provide more timely access and high-quality care to the 
veterans is fantastic.
    And I really appreciated it when Dr. Robbins told me that 
Mr. McIntyre personally came to the Albuquerque VA last Friday. 
And when Mr. Gibson was Acting Secretary, he had asked us if we 
had any challenges with PC3.
    And he mentioned how closely Mr. McIntyre and TriWest is 
working with VA. And I think that personal meeting demonstrates 
the kind of commitment that TriWest has to meet the VA's needs 
and providing care closer where veterans live.
    Mr. Lamborn. Okay. Thank you.
    The Chairman. Mr. Pearce.
    Mr. Pearce. Thank you, Mr. Chairman. Ms. Freeman, you've 
heard the comments about the payment and it's something that I 
hear frequently by providers. Is that something that you all 
dedicate an office to or staff to or how do you handle those 
complaints?
    Ms. Freeman. Sure. So there is a centralized process for 
fee payments; is that correct?
    Dr. Robbins. For the New Mexico VA health, there is a 
coherent centralized office under one management.
    Mr. Pearce. So it exists already?
    Dr. Robbins. Yes.
    Dr. Highberger. Well, there are two separate things. And I 
think what you may be asking about is the actual payment of the 
bill. So the payment of the bill is actually a partnership that 
VISN 18 has developed with VISN 19.
    We were struggling with paying our venders. We knew that 
was not good for our relationship and that ultimately hurts our 
veterans. So what we did was we found a VISN who was doing it 
well. And instead of trying to rebuild or duplicate, we said 
can we partner.
    And we helped with resources to them to then pay our bills. 
So in the facilities we have a non-VA care office who 
coordinates, who makes sure that everything is functioning 
correctly, who makes sure that the billing to VISN 19 is going 
to pay our bills.
    Ms. Freeman. If I may add. A target level similar to what 
occurred a few years ago in the third--in the medical care 
costs recovery, whatever the acronym for that is, for veterans 
paying in when they have a co-pay. That was centralized 
regionally with a similar effort that should be going forward 
in FY 15 to further centralize those payments.
    Mr. Pearce. I'm just trying to draw attention with a little 
WD40, because it doesn't work very well a lot of times.
    Ms. Freeman, does the honor guard come under VA? Honor 
guards for burials, is that a part of the VA?
    Ms. Freeman. I would be happy to follow up on that.
    Mr. Pearce. Let me make a comment in case it does. I've got 
a young soldier here that came today. He just got notified by 
text message that they were going to cut that department out or 
they were going to cut funding to it.
    First of all, that's not the way that you should be telling 
people that have been cut back. And then secondly, you wonder 
why. Because the VA budget is not being cut. So it may not come 
under you. I've been asking questions about that. And I still 
don't have an answer for myself.
    Mr. Robbins, thank you very much for making sure this pilot 
project is ongoing, because it is buzzing around the state. 
People have heard about it, there's a sense of excitement, 
there's a sense of relief. And I appreciate that you have 
honored your promise there at that meeting.
    How many people are going to actually be seen in this pilot 
project? Our agreement was one day. They've actually made it 
several more days to make it more comprehensive. How many 
people are we going to see, just give us an ideas of that?
    Dr. Robbins. It's roughly nine, it should be nine patients 
today and tomorrow that are primary care.
    Mr. Pearce. At one point you had 35 or 36. Did they just 
not materialize, what happened there?
    Dr. Robbins. It was a variety of issues. The primary issue 
was the primary care was wanting to focus on a small enough 
group to where we could be sure that we got something going as 
an additional start.
    Mr. Pearce. Do you have an attempt to kind of continue this 
on and then maybe expand it out? Because the further you get 
away from Albuquerque, the longer the drive and the more 
intensity.
    So I was in Hobbs, Jal, and back around. They were saying 
when are we going to get our pilot project. So what's your 
intent on the longer term?
    Dr. Robbins. Yes, sir. I just want to comment that I want 
to thank you very much for raising this issue to us and for 
collaborating with us. It's been an excellent experience, very 
positive for the veterans. And we are thoroughly committed to 
this and intend to continue it.
    Mr. Pearce. Mr. Chairman, I have more questions I would 
like to save for the second round.
    The Chairman. Ms. Freeman, in May of last year, the 
Undersecretary for Health instructed you to hold the health 
summit. And you did hold a mental health summit. And you've 
said you've got another one coming up I guess in September or 
October.
    One of the things they asked you to do was identify 
community partners. Who did you identify as your most active 
community partners during that summit? And did you enter into 
any formal agreements with any of them?
    Dr. Robbins. Sir, we did not. The New Mexico VA did not 
enter into any formal agreements based on that summit. There 
was a lot of dialogue. There were two very important issues 
discussed and I believe improved on.
    One was access by who to call, who to call if you have a 
problem. We're in the VA, we're in the VA system to call. And 
the second was the suicide prevention coordinator developed 
some additional contacts and ability to do more outreach.
    The Chairman. How do you schedule your appointments now, 
how is that working? And mostly primary, maybe mental health. 
This is the whole thing that blew up.
    Dr. Highberger. Right. I can speak to that. What we're 
doing and we have been doing for several years in VISN 18 is 
trying to audit, trying to find those areas to recommend 
specifically to a facility to modify, and trying to get to 
where we're in compliance with the scheduling directive; and 
most importantly that we're able to thus get people the 
appointments when they need them, where they want them.
    And it has been a challenge. It's taking a long time. The 
efforts that we've been doing we've ramped up the speed of. I 
think it's been hard for our schedulers to fully understand and 
implement. I think it's a complicated process. It's taking a 
lot of reteaching to get it right. But we're making sure we get 
it right.
    The Chairman. What's the complicated process?
    Dr. Highberger. So in that system, again it's a blue screen 
DOS system, it is a challenge for the staff.
    The Chairman. I'm sorry. But is that not part of the 
problem, you've got a DOS system today?
    Dr. Highberger. I agree. I absolutely agree.
    The Chairman. Do you know how many hundreds of millions of 
dollars have been appropriated to VA for IT and we're still 
using a DOS scheduling system?
    Dr. Highberger. I agree.
    The Chairman. Not your fault.
    Dr. Highberger. I agree. And when people come in, some 
people--I'm old enough, I remember the DOS system and blue 
screens and how you have to type commands prior to better 
technology. Some people have never even seen that technology 
and they're hired into those roles. So that's one issue.
    The second issue that I think is more important is lot of 
people who were doing it wrong had no clue they were doing it 
wrong, including even now with retraining we have some people 
speak up, they say this is what you do, they are able to 
verbalize it.
    And one of the benefits of--our staff went down observing 
them scheduling--is that they will then not do it correctly 
even after they just verbalized it correctly.
    So there's more education and more communication that has 
to occur. There's a lot of auditing that has to occur. We want 
to get it right. We're trying every which way to get it right. 
But it's still a work in progress.
    The Chairman. Whose responsibility is it to make sure it is 
done correctly?
    Dr. Highberger. I think it comes at many levels. I think 
one is that we have a direction that we're given that is 
challenging, it's not what we do in the community. So we talk 
about desire dates.
    These are things that don't get looked at or examined in 
the community. So it's a new concept to try to teach people. 
These are entry level positions typically in the system. So 
these are people's first exposure to VA. And there's a lot of 
learning.
    They're also high turnover positions. So even if you are 
doing the right thing and supervising, you're following through 
and you're educating, your staff are turning over repeatedly.
    And it's a good thing because they're usually getting 
promoted. Most of these people are veterans, most of them are 
getting promoted up through the system. But you've got to start 
over then.
    So I think it comes from the supervisor, it comes from the 
employee, it comes from what we're directing above, you know, 
about what to do. And it's not been a simple thing to fix.
    The Chairman. Doctor, one of the things that I've heard 
from physicians in particular is that they have no control over 
the scheduling system themselves.
    And so if you say this patient should be seen within five 
days, you don't know whether that patient gets seen within five 
days. And we now have horror stories out there that have 
occurred because the doctor's orders were not followed. How do 
you prevent errors like that from occurring?
    Dr. Robbins. So I agree, sir, that that is probably one of 
the worst things that can happen. And one thing that we've done 
is in our facility, one of the barriers to getting the 
scheduling process right has been that the schedulers were 
scattered all across the facility or organization.
    We're beginning to unify that and pull in schedulers into a 
single organizational unit so that we can train them 
consistently, so that they can feel that they're getting a 
consistent message about that.
    I will say that, because of my concern about that specific 
area, when I went around to each of the CBOCs and as well as in 
the main facility, that is something I specifically asked about 
for everyone.
    If the physician orders something, the physician orders 
some follow-up, and you cannot meet that, meet what the 
physician wants, you must go back to the physician or the 
provider and get clarification. It has to be a medical 
decision.
    The Chairman. As the acting interim medical center 
director, do you still see patients?
    Dr. Robbins. I do not, sir.
    The Chairman. Are you credentialed?
    Dr. Robbins. Sir, I have credentials as a part of my normal 
job as CMO. But I don't have privileges so I'm not able to 
practice.
    The Chairman. We keep talking about lack of physicians, yet 
we have physicians all through the VA system that don't see 
patients. I mean I know there's a lot of things you can't do.
    But in an emergency, when we need to serve the people I 
find that hard to believe. But that's the way VA has always 
done it. So again I'm not trying to come down on you. But I'm 
just telling you, do you have any idea on how many physicians 
work for VA that don't see patients?
    Dr. Robbins. I don't, sir.
    Dr. Highberger. I would like to respond to that. It's my 
impression, this is just my impression, that it's about 50/50 
with people continuing to see patients when they take on a full 
administrative load.
    I do still see patients, I am credentialed and privileged. 
I have tried to keep even just a half day every other week. And 
I can tell you that the administrative duties have wiped that 
out nearly completely.
    Our business was downsized, I don't have support staff. 
It's not as simple as just dropping my duties. If I'm not there 
as the acting chief medical officer to review those applicants 
for the Phoenix facility, for Albuquerque, for El Paso who have 
issues with their credentialing, that person can't get hired 
until I do it. I'm the only one that can do it.
    So there's a real trade-off there. Now, I do still want to 
see patients. I was assisting El Paso by telehealth. I can tell 
you that that pull for me to do that is very strong. But when I 
go over to Phoenix or I go to a CBOC that I'm privileged to see 
patients in, there isn't the space for me.
    The Chairman. Part of the bill is we have billions of 
dollars for space. But, you know, one thing the VA is not good 
at doing is thinking outside the box. Instead of extending the 
hours of a facility, they want to build a whole new facility.
    It's like why not extend appointment times that just happen 
to be when a veteran probably could come so they don't have to 
take off work to go to VA.
    But because VA wants to do fairly normal working hours, 
we've got to build a whole other facility because we don't have 
the space. So we're going to have to crack this nut. And it 
ain't going to be easy.
    Dr. Highberger. I agree. And I did work extra evenings even 
to support that CBOC to do that.
    The Chairman. You said the key. You said the key. Support 
is important. I mean I don't know how many veterans have told 
me their doc never looks them in the eye because they're 
staring at a stupid computer screen.
    Why? Because they have to fill out all kinds of garbage to 
CYA VA 20 years down the road if we ask did you do this, did 
you do that.
    Look, that's not what a highly skilled, highly paid 
physician should be doing. They don't do that in the private 
sector. But VA does it. We've got to fix that.
    Dr. Highberger. I agree. I think one of the most important 
things that I see in that bill, at least specifically speaking 
to VISN 18, is space. So I've had times where I've scheduled 
patients.
    And I literally had to take a patient over into my VISN 
office that is not set up for seeing patients. People open up 
my door and interrupt. And I had to stop because it wasn't 
right, it wasn't right.
    And so, you know, I think with additional space, you're 
going to see a lot more patient care occurring from 
administrative physicians. It is a desire of mine to definitely 
do that.
    The Chairman. I'll bet you don't. I'll bet you don't. 
Because that's not what they're accustomed to doing. But I hope 
you're right.
    Mr. Lamborn.
    Mr. Lamborn. Thank you. Let me build on this really 
important line of thought that the chairman has been pursuing.
    I know VA has a lot of metrics. So many that that consumes 
a good part of your working day. Do you think that we could 
really reduce the number of--I know probably every single one 
of those is well-intentioned. But can we do a drastic job of 
reducing that so that more patients can be seen during a given 
day, any one of you?
    Ms. Freeman. So I really appreciate the question, because 
there used to be something called a performance measure work 
group nationally. And I was one of the few field members as a 
facility director on that group.
    Every time a new measure got added, you know, if it wasn't 
myself personally or my physicians, my nurses or my staff would 
be impacted by those additional metrics.
    And so I completely agree with you that my observation in 
the community where I live and my regular job, they have a 
corporate scorecard that has ten or less. And even the board 
pushes back and says it should be seven or less corporate 
goals.
    And that's what community healthcare systems, at least what 
I've seen, operate under. So we have a very clear goal 
deployment.
    I'm not saying there are lots and lots of things we have to 
do in the background because we are healthcare and there's lots 
of outside entities that audit us. And it's very important to 
ensure the quality of our care.
    But we need to be able to articulate that to everyone, from 
the front-line employee to the head administrators, so that 
everybody is working toward the same direction.
    Mr. Lamborn. I really--I hope that this is one of the 
things that the Congressional CARES Commission--I hope I 
pronounced that correctly. But one of the commissions that the 
bill sets up, Mr. Chairman, that's going to look at VA from the 
ground up.
    I really know we need to get into this so that highly 
trained care providers can get back to the basics of what they 
are trained to do and do not have to have their face glued to 
the computer screen like the chairman just said.
    Dr. Highberger, what do you say about that?
    Dr. Highberger. I think what I see is that you throw so 
many metrics at people--it becomes a blur. I think sometimes 
it's easy to get lost in the real message that's supposed to be 
there. I know for VISN 18, what we've been preaching for years 
is that it is not about the metric. The metric reflects the 
care.
    I don't know how well we get that message communicated all 
the way down to every employee. But I know that's what we 
believe. I think, if you look at it that way, having more 
metrics perhaps is okay. It's just different reflections of the 
care.
    I think that the way we've done it, though, we've had too 
many splittings off in too many directions and then losing the 
real focus, which is the veteran and what is the care like for 
them, how are they experiencing it. It doesn't matter what the 
metric says.
    Mr. Lamborn. And lastly, and maybe this is a metric. But 
what is the average waiting time in New Mexico for primary, 
specialty, and mental healthcare?
    Dr. Robbins. Sorry. Give me just a minute. The average 
primary care wait is 47 days. The average specialty care wait 
is 64 days. And the average mental health wait is 41 days. 
Those are new patient wait times.
    Mr. Lamborn. New patient. If someone calls in for ongoing 
care, it could be different, higher, lower? Do you have those 
numbers?
    Ms. Freeman. The VA is reporting wait times in two 
different ways. He just gave you the prospective wait times. 
And the completed new patient primary care average wait time is 
the end of June; is that correct?
    Dr. Highberger. Correct. It's appointments that were 
completed at the end of June.
    Ms. Freeman. So for appointments it's the end of June. For 
primary care for new patients the time they actually wait----
    The Chairman. Wait, wait, wait. What the hell is a--what 
did you just call it, a primary prospective new patient? What 
kind of--you guys, quit. You keep changing the rules.
    The Chairman. All we want to know is how long does it take 
a veteran to see a doc, period?
    Dr. Highberger. Sir, I agree.
    The Chairman. Don't give me three different ways to do it. 
This has gone real well up until this last little bit.
    Dr. Highberger. So these are the data that are published on 
the website for transparency purposes.
    The Chairman. That doesn't mean anything. I don't care 
where it's published.
    Dr. Highberger. I understand. This is what we're----
    The Chairman. Anybody in here get a primary care 
appointment within 40 days?
    There ain't a hand up. None. When did we start this new 
measuring?
    Dr. Highberger. The data is the same.
    The Chairman. No, no, no, no. When did we start this new 
process? Because it's something that I've never heard of 
before.
    Dr. Highberger. So this is the new process.
    The Chairman. No. My question is when did you start it?
    Dr. Highberger. It was in May.
    The Chairman. That's all I need to know. When the crap hit 
the fan, you changed the metric again. Stop. Stop it. These 
veterans deserve better.
    Dr. Highberger. I agree. We have no control over these 
metrics, sir.
    The Chairman. Yes, you do. Raise your voice. Tell your 
leaders it's not working, your veterans aren't being served. 
Don't tell me you can't do it.
    Dr. Highberger. We are and we have.
    Ms. Freeman. And we will.
    Dr. Highberger. And we will continue.
    The Chairman. Good. Steve.
    Mr. Pearce. Thank you, Mr. Chairman. One of the things that 
I hear literally from providers from VA and from veterans alike 
is fear of reprisal.
    So many people did not want their names used as I talked 
about their items. Are you all addressing the fact that we 
can't cure the problems when people can't talk about it inside 
the system?
    Ms. Freeman. Absolutely. And one of the things at my home 
facility that we promulgate and that I have shared with some of 
the executives in VISN 18 to see if they're interested in 
trying to hear is we really want a healthcare system where 
every employee that comes to work every day sees themselves as 
a problem solver.
    So they're all contributing to continuous improvement and 
improving the quality of care we provide to veterans. And it's 
been stated, you know, over 30 percent of our employees are 
veterans. We are veterans serving veterans.
    Mr. Pearce. But there's still fear of reprisal.
    Ms. Freeman: Absolutely. And as the chairman mentioned at 
the very opening of this hearing, a culture is our habit, it's 
the way we do things. And it won't change overnight.
    But we have to start. We have to engage every employee 
every day and continuously improve. And raising their hand 
saying the issues that they think need to be addressed and have 
a system of closing that loop and addressing those.
    Mr. Pearce. Dr. Robbins, we have discussed in one of the 
previous meetings a practice where you have the physician 
leave. You assign his patients over to a doctor that didn't see 
patients in order to make the system sort of look like it's 
working on paper or the computer. Has that situation been 
resolved?
    Dr. Robbins. Yes, sir.
    Mr. Pearce. That's all I want to know. Just it's been 
solved. What is the scope, Dr. Robbins, of the nine people 
being seen here today and in the future, do we have any PTSD, 
anybody seeing mental health providers here as part of that?
    Dr. Robbins. So the nine folks today and tomorrow, those 
are all primary care. Those are primary care appointments.
    Mr. Pearce. So you are open to people seeing mental health 
professionals here?
    Dr. Robbins. Absolutely.
    Mr. Pearce. So you were there for a fairly energetic 
exchange between your staff member and myself over the fact 
that people--doctors, hospitals, will not see people for 
basically the cost of gasoline.
    I suspect that's the reason that we've never moved any 
further towards letting veterans see local providers, because 
of that internal belief that the system doesn't need to change 
and will never need to change.
    Is there any more clarity inside your staff there in 
Albuquerque about the willingness of local doctors, local 
hospitals to see patients and the reasonableness of the 
service?
    I mean you heard one guy say--you heard Mr. Moncrief say 
his appointment was 75 bucks. And you've got to pay him $160 
for gasoline. Is that sinking in, especially the gentleman that 
we had the discussion with?
    Dr. Robbins. Yes, sir. We clarified that shortly after you 
left.
    Mr. Pearce. Okay. I think my last--that was my last 
question. No, no. I have one more. What level did you have to 
go to to get this pilot project approved, were you able to do 
it or did you have to go to a higher chain of command, did you 
have to go to the Secretary level?
    Dr. Robbins. Sir, we spent some effort and some time trying 
to figure that out. But as it turned out, these were actions 
that were within our existing authority at the facility level.
    Mr. Pearce. So you all were able to make the decision in 
Albuquerque, you did not have to get an approval to run this 
project here?
    Dr. Robbins. That's correct, sir.
    Mr. Pearce. Mr. Chairman, I yield back. And thank you very 
much for having this committee hearing here in Roswell, New 
Mexico.
    The Chairman. I want to thank everybody for attending. And 
I do want to say thank you, VA, because you are the tip of the 
spear. And don't think that, because you're way out in 
Albuquerque and the central office is way over in Washington, 
that you can't make a difference, because you can. You can.
    Your veterans are telling you what they need. The system 
has got to change. As a mental health provider, you know you 
have to listen. And unfortunately that's not been the case at 
VA for a long time.
    We have a golden opportunity to help VA become the very 
agency that they should be. And I have said it a dozen times in 
the last week.
    Thank you for being here. We truly appreciate what you do 
on a daily, weekly, and nightly basis because I know you work 
hours that many don't think you do.
    I would ask unanimous consent that all members have five 
legislative days in which to revise and extend their remarks.
    The Chairman. Again, thank you, everybody, for being here. 
This hearing is adjourned.
    [Whereupon, at 1:00 p.m., the committee was adjourned.]

                                APPENDIX

                                 

             Prepared Statement of the Chairman Jeff Miller

    Good morning and thank you for joining us today.
    I am Jeff Miller--Chairman of the Committee on Veterans' Affairs 
for the United States House of Representatives and Congressman from the 
First District of Florida, where--as we like to say--thousands live 
like millions wish they could.
    I am joined here today by senior Committee Member and the 
Congressman from the Fifth District of Colorado, Doug Lamborn, and by 
our friend and colleague and your Congressman, Steve Pearce.
    I know I speak for Rep. Lamborn (Doug) as well when I say that I am 
grateful to Rep. Pearce (Steve) for his hard work, leadership, and 
advocacy efforts on behalf of New Mexico's servicemembers and veterans.
    I am grateful to him for inviting us to New Mexico today and am 
honored to be here in Roswell with all of you.
    Before I go any further, I would ask all of the veterans in our 
audience today to please stand, if you are able, or raise your hand and 
be recognized?
    Thank you so much for your service.
    Ensuring that you and your veteran friends, neighbors, and 
colleagues in New Mexico and across the country have timely access to 
high-quality healthcare through the Department of Veterans Affairs (VA) 
is why we are here today and I am grateful to you for joining us this 
morning.
    As you all know, in April, a Committee investigation and 
whistleblower revelations exposed widespread corruption and systemic 
access delays and accountability failures across the VA healthcare 
system that left thousands of veterans--including some right here in 
New Mexico--waiting for weeks, months, and even years for the 
healthcare they earned through honorable service to our nation.
    In the four months since, the Committee has held multiple hearings 
to get to the bottom of the Department's deficiencies; VA senior 
leaders have resigned and been replaced; and, nationwide initiatives 
have been undertaken.
    Just last week, Congress passed a bipartisan Conference agreement 
that will improve accountability for VA employees; increase access to 
care for veteran patients facing lengthy waiting times or residing far 
from the nearest VA facility; and pave the way for long-term reforms 
that will dramatically improve the Department for veterans today and 
for generations to come.
    Needless to say, it has been a busy summer.
    However, our work is just beginning.
    During today's hearing, we will discuss the challenges Roswell 
veterans experience accessing care--particularly mental healthcare--
through Veterans Integrated Service Network (VISN) eighteen and the New 
Mexico VA healthcare System.
    In short, things could certainly be better.
    VA's nationwide access audit found troubling scheduling practices 
were in place at the Albuquerque VA Medical Center and I want to hear 
from our witnesses-- local veterans and local VA officials--how those 
practices have impacted the care veterans receive here and what actions 
have been taken and still need to be taken to improve access to care 
for New Mexico veterans.
    I look forward to our discussion this morning and to taking your 
thoughts and ideas back to Washington when we leave.
    I thank you all once again for being here this morning.

                                 

  Prepared Statement of John Taylor, Sergeant, U.S. Army (100% Combat 
                             Disabled Ret.)

    Chairman Miller and Members of the House Committee on Veterans 
Affairs, it is an honor to provide testimony before you today.
    My active duty combat military experience was with the 101st 
Airborne Rangers in Vietnam. After seeing many of my brothers die in 
heated combat situations within the infamous A Shau Valley area of Thua 
Thien/Hue, and being shot twice and bayoneted on the same day, dying on 
the MASH unit surgery table (and obviously returned to life), I never 
imagined any of us would come back home to die directly related to post 
combat medical care in our VA hospitals. Sadly, as you are now aware, 
that has become a painful reality.
    After being combat disabled retired from the military, I completed 
my degree in Business Administration, with a Pre-Med Biology minor. 
Half of my career was spent in corporate management for Dun & 
Bradstreet. More important to this hearing, I spent the last half of my 
career (12 years) in medical administration; hospital director, nursing 
home administrator, medical hospital-satellite manager, urgent care 
center director, substance abuse center director and psychiatric center 
director.
    In the interest of saving this Committee time with respect to my 
evaluations and solution recommendations, please let me refer you to a 
previous field hearing you had on 10 July 2014, ``Service should not 
lead to suicide: Access to VA's mental healthcare.'' One of my younger 
brothers'-at-arms, U.S. Army (RET.) Sgt. Josh Renschler's gave an 
excellent testimony before this Committee. Even though we came from 
different wars, basic problems, observations, and suggested resolutions 
are essentially the same. I can, however, give you a significant 
variation I would term ``acute rural'ality''. Being in a rural, desert 
community, systemic problems encountered throughout the country are 
greatly intensified in southeastern New Mexico. As a quick example; 
Following the Cares Commission findings during President Bush's last 
term in office, a Director of Rural Administration was created to help 
eliminate our acute problem of rural access in our area. As it turned 
out, that rural administrator responsible for resolving our problems 
was none other than our Administrator of the Albuquerque VA Hospital,--
the very person, historically, refusing our request for local fee-base 
services. Ineffectual outcomes are obvious.
    For the last nine years, I have published a weekly ``Veterans 
Advocate'' column in our local newspaper, the Roswell Daily Record. The 
column is a volunteered, non-compensated, freelance work, having no 
allegiance to any person or group, except to my brother and sister 
veterans. Over the years, I've made members of both sides of the aisle 
uncomfortable to say the least. However, the majority of my rants have 
now shown to be true. Like so many other public-forum veterans' 
advocates are asking, ``Why did it take the recent deaths of so many of 
us to prove what we advocates have been claiming for so many years was 
true?''
    It is important to note, our deaths were majorly not due to medical 
care provided by our VA medical professionals (physicians, nurses and 
medical support personnel), but from administrative ``games'' played by 
VA administrative leaders and by system oversight groups. I've made 
that statement publicly, several times over the last nine years, only 
to be ignored or politely told either ``were working on a resolution'' 
or ``you're not correct in your accusations''. Finally, saddest of all, 
my claims have been validated with the many deaths recently 
``uncovered'' (and still being uncovered) thanks to courageous 
whistleblowers. The retaliation they received, as you all have been 
made aware, is the perfect example of the VA's response to anyone 
questioning the VA's activities. Veterans, families and friends have 
not, and continue to not, come forward due fear of reprisal. The VA has 
historically denied this to be true, but as you yourself have recently 
seen, the VA seems to have a problem with the truth. I personally can 
offer proof this has occurred long before the recent ``awakening''.
    I have respectfully submitted a few of my VET ADVO columns in 
support of my testimony today, most of which are 6 to 9 years old. This 
illustrates real-life catastrophes I have encountered over my nine 
years as advocate, which were literally ignored or denied as being 
accurate by our State VA administrators and Government officials. We 
all now know how invalid the VA denials were, and still are. Two 
specific sets of columns illustrate factually the problems and battles 
we have faced with the Albuquerque VA Hospital administrators, 
consistently denied by the VA as being accurate.
    1. The first was a series of columns I did on a chronic PTSD 
veteran who over the space of more than one year threatened to commit 
suicide due to his Desert Storm nightmares. His wife approached Col. 
Ron McKay (USMC Retired) and me with horror stories of her lack of 
effective treatment for her husband by the VA. Apache (my column name 
for my brother to respect his privacy) had undergone several 
``treatment modalities'' lasting from three days to three months in-
patient sessions. More than once, he was sent home in a cab (for a two 
and one half hour drive), before which he would ask the driver to 
``swing by'' the nearest Albuquerque liquor store to make his journey 
easier. His primary substance abuse/dependency directly related to his 
PTSD was alcohol. Knowing this, his treatment team and or patient 
discharge planner should have known this was a perfect storm doomed to 
failure. Each time, Apache return home totally inebriated, once again 
threatening suicide. He was instructed by his Albuquerque VA treatment 
clinician to report to a local VA social worker for ``after-care''. 
During the first visit (Apache and his wife), as reported by his wife, 
the counselor asked, ``So what is it you want me to do? You know, you 
could go to AA and get some help.'' A furious Apache and his wife got 
up and left. In my experience as a director of a psychiatric center and 
an inpatient substance abuse center, after-care for either malady 
requires, at a minimum, the services of a certified psychiatric 
counselor or certified substance abuse counselor (for facility 
licensure by Texas and New Mexico), not a social worker. Eventually, 
Apache was found dead one night outside his house, in spite of repeated 
request to the VA for help keeping him alive. The VA response? He was 
non-compliant. In other words, they gave up!
    2. The second set of columns dealt with several cases I followed 
involving the unacceptable six-plus hour round-trip drive to the 
Albuquerque VA Hospital from Roswell. One involved an 86-year-old 
veteran with stomach cancer (with an active drainage catheter) who had 
to be driven to Albuquerque 2 to 3 times a month by his 87-year-old 
wife, who was in failing health herself. His primary care physician at 
the VA Artesia clinic had requested approval for him to be seen 
locally, in Roswell. That approval never came. To this day, I have the 
uneasy feeling Mr. Borum died prematurely due to the stress this put on 
his system.
    3. Additionally, in one column I actually reported a conference 
call I had with VA Albuquerque Administrative Staff concerning fee-
based (local contract) dental care for 100% service-connected veterans 
in Roswell. The assurances and ``promises'' of local contract dental 
care by administrative heads in Albuquerque were later found to be 
lies, subsequent to my telephone visit with a staff dentist at the 
Albuquerque hospital. When I approached the VA Hospital Administrator 
at that time, he refused to review the incontrovertible evidence I 
offered him. His response to me (several times) was, ``My people don't 
lie!'' I have reliable witnesses to that encounter. To the point of 
ineligibility for local care (fee-based services) in Roswell, Roswell 
has been denied local access to fee-based services because it was 
``determined'' by the VA to be less than 40 miles from the nearest 
CBOC. That also has been a lie each and every time it was offered by 
the VA. Last week, I measured the actual distance from our nearest CBOC 
(Artesia, New Mexico), and found it to be (exactly) 45.6 miles to my 
front door, and 43.8 miles from the center of town, accurately showing 
half of Roswell is at least 44 miles from the Artesia VA CBOC (greater 
than the ``less than 40 mile'' rule). This certainly was not the 38 
mile VA calculated distance given in our several denials for local 
contract services. Additionally, when Taos, New Mexico received a 
``shadow clinic'' which we were also promised, we were denied due to 
the 38 mile determination. I did a study finding that Taos was in fact 
closer to its nearest CBOC than Roswell was to the Artesia VA clinic. 
In fact, there were over 100 clinics built in our quad-state region in 
violation of the ``40-mile'' rule.
    I apologize for this lengthy testimony, but after nine years of 
reporting on these issues and warning everyone of the obvious, 
predictable outcomes, I hope this report does not, once again, fall on 
deaf ears. Simply stated; (1) Systems monitored by its own department 
members (no matter the claims of independent watchdog status) do not 
and will not work. (2) Paying bonuses to upper echelon administration 
is a crafty mechanism created by ``upper management'' to milk the 
system. I know! I've been there. In my many years as a medical 
administrator, my reward (bonus if you please) was continued employment 
next year. The contrived reason for VA bonuses (reported in other House 
and Senate committee hearings) is to entice and retain competent 
administrators. That, Hon. Committee members, is a fallacy perpetrated 
on those who have not worked in the medical arena. Competence in our 
current VA administration (based on this bonus rule) has been proven 
grossly lacking among our current VA ``hand-pick'' wonder kids! In my 
experience, it's safe to say you would find a sufficient queue of 
qualified applicants for each VA administrator position you currently 
find ``not up to par''. Current doctors and medical administrators 
being RIF'ed (Reductions in Force) in the Administration's military 
drawdown could easily and effectively be placed in certain comparable 
positions recently found ``lacking'' within the VA administrator 
network.
    I sincerely hope my testimony and attached resource materials will 
help you with your enormous task of keeping my brother and sister 
veterans alive once they return home, after surviving death on the 
battlefield.
    I would be pleased and honored to answer any questions you may 
have. God bless you in your efforts, God bless my brother and sister 
veterans, and God bless our Nation. Thank you.

                                 

                 Prepared Statement of Richard Moncrief

    I would like to thank the committee for giving me the chance to 
speak out about the lack of Mental healthcare in the Southeast corner 
of the state.
    I have been using the Mental Health services in the Artesia Clinic 
for several years now. With the loss of Dr. Peter K. Hochla we now are 
going to be forced to use the telemed system which is a very impersonal 
way of conducting mental health. The men and women who suffer from PTSD 
and TBI need to have a live physical being to talk to. Better yet to 
have Group Therapy with a skilled group leader and a Psychologist would 
even be better.
    Having a warm body to talk to, in person is better than a Flat 
Screen for the patient. The talk is more personal and you can see the 
body movements and make better eye contact with the person doing the 
counseling.
    When Dr. Peter K. Hochla was here every 3-6 months, I still needed 
to talk to someone to be able to let my hair down and be relaxed. I 
ended up hiring a MA, LPCC (Licensed Professional Clinical Counselor). 
I tried to use TRICARE, but they did not pay the going Medicare rate so 
I ended up paying for the Counselor out of my pocket.
    There is a very great need for some kind of skilled counselor in 
this part of the Country.

                                 

              Prepared Statement of Ms. Elizabeth Freeman

    Good morning, Chairman Miller, Congressman Pearce, and Congressman 
Lamborn. Thank you for the opportunity to discuss the New Mexico VA 
Healthcare System's (NMVAHCS) commitment and accomplishments in 
providing Veterans accessible, high quality, patient-centered care and 
to specifically address rural healthcare and access to mental 
healthcare in New Mexico. I am accompanied today by James Robbins, MD, 
Interim Medical Center Director for NMVAHCS, and Lori Highberger, MD, 
Deputy Chief Medical Officer and Mental Health Lead for the VA 
Southwest Healthcare Network.

New Mexico VA healthcare System Overview

    The NMVAHCS serves Veterans in New Mexico, southern Colorado 
(Durango area), and west Texas. NMVAHCS is comprised of the Raymond G. 
Murphy VA Medical Center (VAMC) with 13 Community-Based Outpatient 
Clinics (CBOC). The Raymond G. Murphy VAMC is a Joint Commission-
accredited, VHA complexity level 1a, tertiary care referral center 
located in the heart of Albuquerque, New Mexico. It provides a full 
range of patient care services with state-of-the-art technology as well 
as education and research. It is the only VAMC in New Mexico.
    The Raymond G. Murphy VAMC is a teaching hospital, affiliated with 
the University of New Mexico School of Medicine and College of Nursing. 
It has an active partnership with Kirtland Air Force Base 377th Medical 
Group and collaborates with Indian Health Service and Tribal healthcare 
organizations. The facility has an active Community Living Center, a 
26-bed Spinal Cord Injury Center, and a strong commitment to 
psychosocial rehabilitation and vocational rehabilitation. VA-staffed 
CBOCs are located in Artesia, Farmington, Gallup, Silver City, Raton, 
Santa Fe, and Northwest Metro (Rio Rancho), New Mexico. Contract CBOCs 
are located in Alamogordo, Truth or Consequences, Espanola, Las Vegas, 
and Taos, New Mexico, and Durango, Colorado. The VAMC is a tertiary 
referral facility for Veterans from the VA facilities in Big Spring, El 
Paso, and Amarillo, Texas.

Rural Health in New Mexico

    The VHA Office of Rural Health (ORH) supports programs and 
initiatives in the areas of Veteran transportation, telehealth, 
resident and allied health student rural clinical training and 
education, and care closer to home via primary care and mental 
healthcare extension teams that leave the VA facility and treat 
Veterans in their remote communities. Over 45 percent (77,493) of New 
Mexico's 170,799 Veterans live in rural areas of the state. 
Approximately 74,713 New Mexico Veterans are enrolled in VHA 
healthcare, and 47 percent (34,982) of those enrolled Veterans live in 
rural areas. NMVAHCS serves a geographic area that is 121,826 square 
miles. ORH currently supports nine projects for a total of nearly $1.9 
million in the state of New Mexico. These projects increase rural 
Veteran access to mental healthcare, women's healthcare, primary care, 
pharmacy services, and neurology services. Five of these nine projects 
use telehealth to deliver healthcare closer to Veterans' homes.
    One currently-funded ORH initiative is Home Based Primary Care 
(HBPC) for Veterans residing in rural areas near Santa Fe and Artesia. 
The HBPC program provides primary care services for frail, chronically-
ill Veterans in their own homes. HBPC is available in the Gallup CBOC 
and is being expanded to the Santa Fe and Artesia CBOCs. Another ORH-
supported initiative focuses on diabetes education and overall health 
and wellness for Southern Ute American Indian Veterans. NMVAHCS 
continues to work with ORH to develop innovative project ideas to 
increase rural Veteran access to care and services.
    In the recent past, Farmington, Silver City, Raton, and Artesia 
CBOCs were relocated to new clinics with increased space. New clinics 
for Gallup and Santa Fe CBOC relocations will be activating in calendar 
year 2014. The Truth or Consequences Contract CBOC will have a new 
contractor in approximately one year.

Telehealth in New Mexico

    The VA healthcare system offers expanded access to mental health 
services with longer clinic hours, telemental health capability to 
deliver services, and standards that mandate rapid access to mental 
health services. Telemental health allows VA to leverage technology to 
provide Veterans quicker and more efficient access to mental healthcare 
by reducing the distance they have to travel, increasing the 
flexibility of the system they use, and improving their overall quality 
of life. This technology improves access to general and specialty 
services in geographically remote areas where it can be difficult to 
recruit mental health professionals. In areas where CBOCs do not have a 
mental healthcare provider available, VA uses secure video 
teleconferencing technology to connect the Veteran to a provider within 
VA's nationwide system of care. The program is also expanding directly 
into the home of the Veteran using Internet Protocol (IP) video on 
Veterans' personal computers.
    There is increased support for group specialty care through the 
expanded use of Clinical Video Telehealth (CVT) technology. The use of 
this technology in homes is on the rise, especially aiming to assist 
American Indian Veterans, who are the most rural, isolated, and 
transportation challenged. Other initiatives include expansion of 
telehealth specialty service, which includes anticoagulation 
monitoring; dedicated space for telehealth education for staff and 
Veterans of rural health service; and health fairs at NMVAHCS CBOCs.
    In Fiscal Year (FY) 2013, NMVAHCS served 5,168 Veterans through 
telehealth, and 59 percent (3,031) of these Veterans lived in rural 
areas. Of these, 1,002 Veterans accessed mental health services through 
CVT in FY 2013, 90 percent (897) of whom lived in rural areas.

Mental Health Services Engagement Initiatives

    VA is working closely with its Federal partners to implement 
President Barack Obama's Executive Order 13625, ``Improve Access to 
Mental Health Services for Veterans, Service Members, and Military 
Families,'' signed on August 31, 2012. The Executive Order affirmed the 
President's commitment to preventing suicide, increasing access to 
mental health services, and supporting innovative research on relevant 
mental health conditions.
    On February 1, 2013, VA released a report on Veteran suicides, a 
result of the most comprehensive review of Veteran suicide rates ever 
undertaken by the VA. With assistance from state partners providing 
real-time data, VA is now better able to assess the effectiveness of 
its suicide prevention programs and identify specific populations, such 
as Veterans living in rural areas, who may need targeted interventions. 
This new information will assist VA to identify where at risk Veterans 
may be located and improve the Department's ability to target specific 
suicide interventions and outreach activities in order to reach 
Veterans early and proactively. The data will also help VA continue to 
examine the effectiveness of suicide prevention programs being 
implemented in specific geographic locations as well as care settings, 
such as primary care, in order to replicate effective programs in other 
areas.
    In an effort to increase access to mental healthcare and reduce the 
stigma of seeking such care, VA has integrated mental health into 
primary care settings. The ongoing development of Patient Aligned Care 
Teams to deliver primary care will facilitate the delivery of 
integrated primary care and mental health services. It is VA policy to 
screen patients seen in primary care in VA medical settings for PTSD, 
MST, depression, and problem drinking. The screening takes place during 
a patient's first appointment, and screenings for depression and 
problem drinking are repeated annually for as long as the Veteran uses 
VA services. Furthermore, PTSD screening is repeated annually for the 
first five years after the most recent separation from service and 
every five years thereafter. Systematic screening of Veterans for 
conditions such as depression, PTSD, problem drinking, and MST has 
helped VA identify more Veterans at risk for these conditions and 
provided opportunities to refer them to specially trained experts.
    VA operates the National Center for PTSD which guides a national 
PTSD Mentoring program, working with every specialty PTSD program 
across the VA system to improve care. The Center has also begun to 
operate a PTSD Consultation Program open to any VA practitioner 
(including primary care practitioners and Homeless Program coordinators 
from every location) who requests expert consultation regarding a 
Veteran in treatment with PTSD. So far, 500 VA practitioners have 
utilized this service. The Center further supports clinicians by 
sending subscribers updates on the latest clinically relevant trauma 
and PTSD research, including the Clinician's Trauma Update Online, PTSD 
Research Quarterly, and the PTSD Monthly Update.
    To support Veterans who use VHA mental health services and build on 
the work of the 2012 Executive Order from the President, VHA has hired 
and deployed over 950 peer support staff to mental health programs 
across the country. Peer Specialists are Veterans who have been 
successfully and actively engaged in their own mental health recovery 
for a minimum of one year and who are trained and certified to provide 
peer support services. Peer Specialists work as members of mental 
health treatment teams and help Veterans achieve their treatment and 
personal goals, and they demonstrate that recovery is achievable.
    No Veteran should have to wait for the care and services that they 
have earned and deserve. NMVAHCS intends to continue to work to meet 
Veterans' needs using the following initiatives:

         Recruit and fill mental health vacancies.
         Explore recruitment incentives to entice psychiatrists 
        to relocate to NMVAHCS. There is an industry shortage of 
        psychiatrists.
         Increase the number of Albuquerque-based mental health 
        clinicians trained in and certified to deliver telehealth and 
        other virtual care modalities such as CVT in the home to 
        provide increased access for rural patients.
         Realign all outpatient mental health programs under 
        one outpatient Mental Health Division to increase patient 
        access to specialized mental health services.

Conclusion

    NMVAHCS is committed to providing high-quality, safe, and 
accessible care for our Veterans. We will continue to focus on 
improving Veterans' access to care. Our location presents unique 
challenges with regard to distance, culture, and constrained healthcare 
markets. Our rural health programs are robust, and we will continue to 
strive to serve Veterans in rural areas.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. I would be pleased to respond 
to questions you or the other Members of Congress may have.

                                 [all]
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