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VA HEALTH CARE: ACCESS DELAYED, ACCESS

DENIED

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY,

VETERANS AFFAIRS AND INTERNATIONAL

RELATIONS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

OCTOBER 15, 2002

Serial No. 107–238

Printed for the use of the Committee on Government Reform

(

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

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York

CONSTANCE A. MORELLA, Maryland

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEPHEN HORN, California

JOHN L. MICA, Florida

THOMAS M. DAVIS, Virginia

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

BOB BARR, Georgia

DAN MILLER, Florida

DOUG OSE, California

RON LEWIS, Kentucky

JO ANN DAVIS, Virginia

TODD RUSSELL PLATTS, Pennsylvania

DAVE WELDON, Florida

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

C.L. ‘‘BUTCH’’ OTTER, Idaho

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

JOHN SULLIVAN, Oklahoma

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELEANOR HOLMES NORTON, Washington,

DC

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

THOMAS H. ALLEN, Maine

JANICE D. SCHAKOWSKY, Illinois

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

——— ———

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

JAMES C. WILSON, Chief Counsel

ROBERT A. BRIGGS, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS AND INTERNATIONAL

RELATIONS

CHRISTOPHER SHAYS, Connecticut, Chairman

ADAM H. PUTNAM, Florida

BENJAMIN A. GILMAN, New York

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEVEN C. LATOURETTE, Ohio

RON LEWIS, Kentucky

TODD RUSSELL PLATTS, Pennsylvania

DAVE WELDON, Florida

C.L. ‘‘BUTCH’’ OTTER, Idaho

EDWARD L. SCHROCK, Virginia

DENNIS J. KUCINICH, Ohio

BERNARD SANDERS, Vermont

THOMAS H. ALLEN, Maine

TOM LANTOS, California

JOHN F. TIERNEY, Massachusetts

JANICE D. SCHAKOWSKY, Illinois

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

EX OFFICIO

DAN BURTON, Indiana HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel

KRISTINE MCELROY, Professional Staff Member

JASON CHUNG, Clerk

(III)

C O N T E N T S

Page

Hearing held on October 15, 2002 .......................................................................... 1

Statement of:

Burger, Leslie, Network Director, Veterans’ Integrated Service Network,

Department of Veterans’ Affairs; Wayne Tippets, Director, Boise Veterans’ Administration Medical Center, Department of Veterans’ Affairs;

and David K. Lee, Chief of Staff, Boise Veterans’ Administration Medical Center, Department of Veterans’ Affairs .............................................. 38

Jaurena, Mitchell A., USMC retired, veteran; E. Lee Bean, veteran; William T. Smith, veteran; and Richard W. Jones, Administrator, Idaho

Division of Veterans’ Services ...................................................................... 13

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

Bean, E. Lee, veteran, prepared statement of ............................................... 18

Burger, Leslie, Network Director, Veterans’ Integrated Service Network,

Department of Veterans’ Affairs, prepared statement of .......................... 43

Jaurena, Mitchell A., USMC retired, veteran, prepared statement of ......... 15

Jones, Richard W., Administrator, Idaho Division of Veterans’ Services,

prepared statement of Mr. Teague .............................................................. 25

Otter, Hon. C.L. ‘‘Butch’’, a Representative in Congress from the State

of Idaho, prepared statement of ................................................................... 7

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

of Connecticut:

Prepared statement of ............................................................................... 3

Prepared statement of Rex T. Young, Meridian, ID ............................... 36

Smith, William T., veteran, prepared statement of ....................................... 21

(1)

VA HEALTH CARE: ACCESS DELAYED, ACCESS

DENIED

TUESDAY, OCTOBER 15, 2002

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS

AFFAIRS AND INTERNATIONAL RELATIONS, COMMITTEE ON GOVERNMENT REFORM, Boise, ID.

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

Post 63 Hall, 3008 Chinden Blvd, Boise, ID, Hon. Christopher

Shays (chairman of the subcommittee) presiding.

Members present: Representatives Shays and Otter.

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

Kristine McElroy, professional staff member; and Jason M. Chung,

clerk.

Mr. SHAYS. A quorum being present, the Subcommittee on National Security, Veterans’ Affairs and International Relations’ hearing entitled, VA Health Care: Access Delayed, Access Denied, is

called to order.

The subcommittee convenes this hearing to continue our oversight of the Department of Veterans’ Affairs, VA, health care system. We meet this morning in Boise, ID because Congressman

Butch Otter asked us to focus on the unique challenges facing veterans and the VA in the Northwest service network. Congressman

Otter is an active, extraordinarily active and very articulate participant in our efforts to make Federal programs more effective and

efficient. It is a privilege and a pleasure to be here with him today.

And I will say he didn’t tell me I could wear jeans.

Regionalization of VA health care held the promise of delivery

modes more directly tailored to local needs and funding levels more

sensitive to area demographics. But rigid one-size-fits-all rules continue to produce systemic problems with access and waiting times

in many regions. These chronic shortfalls are addressed only with

an episodic infusion of supplementary resources. A more permanent approach is needed to match veterans’ growing needs with VA

health care capacity.

For a variety of reasons, including an attractive pharmaceutical

benefit, many more veterans are seeking access to VA care. Medical

centers and community-based outpatient clinics are hard-pressed to

keep pace with demand relying on productivity increases alone. At

some point, the quality of care will be affected if we continue to ask

smaller medical staffs to serve more and more patients.

In this region, waiting lists have reduced slightly and patient

satisfaction with the quality of care remains high, but as we will

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hear in testimony, access to care for service-connected veterans can

still be long delayed, in effect denied, amid the crush of enrollment

applications by those in lower eligibility categories. So we ask our

witnesses to describe how the VA health care system can be improved to become the agile, sophisticated, patient-centered provider

envisioned by Congress. We welcome them, and we look forward to

their testimony.

And I would just like to say I have been in Boise before, I love

being here. It is a great community, a wonderful State, and I was

happy that Butch asked more than once that we come and to say

that this subcommittee is delighted to be here. We look forward to

the testimony from our witnesses, and we will invite any—at the

end, we will invite of those who are in attendance today to address

the committee. We won’t swear you in like we will our panel one

and two, but we will invite you to make testimony to this committee if you would like to.

At this time, the Chair would like to recognize Mr. Otter.

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

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Mr. OTTER. Well, thank you, Chairman Shays, and I appreciate

you accommodating us and holding this meeting in Boise. I also appreciate all of your efforts and your accommodation on all our

logistical changes, because I think as the entire audience knows,

we had to constantly change time and place as a result of most of

our activities, or in some cases inactivity, in Washington, DC. And

so I also want to say that I appreciate all the witnesses and them

making the accommodations that they had to make in order to be

here today.

Ensuring veterans have adequate access to care at the Veterans’

Administration is an important issue. In the last 7 years, the number of veterans using the VA health system has doubled. The VA

anticipates an increase of another 600,000 next year. Changes to

the VA eligibility standards, the high quality of care delivered by

the VA and the existence of the VA drug benefit have all added to

the increased demand of the VA services.

Given this increase in enrollment it is easy to see why veterans

in Idaho sometimes wait about a year, in some cases longer, just

to get into see a VA doctor. In fact, there are approximately 3,000

veterans today waiting in Idaho, and about two-thirds of those veterans are priority 7 veterans. However, once in the system Idaho

veterans seem to be very pleased with the delivery of the care service that they receive.

Some have predicted that the creation of a Medicare prescription

drug benefit would help to relieve some of the backing of the VA,

one which both you and I voted for. Unfortunately, the Senate has

not followed likewise. Although the House passed the legislation in

creating a Medicare drug benefit in June, the Senate, as I said earlier, did not follow suit. That left the Veterans’ Administration

again to deal with the high number of veterans waiting to receive

care.

In May, this subcommittee held a hearing examining the structured problems that are causing the backlog of VA hospitals all

over the country. During that hearing, I expressed my deep concern

that a system of prioritizing veterans on the waiting list was not

in place. I am pleased to report that on September 26 of this year

the Veterans’ Health Administration issued a directive entitled,

‘‘Priority of Outpatient Medical Services and In-Patient Hospital

Care.’’ Under this directive, the Veterans’ Administration will now

give preference to priority 1 veterans who have a service-connected

disability and a rating of 50 percent or higher and will make every

effort to see that those veterans within the next 30-day period receive such admission.

I believe this directive is a step in the right direction in providing

veterans with more timely access to the care that they need. However, the Veterans’ Administration estimates that there are over

280,000 veterans nationwide who will wait 6 months or longer for

an appointment with a Veterans’ Administration doctor. This directive will certainly help reduce that number, but the logistical and

financial burdens of complying with this directive will be a challenging one for the Veterans’ Administration.

I look forward to hearing from those representing the VA on how

they are proceeding in that process. So as we explore ways to improve the Veterans’ Administration’s ability to address the health

6

care needs of veterans, I think that it is important to factor into

the equation a way to provide the VA with the necessary resources,

regulatory or financial, to address those increasing administrative

workloads.

These hearings are an important chance for us and for your representatives in Congress to listen, to find out your thoughts on how

we can best change the structure of the VA medical system to better accommodate the needs of Idaho’s veterans. Mr. Chairman, I

appreciate your leadership and your interest. I appreciate all of the

hearings that you have had on this and the deep and sensitive concern that you have shown to every panel member that has come

before us, not only today but also in Washington, DC. Thank you

very much.

[The prepared statement of Hon. C.L. ‘‘Butch’’ Otter follows:]

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Mr. SHAYS. Thank you. I thank the gentleman. First, before calling our—recognizing our panel and swearing them in, I would like

to get some housekeeping out of the way and ask unanimous consent that all members of the subcommittee be permitted to place

an opening statement in the record and the record remain open for

3 days for that purpose. Without objection, so ordered. I ask further

unanimous consent that all witnesses be permitted to include their

written statement in the record. Without objection, so ordered.

I would also like to note the presence of Major Ed Freeman, a

Congressional Medal of Honor recipient. This committee is honored

that he would be here. Thank you so much for being here.

And to say that he earned this recognition in his service in 1965

and 1966 and recently received this long overdue recognition, and

to say that it takes my breath away to think of the number of

flights that he made, I think nearly 30, into an area that was totally and completely surrounded by the enemy and over 300 men

were saved, in large measure, because of what he did. I would also

point out that many of the enemy—we lost over 300 men that day

or during that battle, and I think that the North Vietnamese lost

nearly 2,000. So it is an honor to have you here.

But it is also an honor to have everyone who has served our

country. This committee is profoundly grateful, and I can tell you

without hesitation when a Congressman looks at our flag we try to

see this flag through your eyes and recognize that when you look

at this flag you think of the men who never came home, and you

think of the conversations you had with family members about

their lost loved one.

I would also like to recognize any family members who are here

and just say thank you for supporting your family member in their

service to our country. I think sometimes it takes more out of the

family member than it does out of the soldiers who are actually

serving in the battle.

At this time, the committee will recognize our first panel. Colonel

Mitchell Jaurena is a veteran—did I say your name correctly?

Mr. JAURENA. Close enough.

Mr. SHAYS. I want it accurate.

Mr. JAURENA. Jaurena.

Mr. SHAYS. Jaurena. Thank you. That is the way it was——

Mr. OTTER. Is that Irish?

Mr. JAURENA. Basque Irish. [Laughter.]

Mr. SHAYS. Colonel, great to have you here.

Mr. JAURENA. Thank you.

Mr. SHAYS. We have as well—so the Colonel is a veteran. We

have Mr. Lee Bean, a veteran; Mr. William T. Smith, a veteran;

Mr. Richard W. Jones, administrator, the Idaho Division of Veterans’ Services, which is the State provision for veterans. At this

time, as you may know, we swear in all our witnesses. I have been

chairing the committee now for 8 years, and I will tell you the only

witness I have not sworn in was Senator Byrd, I chickened out and

regret it to this day. [Laughter.]

Would you please stand.

[Witnesses sworn.]

Mr. SHAYS. We will note for the record all our witnesses have responded in the affirmative, and Colonel Jaurena, we will invite you

13

to address us first. And we have a 5-minute rule, but what we do

is we allow you to go into the next 5 minutes and ask that you stop

before 10.

Mr. JAURENA. Yes, sir.

Mr. SHAYS. But as close to 5 as you can be is appreciated.

STATEMENTS OF MITCHELL A. JAURENA, USMC RETIRED,

VETERAN; E. LEE BEAN, VETERAN; WILLIAM T. SMITH, VETERAN; AND RICHARD W. JONES, ADMINISTRATOR, IDAHO DIVISION OF VETERANS’ SERVICES

Mr. JAURENA. Good morning, Mr. Chairman and Representative

Otter. I am Lieutenant Colonel Mitchell Jaurena, U.S. Marine

Corps, retired. I was transferred to the Permanent Disability Retirement List on July 1, 2001 after 21 years of honorable service

because of the degenerative nature of injuries I received during Operation Desert Storm while in the Persian Gulf. Upon my retirement, I moved back to Idaho and settled in Nampa. At that time,

I attempted to enroll in TriCare Prime, the military system of

health care, but was unable to find a local provider, as no physician

or medical provider in the Treasure Valley region was accepting, or

is accepting, TriCare Prime patients. Subsequently, however, on

November 6, 2001, the Department of Veterans’ Affairs rated me

as a 50 percent service-connected disabled veteran. Now, as a priority 1 category disable veteran, I was automatically enrolled in the

Veterans Health Care system and during December 2001, the Boise

VA hospital issued me my veterans universal access identification

card and assigned me to a health care team in Boise, ID.

Unfortunately, I was also told at that time that I would be unable to utilize the Boise VA hospital for any care other than emergency care, as there was a 2 to 21⁄2 year-long waiting list at the

hospital for assignment to a doctor. I was also told that I would be

unable to utilize the pharmacy, even if I had a script provided by

a non-VA doctor, as the pharmacy was only available to those with

assigned VA doctor at the Boise hospital. I was also told that there

was a 2 to 3-year wait to receive optical care but hat I would be

able to obtain those glasses if I could provide them with the prescription from an outside pharmacist.

Mr. Chairman, I find it absurd that a combat-related 50 percent

disabled veteran with service connection should be required to wait

for medical care at a VA hospital while those without service connection are receiving care. I find it even more patently absurd that

a priority 1 service-connect disable veteran should have to wait up

to 21⁄2 years for the assignment of a VA doctor just to be able to

fill a prescription at the VA hospital while they are under the care

of a private physician.

But I do need to point out, as Representative Otter did, that the

landscape has recently changed. The Secretary Principi has directed that these 50 percent disabled veterans, priority 1 veterans,

receive care. And as of this time, I have an appointment on October

24, so I will have waited 11 months to receive care at this hospital.

Now, it is really hard to overcome 21 years of training provided

by the Marine Corps. No Marine complains without providing an

alternative solution, but I do realize that Federal funding is not a

bottomless well, and there simply isn’t enough money to go around.

14

I also realize that some veterans will eventually go without. There

have been various plans proposed also by various service organizations, some of them to include a financial means test for veterans

seeking care, in essence, turning the VA health care system into

a welfare health care system. I am against any financial means

test as an eligibility requirement for health care. The only eligibility requirement for health care I would support is already in

place and that is honorable service in the armed forces of the

United States of America in service of our country.

I do believe that those with the highest need based upon service

connection disability ratings should be seen first. The VA already

has a priority health care system for enrollment in place. This

prioritization starts with priority 1 for 50 percent or greater service-connected disability to priority 7 for non-service connected and

non-compensable disabled veterans. I believe that this already-established system should also be used for providing health care and

scheduling appointments so that those who have honorably served

and have suffered the most will receive the first use of the limited

assets available.

Now, if we use the health care system, will veterans fall out if

we use that prioritization? Absolutely. Will they be deserving of

care? Certainly. However, this method of prioritization will allow

for the most disabled to receive care and give Congress and the VA

a clear picture of those veterans left without VA-provided health

care. It would allow Congress to decide on the level of funding that

it is willing to allocate based upon veterans’ needs. It would also

be up to our elected officials to reflect the will of the American people to fund or not fund for the care of its veterans. Thank you for

the opportunity to testify.

[The prepared statement Mr. Jaurena follows:]

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Mr. SHAYS. Thank you very much, Colonel. Would you move that

pitcher so that you could see the light too?

Mr. JAURENA. Yes. I beat it by 12 seconds, Congressman.

Mr. SHAYS. Thank you. It was an excellent statement. Excellent

statement.

Mr. BEAN. OK. Are you ready for me?

Mr. SHAYS. We are, Mr. Bean. Thank you so much.

Mr. BEAN. OK. I am not disabled or anything, I am in pretty

darn good shape, except what I have to say here. I served in the

Navy during World War II aboard ship, and after hearing that several veterans my age, World War II, getting more income than I

do are receiving prescriptions drugs from the VA——

Mr. SHAYS. I am going to ask a question. Can people in the back

hear what is being said right now? Let me just say I apologize for

not being able to pick you up. I am going to ask you—and I am

sorry about that, but I am going to ask you to hold it up, because

I think it is important that everybody hear your statement.

Mr. BEAN. My voice is not that good either.

Mr. SHAYS. Yes. Colonel, I apologize for that.

Mr. BEAN. OK. I can certainly start over then.

Mr. SHAYS. I apologize, yes.

Mr. BEAN. U.S. Navy during World War II, and I heard of veterans receiving prescription drugs from the VA that are in a similar

conditions I am, with more income than me, actually, a lot of them,

and so I decided on December 21, 2000 I went to the VA Center

and enrolled for benefits, gave them my financial so on and so on.

Then in May 2001, after coming home, I found out that friends of

mine had been receiving prescription drugs without even filling out

a financial statement in other VA hospitals. So then I went to

the—called the VA Center and the nurse told me to come down in

an emergency condition. So I went down and was right in and saw

a PA, a nurse’s physician’s assistant, and she examined me, questioned me and using my doctor’s prescription enrolled me to start

receiving drugs, which I did for about 1 year. In February 2000, I

updated my income status. In March of this year, I was informed

by the VA that I would no longer receive drugs because I had not

been able to see a doctor. I then contacted Mr. Otter and other

Congressmen, representatives about this.

It is my belief that if prescription drugs are going to be available

for some veterans, they should be available to all veterans, especially after age 65 whenever you have now become on Social Security and limited income, also a lot of us being in those notch years

where we don’t receive as much Social Security as other people. I

think that the VA should be able to use my doctor. I belong to an

HMO, I have a doctor who writes my prescriptions. Why can’t I

take them to the VA? Why can’t they trust my doctor? They’re both

being paid by government funds. That’s all I am asking.

Now, if it is not available for me, let us not make available for

other people in my situation. I don’t have a Purple Heart, I have

a lot of close calls in Australia while I was in the Navy, I know

that. But I know my wife is 73, I am 77, and we both work parttime to supplement our income. So I am not afraid of that, I am

able to do it. That is about all I have to say. Thank you.

[The prepared statement of Mr. Bean follows:]

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Mr. SHAYS. Thank you very much, Mr. Bean. That is very helpful

testimony as well. Mr. Smith. Evidently, these are mics you have

to have pretty close up to you.

Mr. SMITH. Can you hear me?

Mr. SHAYS. We hear you great.

Mr. SMITH. Honorable Congressmen, ladies and gentlemen, my

name is William T., Tom, Smith, and I am here to speak—my reasons for speaking are the very deplorable treatment to myself and

other veterans who are being subject to what I feel is a completely

overloaded and broken down VA system. They are trying to do

their best, but they can only do so much. They are drastically

understaffed and underfunded.

First, they have no cardiac care unit at Boise VA. For heart

treatment, they send you to Seattle VA. When I had my heart attack in 1996, I spent 5 days at the Boise VA waiting for space to

be transferred to Seattle VA. It took more than 5 days to be evaluated by a cardiac specialist after a heart attack. This is very hard

on patient and family after going to Seattle twice for heart treatment in a very crowded system, the stress of traveling and being

separated from family at such critical times. The next time I had

a heart problem I requested to be transferred to St. Luke’s for

quicker evaluation, and it was a good thing I did. I was near another heart attack, and I had immediate bypass surgery, it was a

six-way bypass. The VA denied co-payment on this surgery, and I

was left with all the bills my private insurance did not cover.

Mr. SHAYS. Mr. Smith, could you just turn the mic the other way

a little bit? Yes.

Mr. SMITH. I am rated 100 percent service connected. My first

trip to Seattle they did an angiogram, the second they did an

angioplasty scan implant. The VA always bills my private insurance for all the treatments and surgery and prescriptions. The real

funny thing about all of this is it would be cheaper for the VA to

pay the co-payment than fly me to Seattle, and yet they denied the

co-payment. It does not make sense. I go to a cardiologist in private

practice because there is not a cardiologist on staff at the Boise VA.

They have one who comes in once a month for clinic, and you must

meet certain criteria to be seen by him. This is almost a joke if it

was not so serious.

Another problem is my hands. I had surgery on two fingers on

my right hand for trigger finger. I have developed trigger fingers

in my hand, two of them, and I have bone spurs on the right

thumb. And this time it has taken me over a year to get an appointment for an evaluation. Surgery will be scheduled for a later

date. In the meantime, my fingers are getting worse, and I can no

longer open it fully. Gripping anything with my right hand is very

difficult, and these conditions get worse daily and less correctable.

When I asked my regular physician about a colonoscopy, I was discouraged about having one. It has taken over a year to get scheduled for a colonoscopy with the medical profession recommending

you should have one after age 50. This just doesn’t seem right.

The problems I have stated above plus some old back injuries

have been shuffled off to a physician’s assistant. I have not seen

my regular physician for the last two scheduled appointments. In

addition to the other problems, I have upper spinal injury which

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causes tremors and excruciating pain in the arms and the shoulders. Plus I have had back surgery on the lower back and two hernia surgeries.

Parking is always horrendous at the VA. If you can find a place

to park, it is generally three to four blocks away from the entrance,

and some days it seems like you can’t find any place to park there.

They really need to do something about the parking there. The lab

is another bottleneck when you go in and if you are going to have

any blood work done or anything. It is not anything to see an

hour’s wait to have the lab work done. If you see your doctor and

go to the lab and get a prescription filled, you can spend a day at

the VA.

My suggestions would be to have the representative talk to the

people at the VA, get their statements. If you catch them coming

out of there real fresh, you can get some good input. I am sure they

would tell you that they feel like cattle being herded through or

just a number.

And the doctors are very reluctant about letting you see another

doctor about your problem. One of the doctors at the specialty clinic

will ask you how you are today. If you tell him you have some

problems, he will tell you, ‘‘We are all getting older and expect the

aches and pains to be worse.’’ And then he will tell you to come

back and see him in 3 months.

It is very reassuring to me to have you Congressmen investigating trying to assist us veterans with our health care problems. I

truly hope my statements here will help others and assist you in

your fact finding. With my sincerest thank you for working to make

things better for the veterans. Please keep up the good work.

[The prepared statement of Mr. Smith follows:]

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Mr. SHAYS. Thank you, Mr. Smith, for your helpful statement.

Mr. Jones. I am going to ask if anyone is in the back and can’t

hear, you just raise your hand and we will just make sure that I

direct the witnesses to speak more into the mic.

Mr. JONES. Good morning, sir.

Mr. SHAYS. Good morning.

Mr. JONES. It is my pleasure to be here this morning and present

the testimony on behalf of Patrick Teague who was not able to be

here and was scheduled to actually provide testimony before you.

I do have his written testimony before me. Patrick is our program

supervisor of the Office of Veterans’ Advocacy for the State of

Idaho, so reading his testimony.

Committee members, veterans and guests, I wish to express my

appreciation for being invited to speak on behalf of Idaho’s veterans today. It is indeed an honor and a privilege to appear before

you.

I would like to begin by saying the care at our VA medical centers serving Idaho’s veterans is outstanding. Sure, you have the occasional horror story of a veteran who has been mistreated or neglected but these instances are few and even fewer once investigated. In my job as a veteran service officer, I speak to veterans

and their dependents throughout the State, and almost to a person

they all tell me that once they get through the door into the VA

medical center, they receive excellent care. Which brings us to the

reason we are here today: Access to our VA medical centers.

If you are a veteran who has been assigned a team, has a doctor

or a physician’s assistant, then you are indeed fortunate. If you are

a veteran moving one State to another, you are facing a wait of up

to a year or longer just to gain access to our VA medical centers.

The exceptions to this are 50 percent service-connected veterans or

those requiring emergency care. By far and away, however, the majority of new accounts are being told to get into an ever-increasing

line and don’t call us, we will you.

This is simply unacceptable and must be corrected. The real tragedy here is that as service officers we are told for years to go out

and find those veterans who have never been enrolled in our VA

medical centers and get them enrolled. When queried by the service officers if the medical center would be available to provide care

for those veterans, the answer was a resounding yes, so we did. We

went out and found those veterans who had never been in the system and had them submit their 10–10EZ forms. Some of those veterans are still waiting to be assigned a team. In the meantime, for

every new account, or ‘‘uniques,’’ as the VA calls them, the VA

medical center gets approximately $1,5000 placed in their account.

I have no problem with that, but I do not understand why the veteran is denied access if the VA medical center has received $1,500

for enrolling that veteran.

Another problem we have that I do not understand is when the

Boise VA Medical Center cannot provide specialty care at the Boise

VA Medical Center, they then schedule the veteran for care in Palo

Alto or Seattle. If the veteran is sent to Seattle, the Boise VA Medical Center gives him $40 for a bus ticket to Seattle. The veteran

then finds transportation from the bus depot to the Seattle VA

Medical Center. When the veteran is finished with is stay in SeVerDate 11-MAY-2000 11:53 Sep 12, 2003 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 D:\DOCS\89163.TXT HGOVREF1 PsN: HGOVREF1
24

attle, he must get the Seattle VA Medical Center to give him $40

for his trip back to Boise. Once again, it is up to him to get from

the VA Medical Center to the bus depot. Then he has the long bus

ride back to Boise. In many cases, these veterans are convalescing

and the bus ride takes its toll on them. Wouldn’t it be better for

the veteran and their families if the Boise VA Medical Center

would refer them for specialty care at St. Luke’s or St. Alphonsus?

The Millennium Health Care Act states that if care in a VA medical center is not available, then the veteran should be referred to

the community. They do not normally do it as it impacts the Boise

budget more than they can afford. Clearly, something must be done

for these veterans who fall through the cracks and are sent to other

VA medical centers for their care.

We must also address the problem of proper funding for those

who travel for a VA medical center appointment, as Idaho is one

of the most rural States in the Union. Some of our veterans must

travel over 500 miles roundtrip for a medical appointment. An example of this would be Salmon, ID in Lemhi County. Those veterans travel 252 miles one way to receive treatment at the Boise VA

Medical Center. Veterans traveling to those appointments receive

11 cents per mile for that appointment, and some of them have $6

deducted from that travel allowance. Any appointment that is not

for a compensation and pension examination will have the $6 deducted from the veteran’s reimbursement, not to exceed $18 in 1

month. This is simply ludicrous because the VA medical centers are

only reimbursing 11 cents per mile as it is. A raise is certainly in

order to help alleviate the cost of traveling to and from an appointment.

In summation, I would like to reiterate that once in the door of

the Boise VA Medical Center, the care is excellent. It is getting

through that door that is the problem. We must secure more funding for our VA medical centers if we are to make a difference in

the current situation. Our Nation’s veterans deserve no less. Thank

you for your attention.

[The prepared statement of Mr. Teague follows:]

25

26

27

Mr. SHAYS. Thank you very much, Mr. Jones; appreciate it. We

are going to start off with Mr. Otter asking some questions, and

I will have some questions as well. And if we ask one of you but

another of you wants to answer the question as well, just jump in

after that person is finished speaking.

Mr. OTTER. Well, thank you, Mr. Chairman, and I would direct

this question to all of the panelists. During our hearings, several

hearings, that we had earlier this year and one late last year, there

were—obviously, we heard about an awful lot of horror stories, and

I think that is what precipitated the priority 1 change that came

about September 26. I can remember in the committee room me offering an example that I am prior service but I have no service disability, no service-connected disability. And yet if I showed up at

the VA hospital with a rodeo accident, I would certainly be put

ahead of, depending upon if I showed up on that priority list, I

would be put ahead of anybody who may have gotten some disability as a result of any military action or any other military service.

We thought that was patently unfair.

My question actually as a result of listening to several folks that

testified and trying to come up with some sort of a recipe, if you

will, that said that the level of service-connected disability coupled

with age should bring us some sort of a ratio of setting priorities.

Would you agree or disagree, and I am not prepared to say you

have got to be a certain age with a certain disability, but would you

agree or disagree with setting a priority, No. 1, based upon the disability and the level of disability and, No. 2, the age of that veteran

that is disabled?

Mr. JAURENA. I will kick it off here, Representative Otter. I agree

with you on the first part. Service connection and the type of disability, I would absolutely agree with that. However, it makes no

difference whether you are 46 like I am or 76 is if you have a degenerative disease caused by a service injury that you are required

to take medication for. As it stands now, I cannot get in to get my

medication at the VA hospital simply because I have been bumped

by priority 7 people. So I do not believe an age requirement is justifiable. You have a system already established within the health

care. It is priority 1 through priority 7. Priority 1 group is 50 percent or greater, priority 2 is 30 or 40, priority 3 is former POWs,

10 or 20’s or Purple Hearts. Those folks have a service connection.

We have already established a system to determine whether they

are eligible or not and set a priority group. I believe we should

stick to it and not deal with the age issue.

Mr. OTTER. Great. Thanks, Mitch. Lee.

Mr. BEAN. I think age partly should be involved because of your

ability to go out and make a living. If I have a good income to

where I could go out to dinner once in a while and things like that,

I wouldn’t even be here. I wouldn’t be asking for prescription

drugs, and that is all I am asking for. And one of the reasons I am

asking for that is I have a lot of friends who are getting these prescription drugs from other VA hospitals by walking in and getting

them.

Mr. OTTER. My apologies for stopping you right there.

Mr. BEAN. OK.

28

Mr. OTTER. That is another question I am going to ask, and since

you brought it up I want to ask you that now. If we had seen a

successful conclusion of the house-passed Medicare drug benefit

bill, which was $350 billion over 10-years, would you then seek access to your drugs through the Medicare program rather than

through the VA program?

Mr. BEAN. I probably would, yes, because I am paying for health

insurance right now, and the high cost of drugs is what is killing

some of us; $55 a month for health care—supplemental health care

in an HMO is not a big deal, but when you start paying a couple

hundred dollars a month for two pills, it gets a little ridiculous.

Mr. OTTER. Thanks, Lee. Tom.

Mr. SMITH. I don’t think that age should really play a factor in

it. I think that any disability, any disabled vet should be—the care

should be accessible for him. I agree with Mr. Bean that there is

a lot of people out there that are getting medication that—I know

some that are getting medication and Mr. Bean would be just as

entitled to it as they are. I don’t have anything further, I don’t

think.

Mr. JONES. I agree with the comments by the other panelists. I

am concerned that it should be based upon their disability. My concern is that you have individuals who had degenerative conditions

and other conditions that with such an undo waiting list, undo

waiting time, their condition would deteriorate so significantly from

the time that they attempted to enroll to the time that they would

actually be seen by a physician and receiving care. I don’t believe

that this is correct.

Mr. OTTER. All right. Let me start with the entire panel again,

and I will start with you first, Mr. Jones, because you brought it

up in your testimony that you represented in Mr. Teague’s place,

you mentioned out-contracting or community contracting. Do you

know that is now the practice in any other place in the United

States where they actually have out-contracting within a Veterans’

Administration region?

Mr. JONES. I am not aware, but I can find out and let you know

very quickly.

Mr. OTTER. I think we will probably get some testimony from Mr.

Tippets or Dr. Lee a little later on on that. How about you, Tom?

Mr. SMITH. Really, I don’t know of any other place where they

are contracting out. However, I do know that the VA here does contract some out to St. Luke’s. I think I would like to see the heart

care increase a little beyond that, because after a heart attack or

anything it is important to get the treatment and know where you

are at immediately.

Mr. OTTER. Tom, relative to your experience between Boise and

Seattle and traveling back and forth from the operation, the sixway bypass that you had in Seattle, do you think you are——

Mr. SMITH. No, I had the six-way bypass here at St. Luke’s.

Mr. OTTER. Oh, excuse me. I misunderstood. Was your—so you

rehabilitation was actually right here in Boise in your home——

Mr. SMITH. Oh, yes.

Mr. OTTER [continuing]. Around your family.

Mr. SMITH. That is right.

29

Mr. OTTER. OK. Well, let me ask you the question anyway in a

hypothetical sense. Do you believe that your healing process, that

your rehab process was much faster as a result of being home within your own community and around your own surroundings than

it would have been had you had to have that in Seattle?

Mr. SMITH. OK. Now, I can relate on that a little bit further

here. After my heart attack I went to Seattle. I waited 5 days here

for a bed in Seattle in the Cardiac Care Unit. I went to Seattle,

and I came back—when I came back I was probably more distressed than I was before I left. The second time I went to Seattle

and they did a skin implant and I came back, I was feeling better

because the stint was pretty successful, and it is not a real invasive

procedure. And I was feeling better and so recovery was probably

good. But when I had the six-way bypass, if I would have had to

travel from Seattle back to here after a six-way bypass, I don’t

know how I would have done it. It is just unbelievable to me that

people do that. I don’t know.

Mr. OTTER. OK. Lee.

Mr. BEAN. No. I have nothing to say about that. The only thing

I was talking about age is that I think all service-connected veterans should all be first, No. 1. All I am talking about are medications. That is all I am talking about when it comes to age.

Mr. OTTER. OK. Thanks, Lee.

Mr. JAURENA. I know of no outsourcing. I haven’t had any medical care here yet, so I can’t talk intelligently about it.

Mr. OTTER. But in your testimony didn’t you offer to us that your

prescription that you got from your own doctor was initially filled

through the VA facility?

Mr. JAURENA. No, it was not.

Mr. OTTER. Oh, I am sorry.

Mr. JAURENA. It was not. They will not fill the script here from

a private physician. You must have a physician in the VA hospitals

before they will fill the script here in the hospital. That is one of

the things I find absurd.

Mr. OTTER. I see. I am sorry, Lee. I guess it was you, just one

more question. Lee, I think it was you that said that your prescription which you received from your own doctor was eventually filled.

Mr. BEAN. Yes. I saw a physician’s assistant, a nurse, and she

looked me over. I didn’t see a doctor, no, but I got my prescription

for 1 year cutoff because I didn’t see a doctor.

Mr. OTTER. Thank you, Mr. Chair.

Mr. SHAYS. Thank the gentleman. I am delighted that this committee is here, and I was thinking before we started that we talked

about how the first hearings of the Supreme Court were wherever

they could have a hearing, sometimes in taverns, and I just will

note that while we are at a tavern of sorts, the bar is not open.

[Laughter.]

And also to say that our perspectives are so different. I am a

Yankee, grew up in New England area, and my constituents have

some real complaints but they are a little different. I will just say

as a side when I was in Whitefish, Montana with a close friend

there were three cars coming in on a main street that we were trying to get on and my friend was driving, and I wanted to see how

she had to react because she had to wait as one car went by, then

30

another car went by and then another car went by and then we got

on the main thoroughfare, and she turned to me as she was driving

and she said, ‘‘I hate traffic,’’ and I was thinking, boy, you would

have to wait for 30 cars before you could get on a main street

where I live. And then I was thinking of distances and I was thinking, though, that my veterans, if they have to go 60 miles, consider

that an outrage. And you all have to go the equivalent in my area

where I live near New York of having to go up to Boston or to Columbus, Ohio, in one or two instances, to get the kind of service

you need. So it is important that Members of Congress get exposed

to these different perspectives, because ultimately we are looking

for ways to write legislation that is going to meet the needs of the

veterans but is flexible to the different groups.

My first question then relates to this. I will start with you. Are

there any community-based health care clinics? For instance, in

Connecticut, as small a State as we are, we are like a county here,

we have one main facility in Westhaven which is kind of centrally

located, at least between the north and the east and west, right on

Long Island Sound, but we have about four community-based

health clinics that our veterans can go to to get the kind of prescription services that you need, not to have a bypass but to go

there. So are there any community-based health care clinics that

you get to utilize?

Mr. JAURENA. There is, Mr. Congressman, there are several out

here, but I have not used them so I can’t speak intelligently about

them. I don’t even know where they are at yet, because I haven’t

had any appointment.

Mr. SHAYS. We will be able to ask the second panel about this.

Mr. JAURENA. I think Mr. Jones and down the line will know

about them also.

Mr. SHAYS. But I would be anxious just to know if any of you—

Mr. Smith, did it ever serve your need, or Mr. Bean, to go to a community-based health care clinic? Are they a big deal in this area

or not that important?

Mr. SMITH. Not me.

Mr. SHAYS. OK.

Mr. SMITH. The only thing I have done was St. Luke’s with the

heart bypass.

Mr. SHAYS. Mr. Bean, did you have occasion to use a communitybased health clinic as opposed to coming to the main facility?

Mr. BEAN. St. Luke’s or St. Jones.

Mr. SHAYS. Yes, Mr. Jones; yes, sir.

Mr. JONES. Congressman Shays, there are three communitybased outpatient clinics in Idaho: One in Pocatelo, which is I believe under the Salt Lake VAMC; one in Twin Falls, which is under

the Boise VAMC; and one in Lewiston. The one in Lewiston is a

part-time—part-time it opens. In all three, it is my understanding

is that you still run into the same situation that there is a waiting

list, and you would still need to go through the VA enrollment

process to receive those services. It is unfortunate that recently,

and I would have to look up the name, of the individual that had

given a directive that we were to stop advertising the communitybased outpatient clinics, and that has resulted in a lot of flack that

she has received for that. But those are in existence and working

31

in discussions with the CARES Group there are discussions of additional community-based outreach clinics opening up, and I think

it is a very appropriate outlet to reduce the pressure on the

VAMCs.

Mr. SHAYS. The VA does a lot of things quite well, and one of

the things, though, there had been this debate and I would—this

may seem a little off the subject, but it would be helpful to know.

I want to take advantage of knowing how you all would feel in this

part of the country. There are some that argue, and I frankly took

this argument but have backed off a little bit because of the response from the veterans, and that was that there are some who

say why not give a veteran a card that notes that they are a veteran and let them go to any hospital in the country and get service? I am not going to tell you what the answers were of my veterans, I want to know what your answers are, and then I am going

to respond to that. Colonel, we will again start with you. In other

words, if you could get a card that said you are a veteran, you can

go to any facility and you wouldn’t have to just go to a veterans’

facility, would you like to see that kind of system?

Mr. JAURENA. I run parallel. I have a card from DOD, it is called

TriCare Prime. I can’t get a doctor to take it because the Federal

Government doesn’t pay enough to those doctors and pays in such

a poor manner and so late that they refuse to take it. I believe the

same thing would roll with the VA system. I am in a system already that does that, and I wouldn’t adhere to any other system

that does the same thing. It doesn’t get me care, so we need——

Mr. SHAYS. You would rather be treated in a VA facility.

Mr. JAURENA. I would rather be treated in a VA facility because

our payments, I believe, will never keep up with what the civilian

community is going to require, and they will not take us. I would

even take it if we did and had a reasonable copayment, sure, but

I don’t believe we can keep up with it. The DOD can’t keep up with

it, I see no reason the VA can keep up with it.

Mr. SHAYS. Mr. Bean? You know what I think I am going to do,

I am going to rotate so that way you can switch the microphone.

We will go to you Mr. Smith, and then I will go to Mr. Bean. So

the question is would you prefer to be treated in a veterans’ facility

or if you could have a card and go to the hospital in the Nation

and prefer that?

Mr. SMITH. Well, right now I would say that the treatment at the

VA center is excellent for what you get, and then I would like to

stay with the VA system. However, it is terribly underfunded here

and understaffed, and with the understaffing and underfunding, I

am seeing a cardiologist right now on the outside because we don’t

have one on staff full-time here at Boise VA.

Mr. SHAYS. Well, you trigger a second question, and that is

would you want to see a hybrid? In other words, if, for instance,

at Boise they couldn’t provide the cardiac type of health care that

you needed, would you like to be able to go to a non-VA hospital

and get that kind of care so you wouldn’t have to go to Seattle to

get the care that you needed?

Mr. SMITH. Yes.

Mr. SHAYS. OK. Mr. Bean.

32

Mr. BEAN. I don’t think I really qualify because I am not disabled, I am not in full claims.

Mr. SHAYS. No, you qualify because you are a veteran and I want

to know what you think as a veteran.

Mr. BEAN. I would just as soon use my Medicare and if the government can help with a supplemental insurance type thing go to

the regular hospital because there are more available.

Mr. SHAYS. OK. Mr. Jones.

Mr. JONES. I would prefer to go to the VA medical center, but

if services at that center were not available, I would prefer

outsourcing within the community so that I wouldn’t have to leave

the community for service.

Mr. SHAYS. And let me just say that is kind of the way I should

have said it. In other words, we outsourced it in the community.

Mr. JAURENA. Mr. Shays.

Mr. SHAYS. Yes.

Mr. JAURENA. Again, I would like to jump back in. Now that you

have thrown a second one into the pile, absolutely, I would like to

go to the VA and then if they could not provide those services,

outsource it out for specialty care.

Mr. SHAYS. So you could be local.

Mr. JAURENA. I believe that system would work wonderfully.

Mr. SHAYS. I can’t think of it being more difficult, Mr. Smith,

than to go to—to have a major operation, I mean one that is one

safe but a major operation and not be relative near your home,

near your family, near your friends. So I have that sense.

Mr. SMITH. I just can’t agree any more than what you said there.

If you are not near your family, you are worrying about them, they

are worrying about you, the whole situation is not good.

Mr. SHAYS. Now, let me just say to any veteran or anyone else

who wants to testify, after we finish one or two, that question

would be something I would be interested for you to address. The

response from my veterans is they are afraid that if we get rid of

the VA system, that ultimately the card will become meaningless,

and they at least like to know they have got this pole in the ground

that basically says this is a VA facility. Also, they feel that the VA

facilities have a little more sensitivity to the illnesses of veterans

but also to understanding their perspective. So the outsourcing, I

think, probably would be more—my own constituents would be

more inclined as long as they didn’t see it replacing the VA facility.

Let me just—I have some questions that staff believes I need to

put on the record, so let me just run through this as well, and we

will start with you, Mr. Bean, since you have the—have you felt

that a communication with the VA facility has been done in a professional way, and do you feel that you have always been kept informed by the VA when you have had requests out there?

Mr. BEAN. I don’t feel like I have been kept informed, but any

time I have called to talk to them they have been very nice, no

problem there at all, but I have not been informed.

Mr. SHAYS. Mr. Smith.

Mr. SMITH. Yes. They have been very professional.

Mr. SHAYS. And they stay and keep you informed.

Mr. SMITH. And they keep me informed.

Mr. SHAYS. OK.

33

Mr. SMITH. The appointments are noted and mailed, and everything is—if I call with a question, it is answered. There is not any

real problem there.

Mr. SHAYS. Colonel.

Mr. JAURENA. They have been very professional and very informative. Not only do they send an initial appointment letter, they

send a reminder letter. So they have been very good. The level of

care I can’t talk about.

Mr. SHAYS. Let me just ask another question. When you go into

the facility you have to wait to get there, but once you are there

do you have long waits?

Mr. JAURENA. I can’t talk to that. I walked in and registered and

got my card, and they said, ‘‘Don’t call us, we will call you.’’

Mr. SHAYS. Right. OK. So you are a work in process right now.

Mr. Smith.

Mr. SMITH. There can be some long waits. As I noted, the lab is

small for that size hospital. I feel there are not enough people in

there. They can’t get people through that need to be done. The

pharmacy is a little bit of a bottleneck. It is better than it used to

be, they are trying to improve things. It is the funding and the

staffing.

Mr. SHAYS. I would just ask you to answer that question, Mr.

Bean, and then, Mr. Jones, I will finish up with you.

Mr. BEAN. I was only there two times and each time I had to

wait, oh, maybe half an hour, something like that, which was reasonable as far as I was concerned.

Mr. SHAYS. In my part of the country, veterans will sometimes

literally wait half a day before they get—they come, they are told

to get there, and they are queued up in big lines and so on. Source

of tremendous disappointment. You know, they wait a long time to

get there, and once they are there they wait.

One of the things I want to put on the record is that the VA has

one of the best drug programs in the Nation, if not the best, because we buy in bulk and we pass on the savings, and the savings

are considerable. And we are using the VA model as a way to look

at Medicare, because Medicare purchases by the government are

basically paid for individually at individual prices, not at bulk

prices. Totally understandable why anyone who is needing drug assistance would go to the VA facility, because you pay a fraction of

what your neighbor may pay if you are fortunate enough to get in

that system. And I understand why, Mr. Bean, you would be working overtime to have that happen.

Mr. Jones, just in a—we need to get to the next panel so we need

to move along, but let me just ask you this: Describe to me how

the State VA facility interfaces with the Federal system as briefly

as you can do that.

Mr. SMITH. Certainly. Let me just start off by saying they have

been extremely professional. The Division of Veterans’ Services in

Idaho operates three State veterans’ homes located around the

State. Each of these veterans’ homes is being serviced by a different VAMC, so I am able to relate and respond not only to the

Boise VA but to the one in Spokane and the one in Salt Lake as

well. In each case, they have been highly professional. The veterans’ homes received a much greater level of service from the

34

VAMCs prior to the State-directed certification by Medicaid. Once

they were certified by Medicaid, there were a number of services

that had been previously available and provided by the VAMCs

that were no longer available to the veterans who were residents

within the veterans’ homes. The VAMCs also operate long-term

skilled facilities themselves, and that is certainly an issue that is

being addressed by the Mill bill and some things like this. But a

long story short, they have been very professional.

Mr. SHAYS. I would just note for the record that when we had

a hearing in New York State about 2 hours north of the city, the

room was packed. It was about a little smaller than this, it probably had about 300 people in it. And at one point, I was defending

the VA, which was not the mood of the group, and a police officer

came up to me and whispered in my ear, he said, ‘‘In case you have

to leave early, there is a door in the back.’’ And I just want to

thank you for the fact I can go out the front door in this hearing.

[Laughter.]

If there are no more—do you have any other questions?

Mr. OTTER. No, I have none.

Mr. SHAYS. Let me say that you all—your statements were really

pertinent and ripe to the topics of the questions, so we had a number of questions to ask, but you answered them in the questions.

So I just thank you for your participation, you have been wonderful

witnesses, very helpful to the committee and we will go on to the

next panel, unless there is just—I usually do this, I forgot to do

this. Is there any closing comment that anyone on this panel would

like to make? Yes, Mr. Smith.

Mr. SMITH. I would like to make one. There is just one statement

I would like to make and that is the things that I have had here

and everything are true, but the main thing that I would like to

see is on heart care. I just hate to think about somebody laying up

there for 5 days like I did the first time when I had the heart attack and then transferring to Seattle. Five days waiting to find out

how much heart damage you have got is just unreasonable.

Mr. SHAYS. It is.

Mr. SMITH. And I would like to see something like that changed.

Mr. SHAYS. And I think both Mr. Otter and I would totally and

completely agree with you. Probably some people in the VA would

as well. So we are going to try to find a way to solve that problem.

Mr. SMITH. Thank you.

Mr. SHAYS. Any other comments? At this time, then, let me call

Dr. Leslie Burger, Network Director, Veterans’ Integrated Service

Network, Department of Veterans’ Affairs; accompanied by Mr.

Wayne Tippets, Director of Boise Veterans’ Administration Medical

Center, Department of Veterans’ Affairs; accompanied by Dr. David

K. Lee, Chief of Staff, Boise Veterans’ Administration Medical Center, Department of Veterans’ Affairs.

Before I swear in the first panel, I do want to put in the record

another witness who was going to be here, Rex T. Young, from Meridian, ID. Meridian, I am sorry, Meridian. And the part of the

statement he said, ‘‘With all the emphasis on early detection and

early treatment, it is not very comforting to be told by a doctor

after an examination that I need to see a urologist and also need

a colonoscopy and be told the urologists are making appointments

35

9 months out and having a colonoscopy appointment made 9

months out.’’ He basically said the delay on seeing the urologist

and obtaining a colonoscopy through the VA system could have lifethreatening. He was in fact told to have one because there was a

concern about his life. That is I think consistent with what we have

heard in other places around the country and consistent with the

panel. We will put this, without objection, his entire statement on

the record.

[The prepared statement of Mr. Young follows:]

36

37

38

Mr. SHAYS. He would have liked to have been here. I don’t know

if it is the hunting season and he is out hunting. Is that a possibility? I understand. OK.

If you would, please, rise before you. Raise your right hand.

Thank you.

[Witnesses sworn.]

Mr. SHAYS. Note for the record our witnesses have responded in

the affirmative, and we have one testimony. Our testimony is from

you, Dr. Burger, but all three will respond to questions, if necessary.

Mr. BURGER. And we will all give some testimony too if you

would permit.

Mr. SHAYS. Right. Oh, you all three want to give some? That is

fine. Yes, that is fine. Let me ask you, though, I am going to ask

you to hold that mic up but close enough so we can hear you.

Mr. BURGER. Usually I am pretty loud.

Mr. SHAYS. OK. Well, Dr. Burger, delighted that you are here.

Thank you, and be happy to take your testimony.

STATEMENTS OF LESLIE BURGER, NETWORK DIRECTOR, VETERANS’ INTEGRATED SERVICE NETWORK, DEPARTMENT OF

VETERANS’ AFFAIRS; WAYNE TIPPETS, DIRECTOR, BOISE

VETERANS’ ADMINISTRATION MEDICAL CENTER, DEPARTMENT OF VETERANS’ AFFAIRS; AND DAVID K. LEE, CHIEF OF

STAFF, BOISE VETERANS’ ADMINISTRATION MEDICAL CENTER, DEPARTMENT OF VETERANS’ AFFAIRS

Mr. BURGER. Thank you, sir. Mr. Chairman, members of the

committee, on behalf of more than the 7,600 dedicated——

Mr. SHAYS. I am going to ask you to put the mic closer.

Mr. BURGER [continuing]. Employees at the eight facilities and

17 community-based outpatient clinics of VISN 20, the Northwest

Network——

Mr. SHAYS. Tell me, the Northwest Network includes how many

States?

Mr. BURGER. Four, Mr. Chairman: Alaska, Washington, Oregon

and much of Idaho.

Mr. SHAYS. OK.

Mr. BURGER. We claim to be the—we encompass 23 percent of

the geography of our great country, actually, and that does present,

as you alluded to, one of the major issues that we have. Our facilities are several hundred miles apart, getting patients seen up in

Anchorage, Alaska and so on and. The idea is our CBOCs, even

though we have 17 CBOCs, they are still a considerable distance

among all our facilities. It has been a major challenge for us.

Mr. SHAYS. Let me just parenthetically ask you, I know a lot of

service men and women who have had the opportunity to serve in

Alaska and then decided to retire there, so are you getting a fairly

large population of veterans going to Alaska?

Mr. BURGER. Yes, sir. We serve between 10 and 15,000 veterans

in Alaska and have opened a couple of CBOCs there and again

have really challenges of getting people from Nome and Barrow

and the Keeneye Peninsula and so on.

Mr. SHAYS. How many veterans total in the VISN 20?

Mr. BURGER. How many are living there?

39

Mr. SHAYS. You know what? Get on with your statement. I

shouldn’t get this—get right to your statement, please.

Mr. BURGER. We served 11,000 veterans this past year in Alaska.

Mr. SHAYS. OK.

Mr. BURGER. If I might, before I make the statement, to respond

to a couple of the questions that were raised from panel one, just

some data for you. We indeed do use contract care considerably in

the network, and fee schedule, fee basis care. I have some data for

that. Non-VA care amounted to over $76 million last year across

our network. And I did comment to you about the CBOCs that now

number 17. About half of those opened in the last few years.

My statement, since the inception of the Veterans Integrated

Service Network some 7 years ago, our network has been a recognized leader in the quality of care it provides to veterans in the

Northwest. Winner of several quality awards, we really are proud

of the fact, as we heard from the first panel, that those veterans

who use our services consistently rate us among the best in VHA

in the patient satisfaction surveys that we do. And something that

we are equally proud of is that our employees rate us very highly

in employee satisfaction surveys. I have provided for you a copy of

the Malcolm Baldrige National Quality Award application. We

have been applying—have applied for the Malcolm Baldrige Award.

A health care organization, private or public, has never won this

award, and we are really pleased in how we are progressing in

doing that. That really does speak to the quality of our organization.

Mr. SHAYS. Good luck.

Mr. BURGER. And as you have heard here from the first panel,

with the passage of eligibility reform and the opening of several

CBOCs across our network, our veteran users have grown some 32

percent, from 125,000 in 1997 to approximately 165,000 this past

year. This represents an overall market share of about 17 percent

of the more than 1 million veterans that live in our network

catchment area.

We have consistently served the highest percentage of priority 1

through 6 veterans in VHA, and that accounts for about 82 percent

of our workload. We are No. 1 in VHA in serving priority 1 through

6 veterans. Our market share of service-connected and low-income

veterans in our area is 33 percent. I would point out to you, Mr.

Chairman, that with approximately 30 percent of our patients

being age 65 or older, we are one of the youngest networks, demographically speaking, and we will face many of the issues that you

face back east in the next decade or so as our veterans age.

Mr. SHAYS. I am going to ask you to put the mic a little closer.

See, we hear you all right, but I just want to make sure.

Mr. BURGER. OK. Maintaining high quality and increasing productivity has been achieved in no small measure by dramatic shifts

from in-patient care to ambulatory care and from acute episodic

care to a patient-focused primary care and disease prevention

strategy. There have been many innovative practices that have allowed us to drive down or otherwise control increased costs in laboratory and pharmacy and radiology. We have adopted changes in

care delivery to include such things as group visits, the use of more

structured telephone followup care, by establishing a 24 by 7 teleVerDate 11-MAY-2000 11:53 Sep 12, 2003 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6633 D:\DOCS\89163.TXT HGOVREF1 PsN: HGOVREF1
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phone care system for our, by improving patient flow in clinical

areas and advanced telemedicine to deliver patient care and other

staff activities and advanced clinic access for appointing. These are

some of the many practices that have really changed the health

care delivery landscape for us and helped us to provide more and

more care more efficiently for our veterans. Each of these innovations is really patient-focused, designed to empower our veterans as

well as to improve our efficiency.

Speaking to budget for a moment, approximately 96 percent of

our network’s budget is allocated through the Veterans Equity Resource Allocation model, the VERA model. This distribution formula takes into account workload, patient complexity and other

local factors. Without sizable increase in workload over the past

several years, our network has fared fairly well in this distribution

process, receiving more funds percentage-wise than the national

average in all but one of the last 6 years.

I have provided an attachment in the testimony that really

speaks to the marked increase in the numbers of patients that we

have taken care of, while at the same time we have been able to

hold down the costs for veterans served, which is really a tribute

to the staff and being able to accomplish that.

Until recently, we have been able to keep pace with these demands for services, but as you know with the economic downturn

here in the Northwest, unemployment is one of the highest in the

country. As of a couple of weeks ago by looking at the Bureau of

Labor and Statistics Web site, Alaska was 51st in unemployment,

highest unemployment in the country, Washington State was 50th,

Oregon was 49th, Idaho was 30th. So unemployment is a major

issue for us here in the Northwest. The States of Washington and

Oregon have been heavily penetrated by health maintenance organizations, and over the last couple of years some of these health

maintenance organizations have dropped coverage on thousands

and thousands of beneficiaries, many of whom are veterans.

I would also point out that health care inflation is at least twice

the overall inflation rate, and the growing cost of medication, which

is up some 15 to 19 percent these past couple of years, and a shortage of health care workers all together have made it such that the

demand for health care services have now exceeded our ability to

provide those services.

The backlog, as you have heard from the first panel, patients

waiting for their first appointment and those waiting for more than

30 days for appointments has dramatically increased. I would point

out that this is a very dynamic waiting list. Every month, hundreds

and hundreds of people are taken off the waiting list and there are

hundreds and hundreds more people that are placed on the waiting

list.

Mr. SHAYS. Yes. The tragedy, though, is in order to get service,

sometimes you are waiting for someone to die.

Mr. BURGER. I would comment to that, sir, and that is that as

our veterans enroll we are now using a questionnaire, so our veterans are asked about their health status and what it is they are actually seeking from us. We are trying to find those veterans who

have a medical acute need, and we are placing those folks, trying

to give them appointments right away.

41

Mr. SHAYS. No, but I am not trying to incite here, I am just trying to suggest not that we are denying someone services who is

about to die, but in order for a veteran to get service he has to

sometimes wait, or she, but has to sometimes to wait for people to

literally pass away so that they are then on that list, and that is

a challenge for us.

Mr. BURGER. OK. Another comment to that, it turns out that

about 25 or 30 percent of our veterans turn over every year. Many

of those——

Mr. SHAYS. I want the definition of turnover.

Mr. BURGER. Many veterans come to us for a single purpose—

single visit for a single purpose. They don’t come back by their

choice. Other veterans indeed to pass on, and another group of veterans actually are transient, they are no longer living here. And

that really accounts for most of that 25 percent turnover. I point

this out to mean that of the 165,000 veterans that we have served

this year, that means that 40,000 of those we did not serve last

year and we have taken on, in addition to that, another 9,000. We

have increased about 5 percent over last year. So of that 165,000

veterans, about 49,000 of them did not come to us for care last

year. So it is a very dynamic process. But even so we are not keeping up. There are more people coming on that list than we are capable of taking off that list.

We have taken many measures to cope with this increased demand. I mentioned that we are querying people at the enrollment

process so if there is medical circumstances that require it, we give

people appointments quickly. We have expanded clinic hours, we

have increased our patient panel size to 1,000 to 1,200 patients for

each of our primary care providers, we have applied supplemental

funding that the Congress has given us, we have begun the process

of expanding our ability to provide primary and specialty care with

that money. In the past 2 months, our waiting list for primary and

specialty care across our network has decreased more than 20 percent. It was as high as 30,000. It is currently well under 23,000.

And Mr. Tippets and Dr. Lee will address Boise specifically about

that. On October 1, we did institute a plan to give priority for appointments to veterans with 50 percent or greater service-connected disability. We have begun to contact those veterans by

phone and by mail.

We have taken a balanced approach now with the additional resources that have been provided in order to meet the full spectrum

of the needs of our veterans. That includes primary care, specialty

care, long-term care and to meet the dramatic increased demand

for compensation and p pension examinations. We can’t do one

without the other. These are all connected, and we are trying to do

this in a balanced way. We have tried to craft a plan that will be

sustainable by bringing on some new staff, by calling on our affiliated universities to assist, by contracting for some services and

using fee schedule for others.

I would emphasize to the committee, as you pointed out, that the

application of supplemental funding is a temporary solution for us.

With this year’s budget, we will not be able to sustain a large number of—the increase that we have taken on and sustain these services next year. For this reason, there is a hesitancy for us to hire

42

employees as the sole means of dealing with this increased demand.

Mr. SHAYS. Let me just ask a question. Your compatriots are also

going to testify. It is 10 minutes now, I did interrupt you a few

times here. How much longer do you think you need?

Mr. BURGER. I have just a closing comment.

Mr. SHAYS. OK.

Mr. BURGER. I just wanted to summarize by saying we have been

a consistent leader in VHA and the quality of care that we are providing, and in spite of the many efforts we are putting forth to provide care efficiently and effectively, including the increase in resources we have been given, we really have come to a point where

the demand has far exceeded our ability to do that. We are assuring that patients with acute medical needs are having those needs

met. We are getting priority to veterans with 50 percent or greater

service connection, and we do anticipate in the very near future

giving priority for others for their service-connected conditions.

Thank you very much.

[The prepared statement of Mr. Burger follows:]

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45

46

47

48

49

50

51

52

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Mr. SHAYS. Dr. Burger, you would have easily finished within the

10 minutes had I not interrupted you. And also I think both Butch

and I—Congressman Otter and I would want you to know is that

we do know demand exceeds supply, so we are not coming here

asking why you are not able to do all the things we want you to

do. We have to provide you the resources to do it. Also, just say

for the record, we have 600—we are increasing the number of veterans who are served nationwide about 600,000 a year. So we are

trying to get more, but there is more than 600,000 that need help,

particularly because of our drug benefit. We have got a lot of new

customers.

Mr. OTTER. Mr. Chairman, if I may note for the record——

Mr. SHAYS. Sure.

Mr. OTTER [continuing]. Dr. Burger, your entire statement in its

entirety, and having read that it is very informative, will be submitted for the permanent record.

Mr. SHAYS. Absolutely.

Mr. BURGER. Thank you.

Mr. SHAYS. And also to say that I don’t know which of you gentlemen, Mr. Lee or Mr. Tippets, should go next.

Mr. TIPPETS. I will go.

Mr. SHAYS. Yes. Thank you, Mr. Tippets.

Mr. TIPPETS. Chairman Shays, Congressman Otter——

Mr. SHAYS. Is that mic on? Yes.

Mr. TIPPETS. Chairman Shays, Congressman Otter, it is my

privilege to make a few remarks regarding the patient care at the

Boise VA Medical Center. Just briefly, I will discuss workload, access to care, the current waiting list and the use of supplemental

funds to decrease the waiting list. If I could refer you to page 9 of

the written testimony, attachment A. In fiscal year 1997, we treated 10,654 patients; in fiscal year 2002, which just ended, that has

increased to 15,329 patients. That is an increase of 44 percent. In

fiscal year 1997, we had 99,000 outpatient visits; in fiscal year

2002, that has increased to 155,000 outpatient visits. That is an increase of 57 percent. During this same time period, funding per patient has fallen from $4,895 per patient to $4,489 per patient. That

is a decrease of 8 percent in funding over that time period in spite

of the workload going up.

Mr. SHAYS. Give me the time period again.

Mr. TIPPETS. 1997 to 2002, for 5 years.

Mr. SHAYS. So you have less per patient today than you had 5

years ago.

Mr. TIPPETS. Yes, sir.

Mr. OTTER. By 400 bucks.

Mr. TIPPETS. Yes. About 8 percent less.

Mr. SHAYS. And if you then equate to increased costs, then the

number would be even——

Mr. TIPPETS. If you—yes. We did not do this on this attachment,

but if you actually put in the medical inflation, that figure goes

down to $3,500 or $3,600 per patient, yes.

Access. During that time period, we have opened a CBOC in

Twin Falls, which is approximately 120 miles east of here. We staff

that CBOC with two physician’s assistants, two nurses, three

clerks and a mental health provider. Each one of the physician’s

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assistants treat about 800 patients. We currently have a waiting

list of about 800 patients at that CBOC. We are actively recruiting

a physician and during the last couple of months have been interviewing. We think we might have a physician to go to Twin Falls.

If we do, that should eliminate that waiting list at Twin Falls

CBOC. At least right now it would eliminate it, but the waiting list

will grow again.

At the Boise Hospital, we currently have a waiting list of about

3,600 veterans that are waiting for primary care appointments, and

that is broken out approximately into 50 percent category 1

through 6 and 50 percent category 7s. And like I said, the Twin

Falls CBOC has approximately 800 patients on their waiting list.

With the new directive, if a priority 1 service-connected veteran

walks in the hospital, that individual gets an appointment within

30 days. We have approximately 200 service-connected veterans, 50

percent and over, that are on our waiting list. We have, I believe,

scheduled half of those people, and we are in the process of scheduling the other half for appointments, so that is being taken care

fairly rapidly.

Let me talk a little bit about supplemental funds. In the fourth

quarter of 2002, Congress passed supplemental funds to the Veterans’ Administration in the amount of $142 million. As a result of

that, this hospital got approximately $1 million. And I would like

to tell you what we have done with that money. If you look at primary care, we have hired two physician’s assistants. Each one of

those physician’s assistants will take approximately 800 patients.

And we are in the process of recruiting for a physician at the Twin

Falls CBOC, which, like I said, should eliminate the 800-patient

waiting list there.

We feed in the community about 65 procedures in orthopaedics.

These are patients that are on the waiting list. We also did about

150 patients that needed cataracts surgery, that was feed in the

community. We took care of about 194 patients in the urology clinic. These are patients that either needed clinic appointments or

surgery. We took care of about 182 patients for audiology exams

and we increased EMT to take care of about 36 patients that either

needed clinic appointments or surgery. So these funds were used

to reduce the waiting list by feeding out most of the care to community providers. In order to continue this, of course, the supplemental funds need to be recurring or we will have to—we will not

be able to do that.

I am going to stop there, and those are all the comments I have.

Thank you very much.

Mr. SHAYS. Thank you, Mr. Tippets. Dr. Lee. I understand, Dr.

Burger, you are also a Major General.

Mr. BURGER. Yes, sir.

Mr. SHAYS. Yes. Hard to know which——

Mr. BURGER. Retired, sir.

Mr. SHAYS. Retired. OK.

Mr. LEE. Chairman Shays, Congressman Otter, it is indeed my

honor as well to be able to testify to your committee. I just wanted

to comment on a few clinical issues as a physician beyond the data

that you have already heard from my colleagues. One that I think

has already been made a matter of the record but just to emphaVerDate 11-MAY-2000 11:53 Sep 12, 2003 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6633 D:\DOCS\89163.TXT HGOVREF1 PsN: HGOVREF1
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size it is that the waiting lists really are a matter of operational

necessity, and we have heard that the high quality of care once you

start receiving care is good and appreciated, and we value that.

But the reason we can keep that quality high is because we do

have to have the waiting lists in order to constrain the workload

to something that can be manageable. It is a highly regrettable situation, however, and one thing I would like to say on behalf of the

providers is that most of us went into health care because we were

driven to help people. Most of us went into veterans health care because we love taking care of our veterans. And so it is very difficult

and in fact even a bit corrosive, I think, at times for our providers

to face veterans who have legitimate needs and not be able to meet

them. So the voice in the face of the provider, I think, is something

else that we should put on the table here.

And then we heard eloquently, I think, from panel one the

human cost to many of the patients. With a supplemental funding

that Mr. Tippets alluded to earlier, I had a real chance to kind of

experience up close and personal many of the people on the waiting

list. And in fact probably about 90 percent of the people that we

took off toward the end of the last fiscal year with the supplemental funding indeed wanted their medications. But some of those

were heartrending stories of people whose medication bills exceeded their Social Security monthly income.

And in addition to that, I wouldn’t want it to be said that many

of these people didn’t have fairly serious health care needs. And

just to paint that I saw two patients, one of whom had very uncontrolled hypertension, and in fact I would characterize as a stroke

waiting to happen, and another patient who had gangrenous foot

that we had to put in for a rather urgent vascular surgery. So

there are many people on that waiting list with rather urgent

health care needs that are not being met, and of course there is a

very real human cost to that. I would be happy to respond to any

questions, but I wanted to put a human face to those things.

One last thing, since I have the opportunity, is that Mr. Smith,

I think, raised a very good point, which is a policy issue. And that

is many years ago we were able to use VA funds to copay Medicare

or private insurance, but there is a general council opinion that we

cannot copay Medicare, and I am told that general council opinions

have the force of law. And there is a VA regulation that says we

cannot copay private insurance. And so for those two reasons, we

are sometimes I think restricted unreasonably from being able to

provide local care while local specialty care might be available

through one of those two mechanisms. And that is a policy that I

would think that you gentleman could change. Thank you.

Mr. SHAYS. Appreciate the testimony of all three of you and we

will also thank all three of you for going the usual protocol, which

is the government official goes first and then the so-called general

witnesses go after. We have in this committee learned that it is

very important to have the human face go first, and you touched

on it, Dr. Lee, and you listened, all of you did, which is what we

like, because then you can comment on that human face as you

have already begun to have done. So I do want to thank you,

though, because it is not a slight, it is just wanting to make sure

56

that we have—you get the point. I don’t have to go on. Congressman Otter.

Mr. OTTER. Thank you, Mr. Chairman. I guess I will start with

you, Dr. Burger. In your region, has the reduction in cost per patient, is that fairly representative of what has happened in the entire region of what Mr. Tippets and Dr. Lee have had experience

in Idaho? It seems to me there are $406 reduction in 5 years not

adjusted for inflation. Is that pretty representative of the entire region? Take your time.

Mr. BURGER. I believe it is, Congressman Otter. If you look in attachment B, as well, we tried to display the data the same way for

the entire region and then for Boise. As you can see, the cost per

veteran has basically gone down across the board for us as a network as well. Now, part of that has to do with efficiencies and trying to become more efficient, but, clearly, we can’t keep up. No

matter how efficient we get, we can’t keep up with the fact that

more and more veterans as we get older take more and more medications. That is true across the country, and the cost of pharmacy

care has gone up 15 to 19 percent. So we are losing ground in that

regard. But, yes, sir, that is a general statement.

Mr. OTTER. How much of the supplemental—we heard what Boise got, $1 million of the $142 million, which I am going to have

to look into that, but how much did the region get?

Mr. BURGER. We received several million dollars as part of the

supplemental, and we allocated that money by bringing all of our

medical center directors together and looking at how we would distribute those resources. Our start point is usually looking at the

overall patients, the numbers of patients served across the system

and where the greatest needs are. We actually probably two or

three different times, it was about $7 million, but we two or three

times went back to each of our facilities and looked at—because the

money came to us so late in the fiscal year trying to spend that

money became an issue, so we went back to the facilities and

asked, ‘‘If we gave you more money, could you, are the providers

in the community willing to take our patients and do that in a

timely way?’’

Mr. OTTER. And their answer was?

Mr. BURGER. In some cases, yes; in some cases, no.

Mr. OTTER. Is that because there is a fixed national cost for some

of these, standard?

Mr. BURGER. There is a demand for services across our region,

and it is not so easy to find a cardiologist or an orthopaedic surgeon or a urologist that has openings, that can take our patients

in a timely way.

Mr. OTTER. Or will provide openings if he doesn’t think that he

is getting his service paid for.

Mr. BURGER. That is true, but on the fee, the way we provide

that by fee, that fee is not set in any particular amount, as was

referred to about——

Mr. OTTER. So that can be regionally adjusted.

Mr. BURGER. That can be regionally adjusted.

Mr. OTTER. Well, it would seem to me that if you handle, and in

your testimony I picked up on 17 percent of all vets?

Mr. BURGER. That is correct.

57

Mr. OTTER. Is that right?

Mr. BURGER. That is correct.

Mr. OTTER. Twenty-three percent of the land mass but 17 percent of all vets.

Mr. BURGER. Right.

Mr. OTTER. It would seem to me that you should have received

about $22 million—17 percent of $142 million supplement.

Mr. BURGER. That is one way of looking at it.

Mr. OTTER. Well, my concern is unless it was higher cost of delivering the service in some other area of the country, why didn’t we

receive our full rata share?

Mr. BURGER. I can’t respond to that, Mr. Congressman. I don’t

know the answer to that question.

Mr. OTTER. If you could find the answer, would you provide the

answer?

Mr. BURGER. I indeed will.

Mr. OTTER. Mr. Chairman, I would ask that answer that was

provided be made part of the permanent record when we receive

it.

Mr. SHAYS. Absolutely.

Mr. OTTER. Let me ask you a question about the prescription

drugs, and we heard in the testimony from when we were trying

to put a face and a voice to the person that needs the care that

why can’t we provide drugs, filling prescriptions, whether it is eye

or visual or whatever, from a physician? If the person has a doctor’s degree and fills out a prescription, it would seem to me—and

if they brought that prescription, No. 1, it would certainly reduce

part of the workload of that waiting list that may be the care out

of private insurance paid for the issuing of the prescription and all

ours would be quite simple in just filling out the prescription. Why

can’t we do that? Is there something stopping us from doing that?

Mr. BURGER. I will respond, and I will ask the others to respond

as well. I believe that is a policy decision that needs to be made.

The Veterans’ Health——

Mr. OTTER. Made or changed?

Mr. BURGER. Changed.

Mr. OTTER. Oh, OK.

Mr. BURGER. The Veterans’ Health Administration thinks of

itself as providing comprehensive, longitudinal care to the veterans

it serves, as opposed to just filling a prescription for someone.

Mr. OTTER. I would yield on that.

Mr. SHAYS. Yes. I think so we can have a candid conversation

there is a part of me that believes it is a way of restricting the use

of these facilities because there is the question of whether they

could keep up with all the pharmaceutical demand. And there is

also, I am wondering as well, not a concern that a doctor on the

outside is just going to basically maybe be a little more lax in

terms of deciding which type of prescription. In the VA, there are

only certain prescriptions that are filled. I mean it is not all prescriptions, right, or is it all?

Mr. BURGER. If we have the medication in our formulary, yes.

Mr. SHAYS. Yes. It has to be part of the formulary.

Mr. BURGER. The formulary.

58

Mr. SHAYS. Yes. I mean there can be three drugs that provide

the same service, and you may only provide one of them in the VA,

and it sometimes raises the question to the doctor through advertising and others might decide that this other prescription is good,

and then there is going to be pressure on the VA to provide that

one. So I think there are other subtle things that they may not be

good reasons but I think they are all—and I am suggesting that

may be a factor and I am curious to have a more candid response.

Mr. BURGER. As you all know, the Department of Defense provides a pharmacy benefit to military retirees and military dependents. Using our formulary, the experiences that we have had in

working with the providers in the community, I really don’t believe

that what you have just mentioned would be an overwhelming

issue that we could not overcome.

Mr. SHAYS. OK.

Mr. BURGER. By sharing our formulary—actually, our network

formulary is on our Web site, it is on the Internet. It is very easy

for providers in the community to know which of those drugs we

do carry so they can prescribe those specific drugs for our patients.

So I don’t see that as really a major issue.

Mr. SHAYS. Would the gentleman continue to yield?

Mr. OTTER. Yes.

Mr. TIPPETS. Let me make just a couple, then I know Dr. Lee wants to address this issue. Our copay is $7, which has got to be

the best prescription benefit that perhaps exists in the country, including any of us that have insurance. I pay more than $7.

Mr. SHAYS. Yes. That one beats it.

Mr. TIPPETS. And I guess the other thing I would say, and Dr.

Lee will talk about a couple of the issues regarding this, we can

do anything that the Congress wants us to do as long as we have

adequate money to do it. The average patient that walks in our

medical center, the average patient probably has, the last time we

calculated, $800 to $1,000 worth of drugs. That is the average patient.

Mr. SHAYS. Per?

Mr. TIPPETS. Per patient, per year. Per patient, per year. And if

we were to provide this benefit, we could certainly do that, but you

are talking about—I have no idea how much, but you are talking

about a lot of people that want this service and you are talking

about a lot of money. With that, I will pass it to Dr. Lee.

Mr. LEE. Yes. If I could respond, I think I would say that it really is not a clinical issue. I think that clinically that could be done.

I think it is a policy and it is an economic issue. It is VA policy

that they only provide care to those who are actively receiving care

and that it be written by a VA physician.

Mr. SHAYS. And I think your point, policy/economic, I think it

has to do with just the incredible potential costs.

Mr. LEE. Yes. But responding to the formulary piece, actually

physicians in the private sector are very used to dealing with different formularies right now, and most health care plans have to

do that. So I suspect that if we worked in combination with the private clinicians, that they would be able to adjust to our formulary.

Mr. BURGER. Yes. If I might make one other comment about that.

We are very proud in our system of having a computerized patient

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record that is probably the best in the Nation, probably the best

in the world, the CPRS system. And over the last several years

now we are getting to the point where Dr. Lee for one of his patients has an icon on his screen and he can call up where that patient has been seen anywhere in the country, and we know the

records. One of the real issues about receiving care outside our system is the idea of how do I know what that provider outside did

to that patient, what was that lab test that was done, what was

that copy of the x-ray or of the electrocardiogram and what have

you? So the recordkeeping is really a major issue for us. It is an

issue in dealing with the Department of Defense in how we are trying to share patients together, because we use two different computer systems. So the recordkeeping is really important. If we more

and more allow our patients care in the private sector, which

makes sense for them to have care—for all of us to get care locally,

how do you get that record incorporated?

Mr. OTTER. Well, reclaiming my time, I also—you know, I recognize the importance of single provider in order to make sure that

we don’t oversupply a patient with needs. But it would seem to me

that there is, besides the costs in terms of facilities and operation

that we talk about here, it seems to me that there is also a human

cost, and I sometimes wonder when I hear these veterans calling

into my office and I get a chance to talk to some of them, my staff

talks to all of them, that there is a—it would seem to me that there

is always a stress level that goes up when they know they need the

drug, they know that they need the—need to be provided their

pharmaceuticals within 30 days because they are going to be out,

and they say, ‘‘Well, we can’t get you in for 90.’’ And it would seem

to me that if there were a way that we could facilitate the private

prescription, the prescription outside the system, to be filled within

the system and maybe an audit or maybe a check or something like

that, you folks have to tell me. You tell me where to go, and I will

start calling the cadence, as far as I am concerned, because you are

the ones who are going to have to tell us what is going to work in

this system.

Let me go to the formulary. Now, does this mean that on the formulary there is a list of drugs that you can provide and then on

that same list there may be some drugs you can’t provide?

Mr. BURGER. There is a national formulary that lists all the

drugs that are available across the whole system. We have within

our network each of our facilities modifies that for its own special

needs. Those are the drugs that are available through the formulary. If there is a medication that is needed outside, then the

physician or the provider must ask—must make a request of that

and actually goes to the chief of staff at each of our facilities to approve that to be purchased outside of the formulary system.

Mr. OTTER. Is the formulary that we use for the vets any different than the formulary that we use for active military?

Mr. BURGER. Yes, there is a difference.

Mr. OTTER. Why?

Mr. BURGER. Different populations, different contracts. You can

get a drug better from one company than another. I believe we do

very well with DOD in pharmacy and buying things together, and

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I believe Mr. Tippets is correct, we probably purchase drugs less

expensively than anyone else in the country.

Mr. OTTER. No question about it. And we are grateful for that,

because it is needed. Mr. Tippets, let me ask you around this whole

question of the availability of pharmaceuticals. The new Regional

Center for Pharmaceutical Dispersement, is that going to help us?

Mr. TIPPETS. It should make the timing much better, because

that is going to be up in the Seattle area. Will that help us take

care of more veterans that want prescriptions? No, I don’t think so.

Mr. BURGER. What we are concerned about with the consolidated

mail order pharmacy is turnaround time. The quality—and it is an

excellent product. I think we will give all of our veterans in the

Northwest better turnaround time if we have such a facility, and

we are also, as you probably know, working with DOD. There are

also 1 million DOD beneficiaries in the Northwest. So if we can

combine those two things geographically, that would make it far

more efficient from a turnaround point of view. Right now we are

using the Levenworth CMOP and I believe that our patients are

fairly satisfied with that. We have had some problems, but I think

we have had those turned around. The turnaround times are pretty

good now.

Mr. OTTER. Dr. Lee.

Mr. LEE. Yes, I would agree. we have actually had a very active

and ongoing process with full formulary adherence and using the

centralized mail pharmacy system at Levenworth, which has driven, to some degree, the cost per patient that Mr. Tippets alluded

to. But that having been said, I think that when we get the new

regional one here up in the Northwest, it will probably improve

timeliness but probably won’t change much else. I think the quality

and the cost will still be about the same.

Mr. OTTER. Mr. Chairman, I appreciate your endurance here

with me. Let me ask just one more question, Dr. Burger, about the

facilities as a whole.

[Changing microphone cords.]

Mr. OTTER. We do have utility in our Congressman from Connecticut; he can do anything. [Laughter.]

Tell me about the facilities. We have talked about the delivery

of care services and the locations where they are and where they

are not, but what about the state of our facilities? Are we investing

in the latest care service or are we going to have to continue to go

to the local hospitals, the local caregivers in order to maintain our

up-to-date delivery of health care services to our veterans?

Mr. BURGER. As to the facilities themselves, we have some really

aging facilities across our network, I think you know that. Actually,

Mr. Tippets is our chief facility management officer, and he really

helps us, as we get funds from the Congress and from VHA, to

renew our facilities and do construction. He has been very much a

player in that. We are really faced with a seismic problem right

now in the Northwest, the whole Pacific Rim, and we have some

buildings that really need seismic improvement. VHA is addressing

that as money becomes available, but that is a continuing issue.

The operational dollars, the need to bring more and more veterans, I think Dr. Lee alluded to that, makes it very challenging in

how one allocates the money that we have. We have this year, as

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we do each year toward the end of the year, look at where we are

in buying the very latest in equipment and do the best we can to

provide the latest equipment. I believe that when we think in

terms of colonoscopes and endoscopes and radiology equipment, by

and large we are doing a good job in having state-of-the-art equipment to take care of our patients. That matches what is available

in the community. But there are pockets in places. As we get into

digital imaging, for example, that is very expensive to do that, and

the technology changes so often that when you make a capital purchase, 3 or 4 years later you are faced with doing the same thing

again. Computers, we just made a choice to purchase—to replace

25 percent of our computers. Trying to keep in that cycle has been

very challenging, but I think the answer is that we are keeping up

but it is a challenge. Would you add anything to that?

Mr. LEE. I think the facilities that we have in Boise, while aging,

have been kept up exceptionally well, and I think they are really

quite good. There really are not enough of them, and one of the

things I have to face all the time is even if I got more clinical providers, I wouldn’t have a space to put them. And so clinic space for

more primary care is an urgent need.

And a few of the other things that exist in Boise are very capitalintensive, and that includes things like cardiac catheterization laboratories and radiation therapy. And, again, Mr. Smith, I think

was very eloquent about the fact that he had to wait before he

could be transferred to Seattle for cardiac catheterization. And

Boise simply does not have enough size at the VA to warrant that

kind of a capital investment. Those sorts of things I think we

would still need to continue to partner with our community.

But I would say we heard from Mr. Smith about the difficulty

of having a life-threatening illness, having to wait a bit, frankly because of nursing shortages in Seattle, to be transferred out there

in a timely way, and then be out there away from his family when

he is having a myocardial infarction. And similar with the radiation therapy, the necessity of transferring cancer patients who

don’t have long to live to a distance place away from their family

and support systems in their last days. And, frankly, many of those

clinicians regard it as nearly inhumane.

Mr. OTTER. Thank you, Mr. Chairman.

Mr. SHAYS. Thank you. If the gentleman has more questions

after, we can come back to you. I represent probably four-fifths of

a county, and in the county there are about 250,000 veterans. I

represent a wealthy district and candidly many choose not to use

the VA facilities, some, simply because they would just as soon go

to their neighborhood hospital or the community hospital, which

is—in my congressional district, we have six hospitals. But what

has started to happen is they may be paying $3,000 a year for—

or $2,000 or $4,000 for their pharmaceuticals, and they are saying,

‘‘My gosh, I can get the best deal in town.’’ So they seem to feel

guilty in one sense that they are not taking advantage of the program, in another sense, they say, ‘‘Well, we have the resources, we

have been able to deal with it.’’ But it is just—after a while they

think they are stupid not to take advantage of this service which

they are entitled to as a veteran. So what has happened is they

have started to really push the VA facility. Now, I know it is being

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pushed in a lot of places, but these are people in many cases who

have some resources. My question to all of you is, all things being

the same, if you did not provide a pharmaceutical benefit, just

wasn’t provided, I am not even suggesting we not, I am going to

suggest the opposite, but if you didn’t provide it, would there be a

backlog?

Mr. BURGER. You will have to speak to Boise specifically, but as

I mentioned in my testimony, 82 percent of our patients are priorities 1 through 6 already. We lead VHA in that regard.

Mr. SHAYS. But 1 through 6 has nothing to do, forgetting even

the wealthy, has nothing to——

Mr. BURGER. But the priority 7s are mainly the individuals that

are seeking a pharmacy benefit or are more and more populating

the waiting list. What I was trying to get at was that as we now

take off the 50 percent service connected and soon we will be taking those seeking care for service-connected conditions, what is

going to be left on the waiting list are really priority 7 veterans,

and the vast majority of priority 7 veterans are the ones that you

describe are there for the pharmacy benefit. So that will become

the case.

Across our system, as we have grown——

Mr. SHAYS. Let me just say, which would suggest, and then don’t

forget your thought, that if we dealt with it the way that Congressman Otter is suggesting, I mean if we could have all the prescription basically handled outside the VA, your backlog would disappear significantly, but then you would have to make sure your

facility could handle the incredible amount of demand on the pharmaceutical.

Mr. BURGER. That is true.

Mr. OTTER. Would the gentleman yield?

Mr. SHAYS. Sure, absolutely.

Mr. OTTER. What if we just did that for a certain period of time

to reduce the list and go from first time service to ongoing maintenance? In other words, what if we just did that for 6 months? What

if we just took the outside prescriptions for 6 months to reduce the

folks that you have got on your list?

Mr. BURGER. That would get rid of the list, but there are lots of

other people that are being added to the list. That is the idea of

the supplemental kind of funding. It is a one-time solution, it

would get the list down, but the other reasons why people are coming in the Northwest with HMOs not being available and those

kinds of things, health care in general not being available, I think

the list would grow again for us, specifically.

Mr. OTTER. Yield back.

Mr. SHAYS. You wanted to respond as well, Dr. Lee.

Mr. LEE. Yes. The other issue I think is the vast majority of the

medications these people are seeking are actually chronic medications. Having had that window of time and looking at them toward

the end of last year, they are mostly for diabetes, hypertension and

heart disease. And at the end of 6 months, those conditions will

continue on, and so we wouldn’t need to have a mechanism to continue to provide for those medications after the 6-month window.

Mr. OTTER. Excuse me, Dr. Lee. Perhaps I didn’t make my question clear, which is not unusual for me.

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Mr. SHAYS. That is simply not an accurate statement. Be careful

now, he is being very subtle here.

Mr. OTTER. I am just saying that looking at the total list in its

totality, and it just seems sometimes overwhelming, and the stress

that goes on with those names that are on the list, and I want to

go back to the human cost in terms of not only the individual themselves but the family. And I am just suggesting that if we used a

time period here where we said we are going to allow those people

to bring in the prescription from their own doctor and for a certain

period of time until we get them into our system and can get them

off the list of waiting and get them on to the list of maintenance,

is that still a problem?

Mr. LEE. Oh, I couldn’t agree you with more. You know, we have

heard about the human costs. I just think we have to be very careful about making sure that we had capacity when the 6-months ran

out to make sure that we can handle it. We are all on the same

wavelength here, we want to provide that care.

Mr. BURGER. If you were to suggest a pilot, and I know Mr. Tippets once before said he would be willing to raise his hand to try

that to see, but I think, Dr. Lee, really, it is what happens at the

end of 6 months? I wanted to just mention that through that last

month in our 5 percent increase in total numbers of veterans,

about 3 percent of that was in the category A, the 1 through 6s,

and about 16 percent was in the priority 7 veterans. So, again,

even in our network where the vast majority of patients are priority 1 through 6, it is the priority 7 veterans that are overwhelming

our system for the drug benefit.

Mr. SHAYS. And most they are interested in what is truly the

best drug program in the country, if not the world.

Mr. LEE. Yes, sir; that is exactly right.

Mr. TIPPETS. Yes. A very high percentage of them are. I think if

you did that, yes, you would—again, this depends on the facility,

the hospital you are talking about. Yes, you would probably either

greatly reduce or eliminate the waiting list but then you have to

figure out what to do with those patients when they need to come

into the hospital.

Mr. SHAYS. In regards to—what neither of us want to do is screw

up a program that is pretty outstanding—which is outstanding, but

at the same time, when you hear Colonel Jaurena speak, he is

service connected and yet he is having to wait, it blows my mind.

I mean it is service-related, it is not an injury that he has had as

a veteran afterwards but totally connected to the service in Vietnam. And by the way, our committee has had countless hearings

on the whole issue of Gulf War illnesses, and we have learned that

there are many who are in fact sick because of their service, and

it has been a long struggle to get the VA kind of to sort it out

themselves.

Let me just ask you, as it relates—and I will get on beyond the

pharmaceutical—but the pilot program, it seems to me, is a nobrainer that we should try seeing what is the impact of prescriptions being filled by outside physicians. Will they start to suggest

more? Since they don’t really—a VA doctor is going to focus on his

patient, but he is also going to know the capabilities of the system,

and so will there be more drugs per patient being prescribed versus

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what a VA doctor is going to do? Who knows. Maybe not, maybe

there shouldn’t be, but it would be interesting to know. And it

would be interesting to know how the VA then fills in actually providing this greater supply now of pharmaceuticals, because you are

going to have to be able to manage more drugs in and out.

One of the things that has been a source of aggravation is that

you can get a 30-day supply and you have to come in and pick

them up. In some cases—I don’t know, in some cases, are they allowed to be sent to the patient? They are being sent to the patient?

Mr. LEE. Yes. The Department of Defense has the 30-day supply

scriptures; the VA actually has 90-day supplies of medications and

mail-out refills. So we are more user-friendly in that respect.

Mr. SHAYS. So you are sending them out.

Mr. LEE. Yes.

Mr. SHAYS. OK. Well, that is interesting. Let me ask you the

question of the supply of physicians, nurses, technicians, administrators. Is your biggest challenge nurses, biggest challenge doctors,

biggest challenge technicians? Where is your biggest challenge?

Mr. TIPPETS. It is not administrators, by the way. [Laughter.]

Mr. BURGER. That is my biggest challenge. Let me speak from a

network perspective. You know, it is interesting that we are geographically isolated in the Northwest, and that really is an issue

for us. When you actually look at the number of nursing schools

or even medical schools, we only have two: One in Oregon, in Portland, and one in Seattle, in Washington, in our area if you look at

the number of nursing schools and pharmacy schools and so on. So

there is a restriction right there, and I have already heard from

nurses that nursing schools are paying faculty enough to attract

faculty, so they can’t expand the size of their classes and so on.

On the nurse side, it becomes very obvious, because nurses take

care of patients that are in-patients, in bed. There is a dramatic

shortage of nurses and that is going to continue to grow. Within

VHA, the average age of our nurses is approaching 50.

Mr. SHAYS. This is all over the country. I just don’t know what

the—and I am told it is not just getting—well, you answer your

question, I am sorry.

Mr. BURGER. And it is. It is a national issue, and it is getting

worse as we all get older and need more care and so on. For us,

specifically, in the Northwest, several of the medical specialties

there is a dramatic shortage—medical technologists, informatic

specialists, laboratory technicians. Imaging technicians are among

those areas that have an absolute traumatic shortage. We have decided as a network, as VHA has decided, to start training its own.

There are debt reduction programs now in people who are going to

various schools. We are in the process now of trying to figure out

how——

Mr. SHAYS. Is this that debt forgiveness for graduate schools?

Mr. BURGER. Yes. So we are going to try to train our own people

in medical technology or in imaging or as prosthetics managers and

that kind of thing. It is a national issue that I believe requires a

national solution.

Mr. SHAYS. OK. I hear you.

Mr. BURGER. It is really getting to be—we are already in that crisis. I guess you hear that from your constituents.

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Mr. SHAYS. Right.

Mr. BURGER. People who drive ambulances drive around our cities, can’t find beds. And I am not talking about the VA, I am talking about in general. I just saw a statistic that said the average

wait for one of our Nation’s citizens to see their physician with an

acute problem is 7 days. That is a national issue, so it is a problem.

Mr. SHAYS. Mr. Tippets.

Mr. TIPPETS. We have a pretty severe problem with nurses going

back—oh, it probably started a couple years ago, and I have been

the administrator of the hospital here for just about 10 years, and

for the first time ever we actually had to go to the nurse registry

and—you know what the nurse registry is, I am sure; yes, that is

where you go to get contract nurses from a private agency to come

into your hospital.

Mr. SHAYS. And your costs go up about 30 percent?

Mr. TIPPETS. Well, yes. Let me just give you an example. To get

a nurse from the nurse registry costs us about $70 an hour, so we

probably should have all gone to nursing school.

Mr. SHAYS. It is not too late. [Laughter.]

Mr. TIPPETS. We have increased our salaries. We have to be competitive with two major hospitals in town. We have increased our

salaries, we are doing fairly well right now. In addition to that, in

conjunction with the Idaho Hospital Association, we have met with

the local university, Boise State, and they have agreed to increase

their nurse class size by 30, and I believe that started this fall.

Mr. SHAYS. But the bottom line is nurses are a concern. How

about doctors?

Mr. TIPPETS. I will let Dr. Lee address that.

Mr. LEE. Yes.

Mr. SHAYS. Dr. Lee, before you answer, if there is any—we are

going to be set pretty soon to go to our open mic, and so if you

would like to speak, Jason, would you raise your hand there? Jason

has a mic, and what we will do is we will want you to fill out a

form so we can give the transcriber your name and address and so

on so we have it for the record. You won’t be sworn in but you will

be invited to address us. Yes, sir. I am sorry, Dr. Lee.

Mr. LEE. Just a comment on the health professions in general.

I regard it as an ecosystem, and you have to have just about all

the species in the ecosystem to make the whole thing function. And

so we have, from time to time, seen various things, like imaging

technicians become mission critical because of near shortages. As

far as physicians are concerned, we are actually not too unsuccessful in recruiting most primary care physicians, but several of the

specialties we need most for aging veterans, like urologists and

orthopaedic surgeons, are actually earning two to three times what

the maximum VA salary is in the community. And, of course, that

makes it much harder to recruit them, and that means that there

are backlogs in some very critical specialties that our veterans

need.

Mr. BURGER. And you can’t buy those services either, because the

demand is there in the community as well.

Mr. SHAYS. Let me just—you talked about, Dr. Lee, listening to

the face of the issue in terms of listening to what the veterans were

saying, and when you heard Mr. Smith speak about the cardiac

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care, what would be the challenge and what is the logic against not

having him receive cardiac care in Boise? I am sure that exists

here, correct?

Mr. LEE. Oh, yes. Our private medical community in Boise is absolutely wonderful. The specialists are good, well qualified, and actually we value a fairly close working relationship as far as the VA

and the community——

Mr. SHAYS. So let us just talk about that particular issue, the

cardiac care. Is that going to be a subjective decision? Would he

have had the right to petition to get it in Boise or would he not

even have the right to do that?

Mr. LEE. Well, he certainly could ask, and it is really largely an

economic issue. We have talked about the fact that we have large

waiting lists and we try to stretch the Federal dollars we get absolutely as far as we possibly can. And one of the ways we do that

is to send cardiac specialty care to Seattle.

Mr. SHAYS. Anybody else care to——

Mr. BURGER. I would echo that. I think it is an economic issue

about how much care. We could attempt to contract with a group

to try to negotiate prices, but, again, the demand for the care in

the community for cardiology care in the community is such that

there is an unwillingness to enter in any——

Mr. SHAYS. So bottom line is you would be paying top dollar.

Mr. BURGER. We would be paying top dollar.

Mr. SHAYS. And so I am reading into your answer that if some

of these fairly expensive procedures, if you contracted for the cardiac care but then added all the others that you could logically include with that, I mean different services, your budget would disappear real quick.

Mr. BURGER. Sure.

Mr. SHAYS. OK. Is there anything that you all—Congressman

Otter, is there anything you want to ask before we get to the floor?

I know we are going to have to—in order to make that flight, we

are going to have to——

Mr. SHAYS. Let me just say, we will stay and take the next flight

if we have to, but I am just curious to know if there is anything

you have to add.

Mr. OTTER. Yes. I would just like to ask Dr. Lee one question

about his ecosystem, which I thought was very analogous to what

our needs are. But one of the things when I take a look at the inventory of our assets, and being prior military, my prior military

was in the 116th Armored Cat. I joined initially 139th engineers

and then we were reorganized during the Vietnam into the 116th

Armored Cat. And we had several medical units attached to us,

and it wasn’t unusual during our summer, our 2 months—or I

should say our 2 weeks in the summer or our monthly meetings it

wasn’t unusual for a medical unit to come in, provide us with the

necessary physicals that were required for that year and that sort

of thing. But it also wasn’t unusual, though I wasn’t part of the

medical group, I was in reconnaissance, for them not to have much

to do.

And I wonder if we have even taken a look at maybe perhaps

tapping that into asset for an occasional reduction or maybe a review of some of those lists. Is there any way we can take these asVerDate 11-MAY-2000 11:53 Sep 12, 2003 Jkt 000000 PO 00000 Frm 00070 Fmt 6633 Sfmt 6633 D:\DOCS\89163.TXT HGOVREF1 PsN: HGOVREF1
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sets and work them together and maybe have a Guard medical unit

come in for a weekend or something like that when they are on

their weekend drill and maybe work on part of this list, because

they are highly professional folks, and every one of them have a

physician?

Mr. BURGER. Can I address that, actually. Well, go ahead, David.

Mr. LEE. Well, I will briefly address and then turn it to Dr. Burger. Yes, I think there is a lot of promise to that, and in fact some

of that happens, and we have a number of people who do their Reserve duty, or at least part of it, by coming out to us. In fact, we

have one physician from Emmit who comes to us on a regular

basis, and he has helped a great deal with some of the workload

and the backlog, and we do have other units that come in on the

weekend. And during those weekend drills, they do provide us with

substantial help, although it takes a while to orient them and get

them up to speed and working with us.

Mr. BURGER. Just a technical point there. When the military restructured itself, the vast majority of the medical units are in the

Reserve, not the Guard, actually, and I don’t know what USAR

units or other—well, Reserve units might be here but not in the

Guard.

May I please respond to the question, you caught me unaware

when you said 17 percent before, and it has been rattling on me.

It is not 17. Seventeen percent is our market share. The $142 million was distributed by VERA by workload, and we did get our fair

share. So that——

Mr. OTTER. We got a per capita.

Mr. BURGER. We got a per capita. We got like everybody else.

The 17 percent relates to our market share of our million veterans.

Mr. OTTER. There is no sense in us leaving any money laying on

the table.

Mr. BURGER. No. We did get our fair share of that money.

Mr. OTTER. Thank you. Thank you, Mr. Chairman.

Mr. SHAYS. Let me invite the three of you to stay, and I am going

to let you have closing comments. We may have just one or two veterans, participants, here who may want to make some comments.

So if you could just—so if you would identify yourself for the

record. I know you have given us a sheet, but identify yourself.

Mr. HARRIS. Good morning.

Mr. SHAYS. Good morning.

Mr. HARRIS. Representative Shays and Otter, I am Eldon Harris.

I am a retired Navy chief petty officer. I retired in 1958, enlisted

in 1938. I have seen many changes in health care to losing lifetime

health care in the Navy. I then go into civilian life and I have a

company promise of lifetime health care; later, lose that. So I am

almost appalled at the arguments we have or what we have to

present regarding basically the pharmaceutical plan, or what we

don’t have as a plan, available for our veterans down at the VA

hospital.

I have gone through pharmaceutical plans that you won’t believe.

At the present time, I am just about as good as I can get. We get

our prescription filled through DOD, the wife and I both, and we

also have available through Fred Meyer’s, a local chain store here,

we can get prescription drugs filled here for $3 a prescription, and

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that is for your regular prescriptions if they are generic and $9 for

the others. So to me, we are missing an awful lot someplace. I

think we need to go back clear up to where this ball starts to roll

and go to these pharmaceutical companies.

Another appalling thing is that if you go to our borders in Mexico

and Canada, 40 percent, or maybe more, of the people going across

the border to fill their prescriptions are either retired farmers or

retired military that don’t have a medical plan or they are not

qualifying for it. This is sickening. If these pharmaceutical companies can go to Mexico or go to Canada, sell the plant and sell these

drugs for that price outside of losing their lobbying policies here in

the United States, there is no reason they can’t do it here. We have

got to be as good a country for the companies as anybody is.

Mr. SHAYS. Let me say we had a hearing in Boston on the whole

issue of the pharmaceutical program, and if you leave your address

with us, we will send you the—should we send the transcript—yes,

we can send you the transcript of that and be interested in your

comment. One of the challenges that exists for pharmaceutical companies, you know that they are basically price controls in both. I

wager to say there has been no major medical breakthrough of any

pharmaceutical company in Mexico because of it. And I would say

to you there is one company in California that has invested $1 billion in hoping to retard the deterioration into Alzheimer’s. They

thought they were going to have a major breakthrough, had a lot

of investors in, but right now it has not proved successful. That $1

billion is out the window. So we are trying to find the way you get

the pharmaceuticals to create the new drugs and invest and risk

and so on, get a return far more than what it costs to produce but

for all they are investing.

What we did do was we did vote in the House for legislation to

say that if you could get a drug cheaper in Mexico or Canada, as

long as it was FDA-approved, that you could import it in as a way

to see if we could kind of level pricing in the United States. It is

very controversial. Your program that you get, though, you are not

getting from the VA, you are getting through the Department of

Defense.

Mr. HARRIS. This is true, what they call the TriCare type thing.

Mr. SHAYS. And your testimony is that you are content with that

program.

Mr. HARRIS. Yes. This is a fantastic deal.

Mr. SHAYS. Yes.

Mr. HARRIS. But here, again, you have to be over 65.

Mr. SHAYS. Right.

Mr. HARRIS. One other thing on this, I noticed in the conversation there is a difference between minimum copay through the VA

and what I can get it at Fred Meyer’s. Evidently, Fred Meyer’s is

getting paid for the difference through Medicare, but the DOD or

VA should be getting——

Mr. SHAYS. What the VA, I don’t know if DOD does as well, is

we buy in bulk, and we are able to basically pass on that savings

to the veteran.

Mr. HARRIS. Well, this rings in another problem, just to touch on

it in a minute. My wife has a condition that takes a special pill.

When we first moved here 3 years ago from Washington State we

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went to Mountain Home Pharmacy, and it got to the point where

she could not get her prescription filled there, because they had no

generic, no crossover. And then we come to find out that the small

pharmacies they only order enough of this one pill for prescriptions

for their local people on the base. So here again you have a cost

breakdown. I did forget when I introduced myself, I am the president of the Fleet Reserve Association Branch 382. I have been a

member for 49 years, so I have seen a lot of changes and have followed this man the last 3 years too. The man sitting behind me

and I have run across a few years, so I am watching all of you. I

haven’t got many years to go but I am watching. I thank you for

this opportunity.

Mr. SHAYS. Thank you. It is an honor to have you testify before

the committee. Thank you very much. Mr. Smith, I think you also

wanted to make a comment.

Mr. SMITH. I am Tom Smith, of course. The comment I had to

make was that the medical flights to Seattle. On the Cardiac Unit,

if you are in there on an emergency, they do fly you up. They fly

you up with a medical plane, a nurse’s assistant and the pilot. And

the plane, I am sure that costs a bunch, and when we start figuring things out, the copay with my insurance would have been far

cheaper than to have the medical procedure done in Seattle. So I

don’t understand why that there is a regulation here that stops the

VA from paying a copay with my private insurance when my private insurance took care of everything but. And it is just a fine line

here, and I don’t understand what it is and why it should be there.

Mr. SHAYS. You know, I should know the answer to the question.

I understand why it exists in Medicare because it is the same

thing: It is the government paying the government. So whether the

government is VA or the government is Medicare, to get a copayment from Medicare is just taking one part of the government to

the other, but I don’t know the private side and why we are not

able to do it on the private side. Can you speak to that at all? Mr.

Smith, you should sit down, I am sorry, because the transcriber

has the mic.

Now we have one other person who is going to—OK. And we will

go to the next person afterwards.

Mr. LEE. Yes. I am very well-versed on that one. The copayment

of the private insurance is a matter of VA regulation, and I am told

I can be disciplined if I ignore VA regulations.

Mr. SHAYS. No, I understand you have got to follow regulations.

Usually when something seems absolutely absurd there is a reason,

and you may not agree with it, yes, but there is a reason why, and

I wish I had why we don’t do it because it seems like a no-brainer.

Mr. LEE. Yes. I don’t understand the rationale either. I agree

with Mr. Smith. By the way, the cost of the air ambulance is about

$4,000.

Mr. SMITH. The copay on that would have been less.

Mr. SHAYS. Right. But how much is an operation in a hospital,

what would that have been in a private hospital?

Mr. LEE. You are looking right around $45,000.

Mr. SHAYS. Right, 45. And at the facility, how much at your facility?

Mr. BURGER. Probably well under $25,000.

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Mr. SHAYS. Right. So you are getting your—you are looking at

total costs. But in the end, we have got to decide there is a point

that even costs notwithstanding there should be a critical mass of

service provided for a veteran, and I don’t think anyone here is denying that. We put these administrators in a difficult circumstance.

We give them a certain amount of money, we have a lot more veterans each year, and we could yell at them, but it really rests on

Congressman Otter’s and my shoulder to just keeping running out

more benefits for—more money for the hospitals, which we do

every year, but it is never quite enough.

Mr. SMITH. I agree that there is not much money to go around,

that is No. 1. And the only thing that I can’t understand and still

don’t understand is why that they wouldn’t be able to have a copay

that would pay with my insurance if——

Mr. SHAYS. I don’t have the answer to your private—why the private insurance, and you have—I am going to leave this as a requirement of my committee staff. You are looking at the Director,

Larry Halloran. Larry will make sure you get an answer and Butch

and I get an answer as to why there is not the private copay and

then if there is anyone in the audience who could answer, I would

love it. But I should know it, I think I was told and I think I have

forgotten. But it may make sense or may not, and we will look into

it, and this is one of the values of the hearing. So you have made

a number of contributions today, and I thank you.

I think we will get to our last witness, not our witness but our

last person invited to make comments. And you have given a form

to—OK, yes.

Mr. WILLIAMS. My name is Gordon Williams, and I am combatwounded Marine, and I am 6-year paratrooper, 22 years active

service. And unlike the rest of the people that testified, I, like a

commander, see the people in action at the VA hospital because my

wife and I volunteer there 2 or 3 days a week. We work there to

supplement the people that get paid. I can tell you that this is one

of the best hospitals that I have ever been in. I have been in a few.

They have the best medical staff and they are overworked and in

most cases underpaid. Mr. Tippets runs a tight ship. There are no

wall-leaners, there are no clipboard carriers, they work. Anytime

you—and they always go the extra mile. If you need a question answered by a doctor and you are in there, he will take the time to

do it, although many people sit out there. And I guess I am beating

a drum for this hospital, and I damn sure am.

Mr. SHAYS. Well, you know what? I was going to ask if any of

the gentleman want to have a closing comment, but I think you

would be foolish to respond. [Laughter.]

And we are going to let your comment be the last word, how

about that?

Mr. WILLIAMS. How about that.

Mr. SHAYS. OK.

Mr. WILLIAMS. Semper fi.

Mr. SHAYS. Thank you very much. We will close this hearing.

Thank you very much. Oh, excuse me, before we close, I want you

to sit down. I do want to thank very much the people who worked

hard on arranging this hearing. Cheryl Miller, Business Manager

of VWF Post 63, thank you very much, Cheryl. We thank Jim

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Adams, Congressman Otter’s district staff, from his staff, and Mark

Warbiss, Communications Director as well from the staff of Congressman Otter. And also Gayle Ruts, Northwest Transcripts Court

Reporter. Thank you Gayle. Is there anyone else we should thank?

Well, I just want to thank all of you for participating. It has been

a wonderful hearing, very educational. I am delighted that the

committee came out. I just apologize to Butch that we didn’t come

out sooner, but we will back on other issues as well. And thank you

all very much. Butch, do you have anything?

Mr. OTTER. No. I thank everybody for being here. I really want

to thank Congressman Shays, Chairman Shays and the entire

staff, Larry, everybody, for coming out, because I know how important, and I think you too, know how important it is to these folks

that were here in this room here today, and I thank you very

much, Mr. Chairman.

Mr. SHAYS. Thank you very much. This hearing is adjourned.

This first adjourn didn’t happen.

[Whereupon, at 12 p.m., the subcommittee was adjourned.]

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