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[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]

                   SERVING VIRGINIA'S RURAL VETERANS

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

                             FIELD HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             July 19, 2010

                   FIELD HEARING HELD IN BEDFORD, VA

                               __________

                           Serial No. 111-92

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                      U.S. GOVERNMENT PRINTING OFFICE
  58-059                   WASHINGTON : 2011
___________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Printing Office, 
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

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

                            C O N T E N T S

                               __________

                             July 19, 2010

                                                                   Page
Serving Virginia's Rural Veterans................................     1

                           OPENING STATEMENTS

Chairman Michael H. Michaud......................................     1
    Prepared statement of Chairman Michaud.......................    53
Hon. Thomas S.P. Perriello.......................................     2

                               WITNESSES

U.S. Department of Veterans Affairs:

  Patricia Vandenberg, MHA, BS, Assistant Deputy Under Secretary 
    for Health for Policy and Planning, Veterans Health 
    Administration...............................................    38
      Prepared statement of Ms. Vandenberg.......................    76
  Daniel F. Hoffman, FACHE, Network Director, Veterans Affairs 
    Mid-Atlantic Health Care Network, Veterans Integrated 
    Services Network 6, Veterans Health Administration...........    40
  Carol Bogedain, MS, RD, CPHQ, FACHE, Interim Medical Center 
    Director, Salem Veterans Affairs Medical Center, Veterans 
    Health Administration........................................    41

                                 ______

American Legion, Michael F. Mitirone, Commander, Department of 
  Virginia.......................................................    20
    Prepared statement of Mr. Mitrione...........................    63
DaVita, Inc., Kevin Trexler, Division Vice President.............     9
    Prepared statement of Mr. Trexler............................    61
Disabled American Veterans, Clarence Woods, Commander, Department 
  of Virginia....................................................    24
    Prepared statement of Mr. Woods..............................    67
Southwest Virginia Community Health Systems, Inc., Howard 
  Chapman, Executive Director, and Member, Virginia Community 
  Healthcare Association.........................................     8
    Prepared statement of Mr. Chapman............................    55
Thackston, Major General Carroll, USA (Ret.), Mayor, South 
  Boston, VA, and Former Adjutant General, Virginia Army National 
  Guard..........................................................     5
    Prepared statement of General Thackston......................    53
Tucker, Lynn, Museville, VA......................................    26
    Prepared statement of Ms. Tucker.............................    74
Veterans of Foreign Wars of the United States, Daniel Boyer, Post 
  Commander, Grayson Post 7726, VFW Past State Commander.........    22
    Prepared statement of Mr. Boyer..............................    65

                       SUBMISSION FOR THE RECORD

Halifax Regional Health System, South Boston, VA, Chris A. 
  Lumsden, Chief Executive Officer, statement....................    79

 
                   SERVING VIRGINIA'S RURAL VETERANS

                              ----------                              

                       MONDAY, FEBRUARY 14, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 9:00 a.m., at 
the Bedford County Board of Supervisors Meeting Room, County 
Administration Building, 122 East Main Street, Bedford, 
Virginia, the Hon. Michael H. Michaud [Chairman of the 
Subcommittee] presiding.
    Present: Representatives Michaud and Perriello.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I'll call the Subcommittee on Health of the 
Committee on Veterans' Affairs to order, and I'd ask the first 
panel to come up.
    First of all, I'd like to thank everyone for attending this 
hearing, especially the veterans who are here with us today. I 
would also like to express my sincere gratitude to the Bedford 
County Board of Supervisors for their hospitality in hosting 
this hearing.
    Today's hearing would not have been possible without Mr. 
Perriello's tireless advocacy for veterans living in Virginia. 
He is a welcomed Member of the Subcommittee on Health of the 
Committee on Veterans' Affairs. He also brings a new energy and 
enthusiasm for tackling the unique challenges facing veterans. 
I really got to know Mr. Perriello when we took a trip to 
Afghanistan together to learn more about the health care 
provided to the men and women who are wearing the uniform so 
proudly. And as Chairman of the Subcommittee and a 
representative of rural communities in the State of Maine, Mr. 
Perriello and I share an interest in making sure our rural 
veterans receive the care they deserve.
    Our veterans, whether they live in rural Maine or rural 
Virginia, face common challenges. Most notably, access to care 
is an issue for veterans living many miles or hours away from 
the closest U.S. Department of Veterans Affairs (VA) medical 
facility. Given these challenges, it is important that our 
rural veterans have access to health care.
    When you look at access to health care, there are many 
tools out there that can help, such as telemedicine, telehealth 
and VA's new pilot program that provides enhanced contract 
care.
    This year we held several important hearings focused on 
rural health. For example, this past April we held a hearing on 
VA's implementation of the Enhanced Contract Care Pilot 
Program. To our surprise, we learned the VA planned to create 
pilot programs within the Veterans Integrated Service Networks 
(VISNs), that were selected under the original legislation, 
VISNs 1, 6, 15, 18 and 19.
    At this hearing in April, we made it clear that Congress's 
intent was to have VA implement this pilot program VISN-wide 
within those VISNs. And when you look at the scoring that was 
provided by VA to the Congressional Budget Office (CBO) on how 
many veterans would be affected by that program, these scores 
indicated that it would be VISN-wide.
    Unfortunately, we just were informed a few days ago that VA 
does not plan on honoring Congress's intent and will only be 
implementing a pilot program in selected locations within the 
VISNs. I'm deeply concerned about this recent development and 
look forward to hearing from the VA today on this very 
important issue.
    Next, in June of this year we held a hearing on innovation 
of wireless health technology solutions as a way to help 
overcome rural health care challenges. At this hearing, we 
heard from the Director of Rural Network Development in the 
University of Virginia Health System, who provided testimony on 
the unique needs of veterans of the Appalachia and the 
importance of innovation in telemedicine and wireless mobile 
health applications.
    Again, I want to thank Mr. Perriello for inviting us here 
today, and I appreciate this opportunity to hear directly from 
the veterans of Central and Southern Virginia about their local 
health care needs. I look forward to the testimony of the 
different panels we have here today.
    Once again, I want to thank Mr. Perriello for all that you 
have done and are doing for our veterans across this Nation and 
in your State of Virginia. I would now turn it over to you for 
your opening statement and also to introduce the first panel.
    [The prepared statement of Chairman Michaud appears on 
p. 53.]

        OPENING STATEMENT OF HON. THOMAS S.P. PERRIELLO

    Mr. Perriello. Thank you very much, Mr. Chairman. I really 
appreciate the sacrifices you've made to come down here and be 
part of this, and also to the Committee counsel, both the 
Democratic and Republican Committee counsel present. The four 
of us did travel together to Afghanistan, not only to look at 
the security situation, but to look at the seamless transition 
or how to create a more seamless transition from the forward 
operating bases through our holding hospitals and back into the 
VA system. Far too many are lost within those seams, as we all 
know.
    We've made dramatic advances in battlefront medicine since 
the Vietnam and prior ages, which means we're able to keep a 
lot of soldiers and airmen alive that would not have survived 
before. That also means we're seeing a complexity of physical 
and emotional issues back on the home front once they have 
returned.
    And one of the things that I want to thank in particular--
and the community here across Central and Southern Virginia has 
been great on this--is that in previous eras sometimes within 
the veteran service organization community, we have seen 
generational battles, one set of veterans against another. We 
have seen an unbelievable unity of veterans of--to make sure 
that we are doing everything we can with our returning Office 
of Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
vets, and I think it's a testimony to the veterans service 
organization (VSO) community and the unity across generations 
that we have been able to respond in such a dramatic way, still 
much more to be done, to make sure that those folks, as they're 
coming back, are getting the best care that they can. And 
again, I think everyone here up in diocese has been interested 
in understanding that.
    As Mr. Michaud noted, he and I both represent quite rural 
districts with high degrees of patriotism and service through 
our armed forces. And one of the things that he and I both 
advocate heavily is trying to get more of the health care to 
the veteran instead of just the veteran to the health care, 
ways that through telemedicine, through primary care within our 
communities, which we'll hear a lot about today, through 
community-based outpatient clinics (CBOCs), and other ways we 
can try to get services to veterans instead of putting the 
burden on them.
    This hearing in many ways is another example of that. We 
want to get out in the field to make sure that we're making it 
as easy as possible to bring the Committee's processes to the 
veterans instead of veterans always having to come up to 
Washington to do so, though many of you have given up your time 
on that front. So we wanted this hearing--I wanted this hearing 
here in Bedford because, of course, no community has given more 
in terms of sacrifice. The great tradition of the Bedford Boys 
and the wonderful D-Day memorial that's here, even with the 
controversy that's unfortunately going on, remains just an 
unbelievable statement of the--of the events of Normandy and D-
Day that should never be forgotten and continue to inspire.
    I remember one of the first programs that I attended up 
there--I believe it was a July 4th ceremony--hearing the story 
of a mother who had just lost her son in Iraq, who that son had 
grown up visiting Bedford and then eventually D-Day Memorial, 
and that had inspired him to enlist and continue that tradition 
that we have seen. So there's so much to be proud of here in 
Bedford. But we also see the challenges of course in the 
system.
    Now, this Subcommittee is on Health. I just want to make 
one brief comment about the Economic Opportunity Subcommittee 
of the Veterans' Affairs Committee that I also serve on, which 
is simply that the unemployment levels for our returning 
veterans right now is astronomical. Some put it at or above 20 
percent unemployment.
    So of course as people are coming back, not only might they 
be facing, say, a foreclosure on their home, their job is not 
there, challenges in their marriage, because we know what a 
strain that these extended deployments can put on our military 
families, perhaps physical and mental challenges as well in the 
health sector, to also be in an environment where we see not 
only general unemployment, but we see employers actually 
resisting hiring veterans. We hear the tragic stories of a 
veteran saying they won't even put their service on their 
resume because employers are concerned whether it's perceptions 
of post-traumatic stress disorder (PTSD) or perceptions of how 
quickly people are getting called back up, or seeing various 
hurdles to veterans getting employment when they should be the 
first in line.
    So we are working on a number of proposals on that 
Subcommittee as well, which won't be the immediate focus of 
this panel, that includes not only the most rapid 
implementation of Senator--of the GI Bill, modern GI Bill that 
our own Senator and many others on this Committee fought for, 
to modernize access to 4-year colleges, but we're also hearing 
from a lot of veterans that, you know, a 4-year college isn't 
for me right now, I need to get 12 months of vocational and 
skills training so I can get a decent wage and support my 
family, and trying to expand and streamline some of the 
vocational skills, training programs, some of the hiring 
programs, to make it more appealing for businesses to hire 
veterans and other issues. So those are things we continue to 
fight on there.
    Here in this Committee again, we are particularly focused 
today on issues of rural health, and I have been very blessed 
by the expertise of the people sitting in front of me and many 
others to talk on a daily basis about the issues that we face 
in terms of access to care, access to specialty care, costs 
involved and other things.
    And with that I want us to move to the first panel, and 
first introduce Major General Carroll Thackston who, in 
addition to being a former Adjutant General of the Virginia 
Army National Guard, is also the Mayor of South Boston, 
Virginia. He has been a tremendous servant both in uniform and 
also in the community. And along with him we have Dr. Roger 
Browne and Colonel Ted Daniel, both retired military. Dr. 
Browne is a general practice doctor in the South Boston area. 
Ted Daniel is the Town Manager. We've also worked together.
    These three gentlemen are tremendous public servants in 
every sense of the word, and we have worked together 
extensively on what I think is one of the most appealing, 
competitive proposals for offering primary care through local 
facilities. It's a project that has been painstakingly put 
together, has tremendous support both from the local medical 
community, the hospital community, the elected officials and 
the veterans community, African American, white, young and old 
in the area, and I think it exemplifies so much what this 
Committee set out to do with this pilot project, and I'm 
looking forward to them speaking.
    We also have joining us Howard Chapman, the Executive 
Director of Southwest Virginia Community Health System and the 
Virginia Community Health Care Association, to talk some about 
their experiences, as well as Kevin Trexler, who's the Division 
Vice President for DaVita, who is going to talk some about 
dialysis and a number of other issues and ways that some of our 
private contractors are interacting with the VA system.
    So, with that, I will have more to say in response, but I 
really appreciate all of our panelists being here to 
participate, all the work that went into your opening 
statements and look forward to what you have to say this 
morning. I yield back to the Chairman.
    Mr. Michaud. We'll start with General Thackston.

  STATEMENTS OF MAJOR GENERAL CARROLL THACKSTON, USA (RET.), 
MAYOR, SOUTH BOSTON, VA, AND FORMER ADJUTANT GENERAL, VIRGINIA 
  ARMY NATIONAL GUARD; ACCOMPANIED BY ROGER BROWNE, M.D., USA 
(RET.), SOUTH BOSTON, VA (INTERNAL MEDICINE PHYSICIAN); COLONEL 
TED DANIEL, USA (RET.), TOWN MANAGER, SOUTH BOSTON, VA; HOWARD 
   CHAPMAN, EXECUTIVE DIRECTOR, SOUTHWEST VIRGINIA COMMUNITY 
HEALTH SYSTEMS, INC., AND MEMBER, VIRGINIA COMMUNITY HEALTHCARE 
   ASSOCIATION; AND KEVIN TREXLER, DIVISION VICE PRESIDENT, 
                          DAVITA, INC.

               STATEMENT OF MAJOR GENERAL CARROLL

                     THACKSTON, USA (RET.)

    General Thackston. Thank you, Congressman Perriello, Mr. 
Chairman. Good morning, ladies and gentlemen. I'm Carroll 
Thackston and the Mayor of South Boston, as Mr. Perriello so 
said. I have served over 10 years, both as Vice Mayor and Mayor 
of our town, which numbers about 8,500 in population.
    I'm also a retired Major General of the United States Army, 
having spent over 40 years, the last 4\1/2\ years as the 
Adjutant General of the Virginia National Guard. I served on 
active duty for about 6 years, spent 35 years in the National 
Guard. And so with this background I have a good understanding 
of the National Guard operations, their goals and objectives 
and the problems, current and future, facing the National 
Guard. So my main focus this morning will be about the National 
Guard and its varying components and its probable impact on the 
Department of Veterans Affairs.
    As I'm sure you are all aware, the Total Force Policy has 
been in effect since post-Vietnam and treats the three 
components of the Army and Air Force, that is, the regular 
forces, the National Guard and the Reserves, as a single force. 
Unlike the impact of Vietnam veterans on the VA system, this 
total integration and increased reliance on combat and combat 
support units of the National Guard throughout the 1990s, and 
the war on terror creates a whole new dynamic for Veterans 
Affairs.
    So before I discuss some of my concerns about the Guard and 
increasing impact on the VA, I would like to tell you about our 
local effort to help veterans of Halifax County and the 
immediate nearby counties. For the past 3 years several of us 
have worked with a small group of local Halifax veterans, 
primarily Vietnam veterans. We have worked to establish a 
primary care facility in South Boston to serve local area 
veterans. We have met many times, and we have travelled many 
miles in pursuit of our goal.
    At this point, we are aggressively seeking designation as a 
rural locality under the VA's Enhanced Contract Care Pilot 
Program. If successful, Halifax Regional Hospital's new primary 
care facility located in South Boston will serve as a pilot 
project for contract care within VISN 6. Our group has also met 
numerous times with Congressman Perriello, his staff and VA 
representatives. We have travelled to Washington and were able 
to meet with Secretary Shinseki. And most recently participated 
in a lengthy teleconference that included Deputy Assistant 
Under Secretary Vandenberg and numerous VA staffers.
    In January of this year, Dr. Roger Browne, a member of our 
group, testified during Roundtable discussions of the Committee 
on Veterans' Affairs on ``Meeting the Unique Health Care Needs 
of Rural Veterans.'' Dr. Browne is credentialed as a specialist 
in internal medicine. He's treated Halifax County veterans for 
over 30 years, and has personal experience as a brigade surgeon 
for the 198th Light Infantry Brigade in Vietnam in 1968 and has 
provided our group with the leadership and the credibility to 
clearly identify the quality of primary health care our 
veterans need and deserve.
    At the finish line we hope to have a new and modern primary 
care center in South Boston operating as a VA primary care 
contractor, providing all Halifax County veterans, both old and 
young, regular forces, Guard and Reserve, with the quality 
primary care, medical care that they have earned and are 
entitled to, both legally and morally.
    There were 1,127 veterans in Halifax County enrolled in the 
VA system at the end of fiscal year 2009. There are 2,954 
civilian veterans in Halifax County according to the most 
recent census data. We want all of them participating in the VA 
health system, and we want a local facility that is convenient 
for them and their families. We want to ensure that our growing 
population of veterans that are returning from current tours of 
active duty, are assimilated back into their home communities 
with the assurance that convenient quality VA medical care is 
there for them.
    Now, as a former Adjutant General of the Virginia National 
Guard from June 1994 to October of 1998, I have some deep 
concerns about the coming impacts of the VA system as a result 
of the extensive use of National Guard combat and combat 
support units during Operation Iraqi Freedom and Operation 
Enduring Freedom in Afghanistan.
    During my tenure as the Adjutant General, in spite of 
actively seeking overseas operations for our 10 National Guard 
divisions, the National Guard was more or less relegated to 
homeland security and domestic crises. As I'm sure you are 
aware, this is not the situation the Guard finds itself in post 
9/11.
    Let me give you some examples. In Virginia, we have 7,838 
members currently assigned to the Army National Guard, which is 
102 percent of our authorized strength. Since 9/11, 8,862 Army 
Guard personnel and over 700 Air National Guard personnel have 
been deployed, 81 Purple Hearts have been awarded to Virginia 
Guardsmen, and ten of our men and women have been killed in 
action. There are currently 630 Virginia National Guard and 
Virginia Air National Guard men and women on active duty.
    If we go to the national scene, the total number currently 
on active duty from the Army National Guard and the Army 
Reserve is 90,144. The Navy Reserve is 6,354, excuse me, the--
the Air National Guard and Air Force Reserve, 14,457, Marine 
Corps Reserve, 4,917, and the Coast Guard Reserve, 787. This 
brings the total number of National Guard and Reserve personnel 
currently activated to 118,659, including both units and 
individual augmentees. These figures are current as of July 13. 
And when you consider the continuing participation of the war 
effort since 2001, the total number of National Guard and 
Reserve numbers is substantial.
    So in conclusion, when we consider the huge influx of 
citizen soldier veterans created by the increase of Guard and 
Reserve forces under the Total Concept Policy, and the 
prosecution of the extensive combat operations in the Middle 
East, there is an enormous workload headed for the Department 
of Veterans Affairs. When you also consider the demands being 
placed on the Department of Veterans Affairs by the intense 
combat environment and multiple tours of duty, combined with 
the efforts to increase VA medical care eligibility for 
veterans, I believe that the VA will have to expand its network 
of health care facilities to meet these increased demands.
    News reports last week indicate that the VA is adopting new 
rules regarding post-traumatic stress disorder that will, in my 
opinion, drastically increase the clinical workload for the VA. 
Reports in this newspaper article cite a 2009 Rand Corporation 
estimate that nearly 20 percent of the returning veterans, or 
300,000, have symptoms of PTSD or major depression. It will be 
interesting to see how these estimates are updated to reflect 
the new rules announced last week.
    The education our group has received in pursuing a contract 
primary care facility for Halifax County has clearly 
enlightened us on the tremendous strides that the VA has made 
since the mid-1990s with the establishment of the VISN and the 
CBOCs, community-based outreach clinics, but we are absolutely 
convinced that the VA will need to rely on the numerous 
professional and highly qualified private sector medical 
facilities to meet the incoming demands for VA medical health 
care.
    Expanding the CBOC system may be prudent and wise, but the 
full utilization of contract medical facilities such as the one 
in South Boston will be essential to meeting these demands, 
both on time and on cost. Our research has shown considerable 
savings in time and fuel by veterans using more convenient and 
accessible primary care locations. Only through an aggressive 
primary care program that is structured to include all 
qualified veterans will the VA be able to cultivate a climate 
of preventive medicine and early detection for serious 
illnesses.
    The VA Medical Center will always be the bedrock of VA 
medical care to take care of the most serious medical problems 
of our veterans and the VISN/CBOC system is a proven winner, in 
our opinion. But we still believe that contract primary care 
using existing private-sector facilities is going to be 
critical to the VA. So we in South Boston, in Halifax County, 
are prepared to lead the way.
    And that concludes my--do we get a chance later on to 
answer questions?
    Mr. Michaud. Yes.
    General Thackston. Again, we thank you very much for the 
opportunity to be here today.
    [The prepared statement of General Thackston appears on p. 
53.]
    Mr. Michaud. Thank you very much, Major General, for your 
testimony. And we're looking forward to working with you as we 
move forward in addressing the concerns that we have heard 
about veterans access to applicable health care services in 
rural areas. Thank you very much for your service to this great 
Nation.
    Mr. Chapman.

                  STATEMENT OF HOWARD CHAPMAN

    Mr. Chapman. I'm Howard Chapman. I'm the Executive Director 
for the Southwest Virginia Community Health Systems. We're 
Federally-funded health centers, community health centers 
(CHCs) that receive Federal support located across the 
Commonwealth of Virginia. There are approximately 24 
organizations with just over 110 sites.
    Southwest Virginia Community Health Systems offers primary 
care and preventive services, but in addition, we have 
provisions for an integrated model of mental health in a 
primary care setting, which works well with depression and even 
substance abuse. It's a collaboration between the primary care 
doctor as well as the mental health provider.
    We provide some degree of medication assistance through the 
Federal Drug Pricing Program and 340B. We also have a 
medication assistance program that uses the patient assistance 
programs through the different pharmaceutical companies. We 
have worked to provide some limited transportation, and all 
this in regard to trying to deliver good primary care services 
in rural areas and knock down the barriers.
    One of the groups that do have a lot of barriers in their 
way are the veterans in our area. So we very much try to take 
advantage of being able to provide them the same level of 
services that we do the rest of the community.
    We have been a CBOC operation, and our contract was 
terminated in May of 2009. We had actually been working in that 
capacity since 2005 and had built--we had just over 800 
patients enrolled within our CBOC operation. We actually had 
been one of the first CBOCs in the Nation. Back during 
President Reagan's Administration, in the early 1990s, 
Secretary Sullivan made the announcement on the Capitol steps. 
And much along the line of, again, trying to develop and extend 
health care services to veterans, they actually tied the 
program to a program in Tuskegee, Alabama, that was looking to 
serve nonveterans in a VA hospital. And various veterans 
organizations, they take back full Congress and asked to appeal 
before we ever saw the first patient. But what we had done was 
been able to work with our local veterans that were 
anticipating having these services in their community and 
directly affecting their lives.
    We worked for probably another 10 years or so to actually 
get those services started back, and it was going very well. We 
were very pleased with it. We did have some issues with the 
Veterans Administration in how they actually had set up some of 
the process. Rather than a direct link in using the VistA 
system that they have as their medical record, we were given 
sort of a dial-type virtual private network (VPN), which was 
extremely slow, really dragged out the length of the 
appointment for the veterans. And, you know, even in assessing 
things like that, we needed to do the preventive measures 
that--that they had in their process, it's really cumbersome to 
work your way through this system. It could have been made a 
whole lot easier through an integrated medical record that 
would have allowed us to use our existing electronic medical 
record (EMR) and dumped information into their system.
    All of the technology things that happen, you know, it 
seems the veterans administration are behind on doing a lot of 
that. VistA is old technology, and I know they've talked about 
moving into a Web-based system, but, you know, it needs to be 
upgraded as we are moving toward this whole area of health 
information exchange and that type of thing.
    I just want to close by telling you that at the close of 
our--our CBOC contract, the Veterans Administration announced 
the meeting in February, and the morning that they had that 
meeting, the temperatures were down in the single digits. They 
had done the melding on Wednesday. Most of the veterans did not 
get their announcement until Friday or Saturday. And they had 
asked us for space to accommodate 50 to 60 veterans. They had 
more than 250 that showed up. So again, the concern about 
veterans and the health care that they receive is really, you 
know, tremendous, a tremendous effort.
    We have maintained and kept a lot of those patients just 
because it's an hour and a half, either to the Salem VA or the 
Mountain Home VA in Johnson City, and again they have set up a 
couple of VA staff, CBOC in Bristol. There's actually one in 
Atkins. And all of this has a considerable amount of cost in 
regard that they don't own the building but lease the space. 
And the renovations and things that they have had to do have 
been again money that's sort of lost in regard to VA paying for 
renovations and constructions that, you know, we can as 
Community Health Systems across the State of Virginia provide 
pretty much immediate access through a contracted arrangement 
to at least 110 sites across the State of Virginia. Most of the 
centers are Joint Commission on Accreditation of Health care 
Organizations (JCAHO), accredited. They meet high quality 
standards, and we're very willing to work with the Veterans 
Administration to see that happen.
    One other thing I would note is that we do have a Statewide 
contract for TRICARE that allows service to military families. 
And the other benefit behind using a community health center is 
not only for the veteran and the services through the VA, but 
we have a sliding fee scale for the families and children and 
spouses of these veterans, that we can offer the same level of 
service based on their ability to pay by total family income 
and total family size.
    So we think it's a great benefit for the veterans. I think 
it opens up immediate access for the veterans and their 
families, and we would very much like to see the CBOC continue 
and be back in line to be able to serve the veterans in our 
community.
    [The prepared statement of Mr. Chapman appears on p. 55.]
    Mr. Michaud. Thank you very much, Mr. Chapman, for your 
testimony. I look forward to asking the questions that we will 
have for you.

                   STATEMENT OF KEVIN TREXLER

    Mr. Trexler. Mr. Chairman, distinguished Members of the 
Subcommittee, I'm grateful for the opportunity to provide 
testimony on behalf of DaVita. I manage more than 80 clinics in 
Virginia, DC, and Maryland. I am also a veteran. I served as a 
naval officer 6 years on an attack submarine. At this time, I 
will summarize my written statement and look forward to 
responding to any questions you may have.
    DaVita is a leading provider of dialysis services in the 
United States. It provides treatment to more than 117,000 
patients each week in more than 1,500 centers, and represents 
nearly one-third of all patients with end-stage renal disease 
or ESRD. We are also a recognized leader in achieving excellent 
clinical outcomes, consistently demonstrating outcomes that are 
among the best when compared to national averages. Our 
testimony today addresses the Subcommittee's interest in 
understanding the quality of and access to dialysis care 
provided to veterans in rural and underserved areas.
    DaVita is privileged to care for more than 2,000 of our 
Nation's veterans in our dialysis clinics across the country. 
Our dialysis providers deliver dialysis treatment in veterans' 
communities when the VA cannot provide reasonable access or 
lacks in-house capability to provide this life-saving 
treatment.
    More than 20 percent of veterans with ESRD in rural 
Virginia have no treatment options within 20 miles of their 
home. We consider ourselves a partner with the VA and are 
committed to providing excellent quality, exceptional clinical 
performance and outstanding customer service to all these 
veterans whom we serve.
    Veterans receiving dialysis treatment are frail patients 
often with multiple illnesses and cannot survive without 
dialysis or kidney transplant. Thus patient access to care is 
critical. Patients receive three treatments per week, every 
week of the year, often 4 hours at a time. Both provision of 
the treatment and the financial aspects of the dialysis 
treatment are unique. Dialysis and all it entails is expensive, 
but in fact it is only about a third of the total cost for 
unmanaged end-stage renal disease patients. I will address both 
of these issues and suggest a way to improve the health status 
for these extremely sick veterans and the VA's desire to reduce 
total costs of purchased care. DaVita recognizes and supports 
the VA's goal for standardizing reimbursement for the purchase 
of non-VA provided health care services and reduce costs in a 
way that--that will ensure that we can continue to provide care 
for all of our veterans in rural areas. I'd like to share two 
ways that dialysis providers and the VA can have win-win 
approach to these issues.
    First, here in Virginia we provide care to veterans through 
VA established existing negotiated contracts. These contracts, 
if continued, will continue to provide mutually agreed upon 
sustainable reimbursement.
    Second, we propose to the VA that they implement a patient-
centered, integrative care management dialysis program for the 
ESRD veterans. Results of this would be improved clinical care 
for the patients and lower total costs to this system. In 
Medicare demonstration projects, we have been able to improve 
clinical outcomes and reduce hospitalizations. Dialysis is only 
about a third of the cost for end-stage renal disease patients. 
The majority of the costs come from emergency room visits and 
hospital stays.
    An integrated care program would focus on all the clinical 
needs of the veteran, and would provide lab, pharmacy, 
medication therapy management, vascular access care, 
vaccination, case management and access to diet and nutrition 
counselors and nephrologists. The VA currently does not receive 
any clinical data about its dialysis patients. In the 
integrated care model, we fix that in the system, but would 
provide an interface between our extensive databases and our 
integration systems.
    In response to the VA's request for dialysis care 
innovation, DaVita will also submit a proposal that reflects 
our expertise in providing and remotely monitoring dialysis 
care in the patient's home that would be of particular benefit 
to patients in rural areas.
    On behalf of DaVita, I'd like to thank you again for your 
interest in the care we provide to our veterans and commitment 
to ensuring that veterans in rural areas continue to receive 
the quality of and access to care that they have earned. We're 
grateful to the Subcommittee for its leadership in seeking new 
ways to promote quality care for all veterans and especially 
the unique population of veterans with kidney disease whom we 
serve. I'd be happy to answer any questions you may have.
    [The prepared statement of Mr. Trexler appears on p. 61.]
    Mr. Michaud. Thank you very much.
    Once again I want to thank the panel for testimony this 
morning and I look forward to working with you as we move 
forward.
    Major General Thackston, I have a quick question. As you 
heard, both Mr. Perriello and myself are very concerned about 
access to health care for veterans who live in rural America. 
Rural health care issues are extremely important and over and 
over again we continue to get legislation that contracts out VA 
services.
    At the same time we have heard some concerns from the VSO 
community. And as a Major General and a former Adjutant General 
of the Virginia National Guard, are you concerned that we might 
no longer need the VA medical facilities, or do you feel there 
always will be a need for the larger medical facilities.
    General Thackston. Yes, sir, I certainly feel there will 
always be a need for that. What we are concerned with--like 
yesterday I ran into a lady and I told her where I was going 
this morning. She said, ``Oh, thank goodness.'' She lived down 
in Clarksville. She said, ``My father is a World War II 
veteran, and he has to have somebody drive him to the VA 
Medical Center in Richmond.'' So there's literally hundreds of 
people like that in rural areas, as I'm sure you know.
    The other thing we're quite concerned with is the 
relaxation of the criteria that will qualify veterans for the 
PTSD as well as--Dr. Browne, if you take a minute, wants to 
explain a little something about how the criteria for heart 
disease has been expanded, which will cover a number of Vietnam 
veterans. Have we got time for that?
    Mr. Michaud. Yes, we will. Before we turn over to Dr. 
Browne, when you look at, for instance, community health 
centers and other qualified health care clinics and hospitals 
in rural areas, and where they're currently located using 
Federal dollars, in a lot of cases, they're in the same area as 
access points recommended in the Capital Asset Realignment for 
Enhanced Services Process in 2004.
    Do you feel that veterans will be less likely to visit 
community health clinics versus a VA facility, or do you think 
they'll be more likely to use a community health clinic since 
it's in their community.
    General Thackston. You mean community health clinics?
    Mr. Michaud. Yes.
    General Thackston. Yes, sir, I feel like they'll be more 
likely, because, for example, this new primary health care 
center we have in South Boston, we have had all kinds of people 
that are qualified to go there, but our veterans can't unless 
they pay, and they have to go to Richmond, Salem, or Durham. So 
I feel like if we have this expanded network, they will 
certainly be used to a great extent. And we have done a rather 
exhaustive study to talk about the costs and reimbursement for 
travel that VA pays for many of these veterans who go to 
McGuire and Durham. And we have these clinics that will 
certainly save the VA money, and it will save our veterans 
time. You know, a lot of them have to take a day off from work, 
and a lot of them have to get somebody to drive them.
    But to answer your question, for serious illnesses and all, 
they will still go to the major VA centers, but we'd like to 
think this community-based, the CBOCs as well as what we are 
trying to establish, will serve an important need.
    Mr. Michaud. Dr. Browne.
    Dr. BROWNE. Well, I agree. I got started in this because 
I've practiced medicine down there for a long time. I would 
like to point out to the Subcommittee that this is a moving 
target. When I go to the barbershop, I wonder whose head 
they're cutting when I see all that silver stuff falling on the 
sheet. I used to be young and strong. Nobody knew when we were 
in Vietnam what was going to happen with this Agent Orange 
business, which is a massively expanded load. Who knows about 
all these other issues.
    Plus, if a veteran becomes 30-percent disabled from a 
service-connected illness, then he becomes or she becomes 
enabled to go for any illness, and people age and they get 
problems. So we think, like the rest of the country, as the 
veteran population ages, their demand for services will 
increase. And that's been my experience. In internal medicine, 
most of the patients are elderly, and many, many, many of them 
are veterans.
    So we see this as a way to integrate to--also to minimize 
the number of unnecessary visits to the mother center. If 
people get chest pain, where do they go? What is it? Well, it 
could be nothing. Somebody needs to sort of triage these 
people. And we see this as a way to improve the quality of 
health care, to intervene with simple measures, to get one-on-
one treatment, and to improve the quality of referrals to the 
VA center, to utilize those physicians better.
    As you know, there's going to be a shortage in this 
country, not only of primary care doctors, but there may be of 
other doctors and nurses. There's going to be a competition 
between the VA systems and other health systems for qualified 
people. This is a way for the VA to immediately expand its 
staff by incorporating CBOCs and--and willing other 
participants and treat, splint them where they lie, treat them 
forward.
    Mr. Michaud. Thank you.
    Mr. Chapman, what have you found to be the biggest barrier 
to working collaboratively with the VA system in the Community 
Health Care Centers.
    Mr. Chapman. I think working in the VistA system with the 
restraints that we had by using the dial-up. Had it been pretty 
much a live connection, where our providers could have done 
that real-time would have definitely speeded the process. Again 
even further to have had the ability to use our own electronic 
health record and then download the information or send it to 
the VistA system--we're not taking anything out of their 
system. We're actually adding information to their system--it 
would have greatly enhanced the ability for us to have been 
able to have done those services.
    You know, if I could follow up on maybe a couple of the 
questions in regard to rural America. You know, again, in rural 
Virginia, by the 2000 census data, we have some communities in 
Southwest Virginia that 14 percent of the householders do not 
have vehicular transportation. So that trip, an hour and a half 
to the nearest VA hospital is almost impossible for some of 
these veterans.
    You know, 12 percent of the households lack basic telephone 
service. So while we all take for granted that we carry cell 
phones, a lot of people out there just don't have that, that 
ability. And so, you know, we think there are a lot of barriers 
to serving the veterans and making these services accessible in 
the communities and the places that they live really is a great 
benefit for the veterans.
    The VA hospital uses the, I think, all open-access 
scheduling. Everyone is given the 8:00 appointment. And again, 
these veterans do go and they sit all day, primarily, before 
they're seen. And that gets to be a real hindrance, to be able 
to ask a friend or a relative or a neighbor to take you to the 
VA hospital and, you know, and be there for a day.
    We've actually used the same scheduling with the veterans 
that we did for our regular patients. They were given a 2:00 
appointment, and they were seen on or around 2:00. They may 
have been delayed somewhat, but again it did allow the veterans 
to be able to take advantage of sort of scheduling their time 
and knowing what they could do and not wasting a day for health 
conditions.
    Mr. Michaud. You mentioned, I think, in 2005 to 2009 that 
you took care of 800 VA patients.
    Mr. Chapman. We have never done any marketing. We've sort 
of just let word spread about the program itself. And again, we 
had some degree of existing capacity that we were able to 
enroll about those 800 veterans. We were actually moving toward 
probably having two or three providers that would just have 
been able to serve the veterans themselves rather than just 
fall to spreading it across all of our medical providers, and 
we think that would have worked out a little better for the 
arrangement. It would have given us access for, on heavy days, 
some of the other providers. All of them would have been 
potential, but we would have had two or three primary providers 
that would have been just serving the veterans. And we think 
that would have made a little better situation than what we 
had.
    Mr. Michaud. Have you looked at the cost of providing 
health care services? Since you no longer, I understand, have 
the 800 veterans, has the cost per patient gone up.
    The second question, relates to quality of care. Is it fair 
to assume that some of those 800 veterans are no longer getting 
VA health care because of the travel distance? What were some 
of the comments from the veterans who might have stayed there 
or gone to VA and then ultimately quit?
    Mr. Chapman. We did actually maintain a lot of those 
veterans, primarily because again the CBOC-VA staff/CBOC in 
Bristol, which again, you know, it's 40 miles away. And some of 
the comments we got from the veterans is, if I've got to drive 
40 miles, I'll drive the other half-hour and go to the VA 
hospital anyway, because if I need other testing, things like 
that done.
    You know, probably in October or November of 2009, one of 
the veterans had commented that they were backlogged, and I 
think it was by about 1,200 patients or more, that they were 
having to schedule appointments, try to get enrolled in the VA 
system at the Bristol CBOC.
    You know, they've built three others from some of what they 
took away from the community health centers, and the VA staff 
models now, again with the extensive amount of money going into 
renovation and things, the facilities that the VA did not own, 
and the--and bring their own providers in. The one in Marion or 
Atkins, Virginia, I think the last count I had, they were open 
maybe 2 days a week, and last count I had, they were about 6 
months behind on--on a wait list of about 6 months to get a 
veteran enrolled in that program. So there's still a lot of 
access issues from the standpoint of the VA.
    The VA hospital in Johnson City and in Salem are extremely 
busy. They don't have the capacity to be able to take these. 
When you see waiting lists of 6 months or more in getting a 
veteran enrolled, it really indicates that there is a need for 
more services out in some of these rural communities.
    Mr. Michaud. Thank you.
    Mr. Trexler, in your testimony you talked about the 
capabilities of remotely monitoring the patient in their home. 
Can you explain to the Subcommittee what type of technology 
veterans might need in their home to be able to be monitored 
properly?
    Mr. Trexler. It would be telephonic, just by phone or also 
video conferencing.
    And there's another part of this program I want to stress 
that particularly applies to rural locations. We would provide 
predialysis education to all the patients, and our research 
shows that patients who are educated choose what's called a 
home modality, the ability to receive dialysis treatment in 
their home 30 percent of the time versus an uneducated patient 
will only choose it six percent of the time. So this would be 
another component of the program that would help veterans have 
access. They won't have to travel three times a week far away 
to receive this treatment. They can do it in the comforts of 
their home.
    In addition to that, we also have a program to provide 
medications to be delivered directly from the center to the 
patient's home, once again reducing the number of times these 
veterans would have to go to the pharmacy, oftentimes have to 
go to multiple pharmacies to get all of their medications they 
require for dialysis, and also improve the adherence because 
we'll get a report that will alert us when the patient runs out 
of medication or when they should run out, so we can remind 
them to refill that and also check to see if they've used all 
of their medication.
    And a third major component of this is by providing better 
education, we reduce the number of crashes into our hospitals, 
so the patients have a gradual transition into dialysis as 
opposed to having an acute illness that causes them to go in 
the hospital, and the benefits of this are reduced total costs 
and improved outcomes and mortality in the first year of 
dialysis.
    Mr. Michaud. And my last question is--and I know this is an 
important issue for Medicare/Medicaid patients, and an issue 
the Committee is somewhat familiar with--about dialysis 
reimbursement rates. VA is looking at adopting the Centers for 
Medicare and Medicaid Services reimbursement rates. In Maine, 
we have the oldest population per capita in the country. We're 
number one for the loser on Medicare. We're number two for the 
loser on Medicaid. Sixteen percent of our population, near the 
top among States. We're near the top. We're a rural State. For 
reimbursement rates, we're second from the bottom for Medicare. 
And that's actually a concern, making sure that providers will 
be able to adequately take care of their patients. And one of 
the reasons why we're near the top for high insurance premiums 
is because there's a lot of cost shifting that's occurring 
because of low reimbursement rates.
    Do you have a brief comment on reimbursement rates for 
dialysis treatment and what might that do for some of the 
facilities that are in rural areas, which tend to have higher 
numbers of Medicare/Medicaid patients.
    Mr. Trexler. I want to focus my testimony on what would we 
would do to provide access for rural veterans and also to 
improve the quality. We've submitted other testimony that 
provides more extensive comments about any proposed changes of 
reimbursement. I'll just briefly summarize them by saying that 
any change could have unintended consequences, and it could be 
negatively affecting the access of care in the rural 
communities for all the reasons that you mentioned. But I'd 
just urge the Committee to make sure you are researching that, 
because no one wants to see any reduction in the access to care 
for our veterans. They've certainly earned it, and I thank the 
Committee for your support, asking the questions and doing the 
research.
    Mr. Michaud. Mr. Perriello.
    Mr. Perriello. Thank you very much, Mr. Chairman.
    Thank you again to all the panelists. A few questions to 
run through.
    First, just so I understand, for General Thackston and Dr. 
Browne, right now with the existing facilities, someone with 
private insurance, Medicare/Medicaid, could attend, but a 
veteran could not; is that correct.
    General Thackston. Correct.
    Mr. Perriello. And to what extent have you and Mr. Chapman, 
to the extent you all are still serving some of those veterans, 
are you already seeing a change in or any trend lines in the 
amount of care or upticks that you're seeing, or is this 
something 5 years off or 10 years off in terms what you're 
expecting for some of the changes that you have predicted.
    General Thackston. You want to answer that?
    Dr. Browne. Well, I can't answer that question at this 
point. We don't have the information. As you know, we have 
researched everything pretty well, and I can't answer that, 
don't have enough data for that. But I expect that if--if you 
read what's in the various literature, General Shinseki's 
decision to include certain new illnesses with Agent Orange, 
that alone is going to massively impact the Veterans 
Administration. I don't see how they'll be able to cope with 
it, frankly. But that alone will clog up the system beyond 
belief, in my opinion.
    Mr. Perriello. One of the concerns we've heard in the past 
is the issue or issues that arise when you handle both a 
veteran and a nonveteran population in the same physical area. 
To what extent did you see that, Mr. Chapman, and to what 
extent has that been thought through or considered in the South 
Boston context?
    Mr. Chapman. Again, we basically were using the existing 
providers we had in working through the--pretty much the 
excessive stacking and had some degree or capacity to observe 
those. We really think it would probably have been better to 
have had more or less a provider or two. Now, I don't think 
there's a difference between, you know, a veteran and a 
nonveteran in the same facility. I think, again, we would have 
been better off to have a couple providers that would have been 
just dedicated to serving the veterans, and then, you know, in 
high demand times we could have had the other providers serve 
as backup to those staff. But we do extended hours, again real 
convenient for the veterans and that type thing, and we didn't 
see a problem with that.
    I think, again, you know, veterans were appreciative of the 
services. Again, they were appreciative of being able to come 
in and appointed a time slot and really great patient 
satisfaction from the veterans in regard to services that they 
were receiving.
    Mr. Perriello. One of the things that I have been so 
excited about with the project you all have put together is not 
just the, you know, the level of detail and the community 
engagement with it, but it seems to me one of the reasons to 
support the pilot program is just to try different things. What 
we know is we are going to see a different world than we saw 20 
years ago in terms of the scale, in terms of the types of 
problems, the complexity, and so it seems like part of the goal 
of this Committee, both before I joined it and now, is to say 
we have to try some different things.
    So if you are saying to a group of people here's what we 
are going to test by the South Boston facility, by the primary 
care facility, and if it works, we will know X, if it doesn't 
work, we know Y, what do you say for us who have to look at 
this across the country that we could learn from what you all 
are putting forward?
    Dr. Browne. Well, one of the things, if we get this far, if 
you grant us permission, is we intend to have a board, made up 
of consumers, veterans, who will meet quarterly and they will 
assess the performance of this. And we would invite 
representatives from the VA to serve on that, and these 
veterans would make a decision about how this clinic is working 
and to meet their needs. And if you met some of the people that 
we'll put on that, on that small group of five, seven people so 
it can function, and periodically review that and make a report 
to the VA or to you, whoever you wish, and then we'll assess 
how things go on as a pilot program.
    As far as the veterans are concerned, I took care of plenty 
of those. They came in my office. They didn't wear a veterans 
t-shirt. They were amongst the people out there. We treated 
them the same. The only difference in my office was sometimes 
we had a huge difference in insurances. It was a matter of 
processing the patient.
    In view of whether you put this clinic here, if you want a 
separate entranceway, we can accomplish that, or separate 
person to deal with that. As you know, Mr. Loftis is interested 
in getting a couple of disabled veterans to work in this clinic 
and provide computer access and to process these veterans. We 
even think that we should be able to enlist veterans at these 
local clinics. A lot of them won't go to Richmond. So who 
knows. I think it's a moving target.
    Colonel Daniel. I'd like to add that, as the General 
pointed out in his presentation, we know we have some 1,100, 
1,200 veterans that are currently enrolled. We know we have 
close to 3,000. And from the beginning we have said, why aren't 
all eligible veterans taken care of? We have some younger 
veterans that are sitting back. They're not getting the primary 
care. They aren't getting educated. That's going to result in 
long range costs to the VA if they have ailment, diseases.
    As far as evaluating the effectiveness of our program in 
South Boston, we're going to be very closely monitoring the 
increase in the number of people who are going to step forward 
and enter the system to take advantage of it. So we'll see an 
increase.
    South Boston is situated where we are more or less equal 
distance between Salem, Richmond, and just a little bit closer 
to Durham. Most of our veterans historically have gone to 
Durham and Richmond as opposed to Salem. The CBOC that's over 
in Danville of course is in the VISN system where its primary 
medical center is Salem. The amount of Halifax veterans that 
are currently going to that CBOC, we don't see any change in 
that. They're convenient to it. They're enrolled in it. We see 
them go there. But we see the increasing workload that will be 
coming as a result of more veterans qualifying and coming into 
South Boston. We see an increase in primary care, primarily in 
the area of preventive maintenance, follow-up.
    Again, the Chairman's question was what is the future of 
the VA centers. My personal opinion is that it is solid. There 
will always be a requirement for it. Our veterans love the 
centers. They prefer a center to go to. And the CBOC system is 
fantastic, and the whole VISN. But our position is that the 
increasing workload is going to require taking advantage of 
every asset you have, and local community primary care centers 
like in South Boston will be able to provide tremendous 
advantages to the veterans and to the VA, and that's why we're 
looking forward to be participating in the pilot program. We 
think we can prove that.
    General Thackston. Mr. Perriello, you were there when the 
ribbon was cut on the facility we are talking about. It's an 
ultramodern building. We feel like there will be no cost 
overhead, this type thing, when veterans use it. So, while the 
CBOCs do a great job, we're talking about something totally 
different. We are talking about a clinic that's run by the 
Halifax primary, Halifax Regional Hospital, and no overhead to 
worry about. We put a couple of volunteers in there with 
computer connections to the VA centers in Richmond, Durham and 
Salem, and we just see it as win-win situation along with the 
CBOCs.
    Mr. Perriello. Let me ask one with question of you all. 
Then we'll wrap this up pretty quickly.
    Mental health capacity, what capacity do you have in South 
Boston? And related to that, one of the things that we found in 
the CHC system is we have been doing more mental health work 
through telemedicine, and somewhat surprisingly we actually 
have a higher show rate for mental health appointments through 
telemedicine than through going in. Some of that is obviously 
it's easier access to it.
    To what extent is there either the capacity in South Boston 
or the technological capacity to do, to be connecting up with 
mental health experts in the VA system?
    Dr. Browne. From a technological standpoint our little 
hospital is on the cutting edge of computer technology, in 
fact, probably ahead of the VA.
    As far as psychiatric care, there are two psychiatrists 
with a large support staff and a mental health group that's in 
there. So I don't anticipate any problem. Many people who have 
experience in combat know about PTSD. It's no stranger. So a 
lot of other physicians with a small amount of education could 
easily take care of identifying.
    And of course this is a way to integrate between the VA--we 
don't see this as two separate issues. We see this as 
supporting the VA, following their guidelines, giving them 
support, but yes, we have the staff to deal--and that's who 
I've sent a lot of people that have PTSD who weren't in the 
military. We use the psychiatrist.
    Mr. Perriello. Well, I really see this as being one of 
those demands that's going to grow tremendously, and creating 
capacity there both in the CHC community, but particularly the 
veterans community, that's going to be crucial.
    When my brother was being recruited very heavily as a high 
school athlete, his coach told him, ``Go where you're wanted 
the most because they'll find a way to make it work for you.'' 
And I think in this case, as we look at the pilot programs we'd 
be hard pressed to find a place around the country that has 
done more work saying we want this to happen here, we want to 
prove it can work here. I think the work you all have done to 
put this together is tremendous, and I appreciate that.
    And I have some questions for Mr. Trexler, but I'll ask 
those offline about quantitative numbers. We have gone back and 
forth with dialysis from assuming it was better to do it in the 
home to bringing people to the clinics, back to the home. The 
upfront costs tends to, of course, be higher to prepare it in 
the home, but we're starting to see that being something that 
pays off over time. So I'm going to want to run through some 
numbers with you both in the Medicare context as well as the VA 
context, which we can do off line.
    But, again, I just want to thank all the panelists for 
their work in the community. Thank you very much.
    Mr. Michaud. I, too, want to thank the panel.
    I have just one more quick question for Mr. Chapman. With 
the community health clinics, is your primary bulk funding from 
the Federal Government?
    Mr. Chapman. Community Health Centers in general are about 
a third Federal Government. The other two-thirds we generate 
through contracts and people service arrangements with 
patients. So virtually it's about a third of our operating 
budget comes from Federal sources.
    Mr. Michaud. And your fee for the services, is that usually 
on a sliding fee scale?
    Mr. Chapman. It is based on a sliding fee scale. We're 
limited to what the insurance companies will pay and contract 
arrangements and that type of thing, so it's much like the 
physician's office down the street.
    Mr. Michaud. How does a contract with the VA system work? 
Is it more lucrative for you, or if you look at a veteran who 
might go in if you were paying on a sliding fee scale, is he 
paying more because you have a contract with the VA system, or 
is it about the same or----
    Mr. Chapman. Well, actually ours is on--in Southwest 
Virginia we don't have a lot of managed care. And the VA 
contract was on a capitative basis. So once we had done the 
physical and had them enrolled, we assumed responsibility for 
their primary care. That was probably in the neighborhood of 
about $30 per member per month, and that assumed, you know, 
taking care of pretty much the whole round of services that we 
deliver through primary care.
    Mr. Michaud. Great.
    Once again, I'd like to thank the panel for your testimony 
this morning as well as for answering questions. We'll probably 
have some additional questions which we'll provide in writing. 
So, once again, thank you very much. You've been very helpful.
    General Thackston. Thank you for the opportunity.
    Mr. Michaud. I'd like to invite the second panel up, and 
I'll turn it over to Mr. Perriello to once again introduce the 
second panel.
    Mr. Perriello. Thank you very much, Mr. Chairman.
    Before I introduce the panel, I want to introduce Martha 
Woody from my staff.
    Martha, if you'll stand up.
    Any veterans that are here today to talk about a specific 
case of theirs, Martha does our casework. She's based out of 
the Martinsville office and previously worked with the VA, so 
she understands the inside of the system as well as the 
veterans. So if anybody wants to grab her, I may ask her to 
just stand outside for a few minutes. So anyone who came 
because they're having a particular issue with the VA, I want 
to be sure that you have a chance to talk to Martha.
    I'll introduce Ericke Cage, my legislative counsel from 
Halifax County who handles my Veterans Affairs' Committee work 
on the policy side. So if it's a policy question, obviously 
you're welcome to talk to me about both case and policy work, 
but I want to be sure that you understood that our team was 
here and can be pulled aside, because these hearings will go on 
for a while, so if you want to grab him at any point.
    With that, I'll invite the second panel to come up: Michael 
Mitrione, Commander, Department of Virginia, for the American 
Legion, and thank him for his tremendous leadership with the 
Legion.
    Dan Boyer from the National Legislative Committee, Past 
Commander, Department of Virginia for the VFW, for the Veterans 
of Foreign Wars of the United States. Again we've really 
enjoyed working with the VFW staff on some of the vocational 
skills training and employment issues as well as on the health 
issues.
    Clarence Woods, the Commander for the Department of 
Virginia for Disabled American Veterans (DAV), who--several of 
these men made quite a trek today to get here and were 
commenting on just how beautiful our area is. So it's always 
nice to show off a little bit the beauty of the Blue Ridge and 
the community.
    And I particularly want to thank Lynn Tucker for her 
participation. She'll talk as a veteran caregiver the amount 
that her sons have sacrificed, that she has sacrificed. As you 
will hear, it is just tremendous. And rather than just focus on 
making sure that her family is getting the care they deserve, 
she's also made sure that she wants to speak out for others who 
are going through a similar process.
    And one of the things that we know is that unlike in, say, 
the Vietnam era where most fighters were going over as single 
individuals and quite young, we're seeing people go over now 
where it's an entire family that's involved, particularly 
extended deployments. An older fighting force is more likely to 
be married. I think Ms. Tucker's words about the experience in 
military families and caregivers is one that you will 
particularly want to hear.
    Again, I want to thank all the panelists.
    Mr. Mitrione, if you can get us started.

  STATEMENTS OF MICHAEL F. MITIRONE, COMMANDER, DEPARTMENT OF 
   VIRGINIA, AMERICAN LEGION; DANIEL BOYER, POST COMMANDER, 
   GRAYSON POST 7726, VFW PAST STATE COMMANDER, VETERANS OF 
 FOREIGN WARS OF THE UNITED STATES; CLARENCE WOODS, COMMANDER, 
 DEPARTMENT OF VIRGINIA, DISABLED AMERICAN VETERANS; AND LYNN 
           TUCKER, MUSEVILLE, VA (VETERAN CAREGIVER)

                STATEMENT OF MICHAEL F. MITIRONE

    Dr. Mitrione. Mr. Chairman, Members of the Subcommittee, 
thank you for giving me the opportunity to address the issue of 
concern to many of the 750,000 veteran families living in 
Virginia. The American Legion greatly appreciates and salutes 
your efforts on behalf of the residents of Virginia. In my next 
article to our members I will be mentioning the efforts of your 
Committee to address the availability of VA care in our 
outlying areas.
    A written copy of my testimony was provided as requested. 
However, given the short time to prepare, it covers these 
topics from a general perspective. I used the intervening time 
to discuss the subject with many of the members directly 
impacted by your issue of interest, and we'll use the time 
available to me this morning to provide a more focused 
viewpoint. Boiled down to its essence, the issue can be 
expressed in three words: ``time and distance.'' Fortunately, 
emergency care is not an issue since the VA has provisions for 
covering expenses and life-threatening situations. The issue is 
in outpatient care.
    Virginia houses three VA medical centers, two outpatient 
clinics, and 10 CBOCs. However, as might be expected economy of 
scale dictates that these scarce resources be placed in areas 
of high density population. This naturally tends to exclude a 
large percentage of our population who choose to live various 
distances from these population centers. To reach adequate 
medical care facilities, therefore, hours can be spent 
travelling to and from their homes. In many cases this involves 
the time not only of the veterans themselves but, as we have 
heard, the availability of volunteers willing to spend their 
time transporting them. In times of adverse weather conditions, 
these time frames can be more than double or triple.
    Not only do eligible veterans have to travel long distances 
to obtain medical care, but sometimes artificial boundaries 
make that travel distance even longer. For example, a Legion 
member advised me there is a VA clinic 19 miles from his house, 
but because of some artificial line of demarcation he's 
required to travel 56 miles to another care facility. That of 
course raises the question why such boundaries exist. Active-
duty military can obtain care from any military facility. It 
would, therefore, seem logical that if a veteran has a valid VA 
card, medical care should be available from whatever facility 
is available.
    The American Legion realizes that the government has 
limited resources and cannot be expected to build and staff an 
extensive network of CBOCs across the landscape. As part of the 
American Legion's efforts on behalf of the veterans, we make it 
part of our mission to conduct site visits to VA medical 
facilities across the country under our National System Worth 
Saving Program in order to assess the quality of VA care. In 
fact, one such visit is scheduled in Virginia for next year, 
and special attention needs to be paid to rural areas due in 
part to the fact that many Reserve and Guard units from rural 
areas have been called up to support war efforts in the Middle 
East.
    In addition, thousands of volunteer hours are spent by 
concerned Legion members in VA facilities across the State. 
Their interaction with veterans within the VA systems provides 
valuable insight and allows us to develop resolutions provided 
to our Congressional representatives. Discussions with a number 
of members represent--result in a recommendation that might 
provide an easier and more cost-effective solution to the 
problem of accessibility to medical care and worthy of the 
study by the VA or other appropriate agency.
    Senior citizens and retired military now have the option of 
being treated by doctors instead of clinics of their choice. If 
the VA had a system of issuing medical cards to eligible 
veterans that could be honored by health care providers, it 
would appear that geographical locations would no longer be an 
issue. Company sponsored health plans provide a list of health 
care professionals authorized to provide services. The VA might 
be able to do likewise.
    The American Legion welcomes the opportunity to work with 
this Committee, veterans of VA and rural health care providers 
to improve timely access to quality primary and specialty 
health care services for veterans living in rural areas. Mr. 
Chairman and Subcommittee, I wish to thank you again for your 
time.
    [The prepared statement of Mr. Mitrione appears on p. 63.]
    Mr. Michaud. Thank you. Mr. Boyer.

                   STATEMENT OF DANIEL BOYER

    Mr. Boyer. Mr. Chairman and Members of the Subcommittee, I 
am honored to be here today to represent members of the 
Veterans of Foreign Wars of the United States here in Bedford 
and around our wonderful State of Virginia.
    I come before you with profound gratitude for what the VA 
is striving to achieve on behalf of our veterans. No agency or 
department is perfect. And yet I know that with the support of 
the Congress and this Committee, the VA is making strides 
forward and is working diligently to care for all generations 
of veterans. With these thoughts in mind, I would like to 
address the rural health care challenges we are facing here in 
Southwest Virginia.
    Access to VA services in rural areas is always a primary 
concern, and that is no different in our region. From my 
hometown of Galax, Virginia, we have the Salem VA Hospital that 
is approximately 100 miles to the northeast. Also located in 
our region is the Johnson City, Tennessee, VA Hospital, and 
that is approximately 125 miles to the west.
    Either of these can be quite a journey, particularly when a 
veteran has two noncontiguous appointments. It can be a 
frustrating process for veterans to travel long distances for 
multiple appointments spread throughout the day. Thus, we are 
very thankful for our community-based outpatient clinic or CBOC 
in Hillsville, Virginia, and we believe that the addition of a 
second CBOC in Marion, Virginia, although limited to 3 days a 
week, will provide even greater assistance.
    There is clearly a need for the VA to open more clinics in 
rural areas. And the onus is on the VA to find solutions for 
our veterans, whether it be through additional private 
contracting, private and public partnerships, collaboration at 
multiple levels of government, or other creative means to make 
sure veterans are getting the care they deserve.
    Another area that will potentially improve access to care 
is telehealth. The VFW believes that this is a major 
opportunity to improve health care outcomes, particularly in 
rural communities. Though there are privacy issues and 
technological limitations that must be addressed, they should 
not delay any expansion of telehealth services. This 
Subcommittee held a hearing that spent considerable time 
discussing rural broadband and wireless expansion, and we 
encourage the Committee to continue expanding the body of 
evidence that clearly supports a robust telecommunications 
infrastructure in our rural communities.
    We're also concerned that many cases of traumatic brain 
injury (TBI) are not being properly diagnosed. We are obviously 
playing catch-up in our understanding of TBI, and access to 
medical professionals who can properly diagnose TBI is a 
problem nationwide. As you might imagine, veterans living in 
rural communities are especially vulnerable to misdiagnoses and 
ill-suited treatment. And the VA needs to make sure a 
sufficient network of doctors is in place to take what we are 
learning and put it to use in these communities. Moreover, 
post-diagnosis treatment can be time-consuming and can hinder 
efforts to treat rural veterans suffering with TBI. This is a 
serious issue that the VA and this Committee need to tackle 
head on.
    Closely tied to TBI is our concern for proper diagnosis and 
treatment of mental health conditions. We applaud VA for 
raising awareness on mental health issues and for working to 
reduce the stigma attached to seeking mental health treatment. 
We urge the Congress to provide continuous oversight of VA 
mental health programs to assure that the need for counseling 
and other types of treatment is being met here and in all the 
rural areas of the country. At the Salem, Virginia, facility 
alone, nearly 2,500 veterans have received diagnoses that may 
be caused by PTSD.
    One concrete step that can be taken to ensure all veterans 
who struggle with mental health conditions receive timely and 
professional care is to staff our rural CBOCs to provide 
inpatient mental health counseling among other specialty 
services. Specifically strong outreach and education programs 
will be necessary to help eliminate the stigma of mental 
illness and other barriers that dissuade many from seeking 
care. We also need meaningful post-deployment health 
assessments that will incentivize servicemen and women to 
provide honest responses so they can receive appropriate types 
of care and secure benefits, which they have earned.
    Routine examinations should include mental health 
assessments. VA staff should be fully competent to identify 
warning signs, should be aware of all available programs and 
should fully utilize them. We all know that suicide among our 
veterans is higher in rural communities. The VA suicide hotline 
is an effective tool for those who call. But we should work to 
ensure every veteran who is at the end of his or her rope knows 
there is a helping hand.
    Again it comes back to outreach. These programs must be 
visible in the everyday lives of veterans. We know this is 
especially challenging in highly rural areas, and we hope the 
VA will redouble their efforts with regard to rural outreach, 
not only for the suicide prevention hotline, but for all their 
programs.
    One way the VA is reaching out to address these and other 
issues is through Mobile Vet Centers (MVCs) that are literally 
going to where our rural vets live and work, ensuring access to 
services is provided where it is needed. However, it is with 
some dismay that I tell you I have not seen or heard of one 
being in our community. With that in mind, the VFW hopes that 
the VA is devoting proper time and attention to evaluating 
successes of MVCs and considering additional resources, if 
there is a demand for more Mobile Vet Centers.
    In rural areas, simple word of mouth is still one of the 
primary ways information is distributed. The VA should not 
overlook hometown newspapers, local VSO chapters and other 
means tailored to our older veterans. Though they should employ 
e-mail alerts, social media and other electronic means to reach 
out, they should not expect these to reach every generation of 
veterans. We want to be a resource for the VA to reach rural 
veterans, and the potential to boost outreach by using VFW 
posts and those of other veteran service organizations cannot 
be overstated.
    Another helpful opportunity for collaboration would be to 
use local VFW posts to conduct local screenings and wellness 
events. Just because a Mobile Vet Center is not available, that 
shouldn't mean the VA can't send a doctor or medical 
professionals to a rural area. Speaking on behalf of the VFW 
here in Virginia, if the VA sends us a doctor, we can supply 
the patients and the physical space needed to screen for mental 
illness and TBI along with other physical conditions such as 
glaucoma, hearing, diabetes and other illnesses. Such 
opportunities would provide a platform for further 
collaboration and would be a positive contact with rural 
communities where there is no VA presence. Everyone benefits 
when mutually interested parties work together. We hope that 
the VA would take seriously the many benefits of increased 
cooperation with the VSO community.
    The Independent Budget said it best when it stated that, 
``Health workforce shortages and recruitment and retention of 
health care personnel are a key challenge to rural veterans' 
access to VA care and to the quality of that care.'' The VA 
must aggressively train future clinicians to meet the unique 
challenges rural veterans face. The VA already has existing 
partnerships with over 100 schools of medicine in the United 
States. Not to apply them or expand upon them if needed would 
essentially squander this vast resource. We cannot allow that 
to happen.
    The VFW is also concerned that the men and woman who serve 
in our Guard and Reserve are not fully utilizing VA benefits 
that they have earned. Demobilizing members of the Reserve 
component or the Guard are often so preoccupied with thoughts 
of family and home that they fail to even mention existing 
health conditions, not to mention ones that will certainly 
develop down the road as a result of their service. Local VFW 
posts often fund and facilitate going away and coming home 
parties for Guard and Reserve units. We have successfully used 
these events to offer assistance with their VA paperwork 
through the Virginia Department of Veterans Services, and we 
will continue to support our returning warriors through events 
and other outreach efforts.
    Finally, I would like to bring attention to the success of 
our Virginia Wounded Warrior Program. Rural veterans are a 
primary target population of the Virginia Wounded Warrior 
Program. I hear and know of very positive things about this 
program, and we hope that the VA will continue to look at this 
hallmark State program and redouble their efforts to work with 
all layers of government, local, State and other Federal 
entities to provide integrated total solutions for not just our 
wounded warriors, but for all who have served and their 
families.
    Mr. Chairman, I again thank you for the honor of presenting 
our priorities to you. I would be happy to try to answer any 
questions that you or the Members of the Subcommittee may have.
    [The prepared statement of Mr. Boyer appears on p. 65.]

                  STATEMENT OF CLARENCE WOODS

    Mr. Woods. Mr. Chairman, Ranking Member Brown and Members 
of the Subcommittee, thank you for inviting the Disabled 
American Veterans Department of Virginia to testify at this 
oversight hearing of the Subcommittee focused on the Department 
of Veterans Affairs and the health care needs of rural veterans 
in the Commonwealth of Virginia.
    As an organization of 1.2 million service-disabled war 
veterans with 38,000 members and 59 chapters located throughout 
the Commonwealth, rural health is an extremely important topic 
for DAV, and we value the opportunity to be here today.
    Mr. Chairman, our former VISN statements were provided to 
the Subcommittee on July 15th. That testimony details a number 
of positions that we have taken by our national DAV 
organization on rural health issues, and I have been told that 
most of those positions are well known to you. So I will not 
focus or remark on those points. However, the DAV Department of 
Virginia subscribes to all those positions, and they are backed 
by the national resolution adopted by our leadership in the DAV 
2009 National Convention in Colorado.
    Virginia's specific concerns as requested by Mr. 
Perriello's office, we wanted to provide the Subcommittee our 
local and regional perspectives and concerns on rural health 
care in the Commonwealth of Virginia.
    In our Veterans Integrated Service Network, VISN, the rural 
health initiatives are centrally funded for only 2 years. The 
DAV Department of Virginia is concerned that the VA medical 
center directors will not continue to support these initiatives 
once this protected and fenced funding ends, and that they 
might be tempted to rob Peter to pay Paul within the medical 
centers by utilizing funds needed by other VA programs and 
applying them to the rural initiatives. We believe that the 
rural initiatives should remain centrally funded and not be 
made to compete with other VA health care programs or the cause 
of a reduction in medical center programs.
    Sick and disabled veterans in Virginia have been waiting 
patiently for many years to see new Virginia Community Based 
Outpatient Clinics or CBOCs, as they're called, to be opened in 
the rural areas of our State. Currently we have approved two 
CBOC projects that are taking far too long. Each of these CBOCs 
is now more than a year overdue in opening. It is our opinion 
that efforts are not being made to open new CBOCs 
expeditiously, and projected opening dates are usually delayed 
by a bureaucratic system that we believe can be improved. Also 
for those that are open in Alexandria, Bristol, 
Charlottesville, Danville, Fredericksburg, Harrisonburg, 
Hillsville, Lynchburg, Norton, Tazewell, Virginia Beach and 
Winchester, VA space planning is needed and should be improved.
    In our experience VA space configuration does not include 
making space available for the occasional visiting clinician, 
but only provides space for authorized permanent employees. 
When visiting clinicians come to provide services to our rural 
veterans in mental health, podiatry and other specialties, they 
either have nowhere to see their patients or space for them is 
very cramped.
    VA space planners need to do a better job of providing for 
itinerant providers within CBOC space configurations. Allowing 
more space than needed by permanent VA staff also provide us an 
opportunity in future years to expand services sooner than 
having to wait additional years for clinic construction 
projects after the need is identified.
    We believe the CBOCs need to provide more services on site 
in order to obviate to veterans needing to travel long 
distances to major VA Medical Centers for services that they 
cannot receive in the CBOCs. The DAV, Department of Virginia, 
believes this problem can be solved by VA building what's 
called super CBOCs or larger and more extensive outpatient 
facilities in rural areas. This should not come at the expense 
of reducing service at our major VA Medical Centers.
    Over the past year, we have noted that Veterans Health 
Administration (VHA) is now working on system redesign, 
reforming the VHA as the new patient-focused medical home. We 
believe this kind of logic could also be applied to VHA-
Veterans Benefits Administration (VBA) system redesign. We 
believe that there are many opportunities between VHA and VBA 
to work together in both the health and benefit area, but they 
are being missed because of lack of coordination between the 
two systems.
    Mr. Chairman, this concludes my testimony, and I'll be 
happy to answer any questions from you or any other Member of 
the Subcommittee.
    [The prepared statement of Mr. Woods appears on p. 67.]
    Mr. Michaud. Thank you very much for your testimony.
    Ms. Tucker, I want to thank you very much as well for 
coming here today, and I'm looking forward to your testimony 
this morning.

                    STATEMENT OF LYNN TUCKER

    Ms. Tucker. Thank you for having me. I'm glad to be here. 
My name is Lynn Tucker, and I'm here to testify on behalf of my 
son, Private First Class Benjamin Tucker, a lifelong resident 
of the rural community of Museville and the Fifth Congressional 
District of Virginia.
    Ben enlisted in the United States Marines in May 2004. Ben 
served for 22 months before tragedy struck in the form of a 
dirt bike accident, leaving him with a traumatic brain injury. 
Ben is classified by the Veterans Administration as 100-percent 
disabled.
    I am here to testify on behalf of Ben's two brothers, 
Corporal Jonathan Tucker and Lance Corporal Clayton Tucker, who 
served two tours as Marines in Iraq. They suffer from the 
effects of repeated IED (improvised explosive device) and RPG 
(rocket-propelled grenade) blasts and the deaths of many 
friends. I am also here to testify on behalf of all veterans 
needing care from the VA.
    My testimony today is based as a caregiver to Ben who lives 
at home in Museville. Ben's story reveals what should be our 
concerns for all veterans, particularly those representing 
rural areas. The concerns are access to primary and specialty 
care, effective and efficient communication within the VA, 
approval and remittance of payments from the VA for medically-
related items and services.
    Problems in any of these areas affect rural veterans like 
Ben, Jonathan and Clay by limiting medical choices, causing 
travel hardships and contributing to an overall breakdown in 
the quality of care and life. What we need to remember here is 
that these individuals and all veterans made a commitment to 
serve and to protect our liberties without the knowledge of the 
ultimate outcome.
    Access to primary and specialty care is imperative for all 
veterans and especially difficult for rural veterans. For Ben, 
who requires frequent specialized care, this is quite a 
challenge. Ben lives 45 minutes from the Danville CBOC, 1 hour 
and 15 minutes from the Salem VA, and 3 hours from the Richmond 
VA. Only the Richmond VA can provide all the different types of 
care Ben needs and is the least accessible.
    In October 2006, Ben returned home after almost a year in 
hospitals and was totally dependent for all his care, as he had 
no voluntary movement and was fed by a gastric tube. He was 
eligible for 15 hours weekly with the VA home health aid 
program. Due to his rural location, locating and retaining 
certified nursing assistants (CNAs) with the selected VA vendor 
was often impossible. Months would pass with no nursing help 
and no help from the VA in locating a vendor with nurses 
willing to drive the extra distance for a rural client.
    Just this last year we were able to retain a reliable, 
caring nurse through the VA when a new vendor was selected. 
With Ben's monthly VA disability payments, another CNA was 
employed after a period of 4 months with no nursing help. 
Overall, low payroll compensation, with the added expense of 
the additional driving, discourages CNAs from accepting rural 
clients.
    Ben has a Codman shunt in his brain to drain excess fluid 
and requires care from a neurosurgeon. The Salem VA does not 
have a neurosurgeon. Therefore, Ben has continued to see a 
Roanoke neurosurgeon practicing with Carilion Hospitals. 
Getting approvals for appointments is so time-consuming we have 
stopped applying for approval of routine visits and use Ben's 
Medicare insurance and pay the balance. This is not an 
appropriate solution for veterans and conveys that the VA does 
not have an appropriate system in place to care for their own.
    Many veterans' families that our family is associated with 
express concerns about waiting for approval and appointments 
with primary care doctors and specialists. Per two VA clinic 
staffers in Salem with the intake of more veterans from Iraq 
and Afghanistan, the situation is growing worse by the day. Do 
VA administrators understand the situation? Effective 
communication is a barrier for veterans seeking care and 
necessary assistive equipment. Communication between VA 
staffers within the administration often results in long delays 
or unnecessary denial.
    During the summer of 2006, Ben applied for a grant to help 
pay for custom wheelchair van. This request was submitted to 
the Roanoke Regional VA office. The form was passed along 
through the VA from person to person until somewhere a copy was 
made and the copy was passed along instead of the original. 
After several weeks inquiries were made of the VA on Ben's 
behalf with no results. It was not until the family actually 
traced the path of the grant form, with the help of Kay Austin 
of the Paralyzed Veterans of America, that it was determined 
the form was in fact on the desk of a VA employee where it had 
laid for 2 months. The employees stated the original was 
needed, but had not tried to locate the original or call for a 
new original. Ms. Austin faxed a new form, and a second 
completed copy was delivered personally to the VA employee.
    Veterans often have to wait for needed medications to be 
refilled. Just this past month Ben needed renewal on a 
medication that took over 12 days to resolve. The CBOC in 
Danville received my request by fax and the receipt was 
confirmed by a nurse. Three of the medications arrived in the 
mail, but the one in question was not on Ben's prescription 
list in My HealtheVet. I called the CBOC and left a message on 
the nurse line. No one called. Inquiries confirmed that the 
message was retrieved off the voice mail but no action was 
taken.
    Finally, the nurse called to say we need to contact 
Richmond for approval. In all it took 12 days for the CBOC to 
tell me to call Richmond. Consider this: If you needed 
medication for your hypertension, would you be willing to forgo 
that for 12 days? Is that not harmful to your health.
    Living in a rural area, with the nearest pharmacy 30 
minutes away and the nearest VA pharmacy an hour and 15 minutes 
away, this problem is compounded. Simple communication would 
have alleviated the waste of time, energy and driving to fill 
this prescription.
    In September 2008, a back sling was requested for Ben by 
the Richmond VA Physical Therapy Department to the Richmond VA 
Prosthetics Department. A picture and an Internet link were 
provided to the employee. After months, many phone calls, e-
mails with the link again, three improper slings were 
delivered.
    Calls were made to the Guldmann vendor in Texas for the 
sling, attempting to provide Ben with the needed equipment. 
After calling the Guldmann headquarters and being given the 
information for Guldmann Mid-Atlantic, on March 4, 2009, the 
correct bath sling was delivered overnight for free by Guldmann 
Mid-Atlantic after hearing the difficulty of trying to procure 
the sling for Ben.
    A veteran in a rural location cannot easily travel to a VA 
center and resolve issues in person. VA employees must respond 
to e-mails and calls and act appropriately to resolve the issue 
of payment. Veterans should not spend days, weeks, or months 
waiting by the phone.
    During 2008, a recumbent stepper was requested to Salem VA 
by a physical therapist for Ben. Ben was taken to the Salem VA 
and evaluated by a doctor who approved the request. After 
months, calls were made about the equipment and found the 
request had never reached the prosthetics department. Shortly, 
the Salem VA called, explaining that Ben needed the evaluation 
he had already completed. The doctor never entered the 
evaluation into the computer and never forwarded the request to 
the prosthetics department.
    Once this issue was resolved and several months passed, 
calls were made again, checking the progress of the request and 
again it was denied. The Danville CBOC was notified but no one 
notified us. Efforts were made to begin tracking the 
documentation to determine why the request was denied. The VA 
employee who denied the request was very exasperated and 
actually said, ``Why am I in the middle of this?'' The employee 
could not grasp why he had to defend his decision nor could he 
present procedural or policy issues related to the denial.
    After a lengthy discussion debating the need for the 
equipment due to Ben's rural location and his physical 
condition, the request was approved and the equipment was 
delivered.
    Payments from the VA for medical services or equipment 
outside the VA system are slow to nonexistent, and this traps 
the veterans between the VA and the outside vendor. After Ben's 
van was delivered in November of 2006, the VA owed a payment to 
the dealer it had already approved. After several weeks the 
dealer contacted his family asking for help in obtaining the 
payment from the VA. Phone calls were made seeking this payment 
to no avail. Several weeks later the dealer requested the 
payment from Ben. The payment for the van finally reached the 
dealer on February 20, 2007, 3 months after the delivery of the 
van to Ben.
    The van is not the only example of poor payment practices. 
Ben currently has collections against him for medical bills the 
VA agreed to pay. At first we paid some of the bills ourselves 
until realizing this wasn't an exception, but the norm. A great 
deal of time has been spent tracking many payments with the 
hospital and the VA not willing to communicate with each other. 
Currently all collection calls are referred to the VA.
    Ben was referred to physical therapy at the Carilion Clinic 
in Rocky Mount. During one of his appointments I was called to 
the front desk because the center did not have the 
authorization number to pay for his therapy. It was necessary 
to contact the VA from the front desk of the facility in order 
that Ben could complete his appointment. Otherwise Ben or his 
family would have had to agree to pay for the therapy.
    Ben spent almost 5 months in 2006 at Craig Hospital in 
Colorado after we paid over $14,000 to have him flown back. On 
his return trip home, the VA agreed to pay for the flight 
because it was necessary for him to be evaluated by the Salem 
VA before returning home. On the day before the flight, the air 
ambulance company asked for a credit card number because the VA 
could not locate or approve payment for the flight. Once again 
many phone calls were made, adding to an already tense 
situation.
    In May 2006, my husband and I sat in a meeting with the 
Richmond VA after Ben was discharged by the Marines in April. 
Ben was an active-duty Marine for 22 months, 2 months short of 
eligibility for VA coverage, with no TRICARE insurance and his 
VA claim not processed. The VA employee wanted to know how the 
bill of approximately $40,000 a month was to be paid if Ben 
continued to stay in the polytrauma unit. With no help from the 
VA, we investigated and obtained COBRA insurance with TRICARE 
for Ben, and the VA was paid.
    As a taxpayer and citizen of the United States of America, 
it is striking how we take for granted the lives of those who 
voluntarily put theirs on the line. Ben, Jonathan, Clay and all 
veterans enlisted without knowledge of the outcome. They made a 
commitment to their country. Where is their country now? Where 
will our country be when all veterans return from Iraq and 
Afghanistan? Will they, too, be burdened with forms, phone 
calls, red tape and delays? Will they, too, be turned away and 
not cared for? We cared to send them.
    Thank you for allowing me to come today.
    [The prepared statement of Ms. Tucker appears on p. 74.]
    Mr. Michaud. Thank you very much, Ms. Tucker, for sharing 
your story with the Subcommittee. And we also want to thank 
your sons for their service to this great Nation of ours.
    Mr. Perriello.
    Mr. Perriello. Thank you, Chairman.
    Ms. Tucker, how many hours do you think you've spent 
processing, appealing the cases involving your sons.
    Ms. Tucker. It's countless hours, especially in the very 
beginning, getting his VA claim processed, dealing with the 
van, dealing with getting nursing care. At one point I was 
noting, you know, how much time I was spending, and, you know, 
it was just totaling up. It was making me very frustrated 
because at that time I needed to be taking care of Ben, not 
being on the phone, arguing with one person after another or 
sitting, simply sitting on hold.
    Once you call into the regional office, sometimes you can 
just sit there on hold for 20 minutes waiting for a person to 
answer. And that's just too many hours. It shouldn't happen. It 
shouldn't happen. It shouldn't happen to do it that way at all.
    Mr. Perriello. And in terms of most of these claims, are 
they going through the Roanoke office, benefits claims.
    Ms. Tucker. As you can see, they went through different 
offices. Salem's currently--I mean, Ben is currently under the 
Salem VA, so we deal with them a lot. But there are some things 
coming from Richmond because of the situation. We were going to 
the Danville CBOC, but what happened in that situation was we 
started getting bounced between the three in a triangle 
sometimes, just trying to get care. It was hard to figure out 
who do I call.
    So as of this past month, I disenrolled Ben from the 
Danville CBOC and started taking him back to Salem. That way 
we'll only have two places to deal with instead of three.
    Mr. Perriello. As you know, there was a much needed 
investigation, Inspector General investigation into the Roanoke 
office, which has a very bad track record on claims. Many 
people working there are great people who are putting in 
countless hours to help veterans. There were both systemic 
failures and personal failures there.
    Have you seen any improvement of late? Are you seeing the 
same pattern of behavior with the various claims you are 
fighting.
    Ms. Tucker. I don't see any improvement over the last 4 
years. Like my testimony said, we're coming up on the fifth 
anniversary of when Ben was injured. And over that time period, 
I do not see any improvement in communication with the VA. And 
I know at the beginning, when I was trying to file some claims, 
I was talking to someone on the phone with the regional office, 
and I was saying, ``If I have it overnighted would that help?'' 
And he said, ``Not really. The mailroom is about 3 weeks 
behind.'' So once it hits the building, that's where you get 
the problem.
    Mr. Perriello. As you have gone through this, have you had 
apologies from people in the system for the delays and the 
mistakes or not.
    Ms. Tucker. Sometimes, yes, you know, I have had apologies. 
I have met some people who are very helpful. Some people I know 
I can call on to help me to get through some things. I have 
also run into some people that were, quite frankly, incompetent 
and should not have been in that position. I had worked for 
some people who simply just were lackadaisical and just cannot 
get back with me.
    Mr. Perriello. With the processes that are going forward, 
what are some of the--aside from dealing with the VA itself, as 
a veteran caregiver, what are some of the challenges you have 
faced over that time period besides the obvious pain and 
frustration of the delays and bureaucracy that we have talked 
about that you face as a caregiver.
    Ms. Tucker. Well, of course, as Ben's mother, and our 
family, all our family, you know, it is traumatic to see 
someone you love so much be hurt. And through that time he has 
had global aphasia and he cannot communicate to us. He does not 
understand language, I'm being told. He cannot even answer 
``yes'' or ``no.'' So it's very frustrating for him and for us, 
trying to keep him comfortable and happy. When he does get 
upset and frustrated, we have to keep trying things, much as 
you would a small infant, trying to figure out what is he upset 
about, until we, you know, can find out how--how to make him 
comfortable and not so frustrated.
    Mr. Perriello. I have met your son, and I know what he goes 
through, but I also know what you go through. And, you know, a 
mother's love is tireless, but it's really incredible what you 
have done, again, not just to take care of him, but also keep 
an eye on his brothers and to speak up for so many veterans.
    One of the things we have done--and Chairman Michaud has 
worked on this, as well--is trying to get more supportive 
caregivers, whether that's extending training benefits or 
health benefits, other things to caregivers who so often, 
whether it's a spouse or a mother or, you know, parent, may 
have to leave a job just to be taking care full-time and 
knowing that, in many cases, that's a higher quality of care 
and a more 24-7 service and where we can help get some medical 
training to the family members and benefits with the family 
member.
    We have had some strides in that area, but we'll continue 
to work obviously with your specific case as well as trying to 
look at where we allow those gaps that families fall through, 
and of course for those who have been willing to make the 
ultimate sacrifice or at least put themselves in a position 
where that might happen.
    We're also seeing in general that because again, as I 
mentioned earlier, these great advances in battlefront 
medicine--I know in Ben's case it was not battlefront, but we 
are seeing people come back who are very young, and we're 
looking at not a couple years of care, but we're talking about 
a lifetime of care. So we need to be incredibly caring but also 
creative about how we think about ensuring not just a minimum 
standard of living but a high quality of life for veterans and 
their family members, and we'll continue to work with you, with 
you on that.
    A couple of questions for the others on the panel. One of 
the things that many of you touched on is while we do have a 
long way to go in terms of access to care for our rural 
veterans, we have also made some strides in recent years.
    And one of the things that I would like to ask that Mr. 
Boyer commented on is what's working in terms of getting 
information out. I do believe that the vans, the rural vans are 
parked out back. I came in the front, so I didn't see them.
    What's working? What do we need to do more of to make sure 
that veterans know what benefits already exist as well as 
trying to fill those gaps.
    Mr. Boyer. Continued outreach and all means of 
communication.
    In my particular case, my VSO is constantly contacted by 
mostly elderly veterans, inquiring about what they're eligible 
for. You know, this is just my observation. I think that World 
War II veterans and, to a degree, Korean War veterans, when 
they were demobilized, made a promise to themselves to never 
get involved again. Mostly for their working lives they did not 
do that, and now in their declining years and limited resources 
and no other insurance, they want to know, well, what am I 
eligible for in the VA, and they're at a loss. When you tell 
them and show them what they're eligible for and they look at 
the paperwork, what they have to fill out, you know, their eyes 
tend to glaze over.
    So we in the VSO community have to be helpful. The Virginia 
Department of Veterans' Services has some 28 field agents 
around the State whose primary purpose is to help the veterans 
fill out the paperwork. Since they are semi-experts, if they do 
the paperwork, it has a chance to be evaluated successfully. I 
just would encourage--you know, in rural areas word of mouth is 
still the--the primary issue, not only for elderly veterans, 
but also for the National Guard and the Reserve, fellows who 
have been demobilized and come back to their rural communities, 
they face the same problem the elderly veterans do but for a 
different reason. They're just not aware of what is available 
although it may have been discussed when they were 
demobilizing.
    For example, there's a program called Benefits Delivery at 
Discharge. But they're just not concentrating. They have their 
minds on other things. We have to continue to try to reach out 
through all the means of communication.
    Dr. Mitrione. In asking that kind of question, what kind of 
services, satisfaction factor, I kind of, like, looked out in 
the southwestern tip, because I thought that was probably one 
of the more remote areas, and I got very good vibrations, very 
good reports from the--the Hills people, that went out to the 
Hillsville, the Tazewell, the Norton, people down in South Hill 
who were very satisfied with the RV that came down, provided 
services down there.
    I think in some cases you see that we have a system that's 
being swamped by requests for services. I think veterans 
organizations such as the VFW, I know that in--in American 
Legion, we're putting a lot of emphasis on our service officer 
program. We have started training sessions across the State, 
trying to get qualified people, trying to reach out to veterans 
who can come to these--these specialists, and these specialists 
take the--their claims. They try and marshal them through the 
system. I think that the--the veterans organizations provide a 
very valuable service in that respect.
    But, again, it's an organization just like any other, not 
only government, but I think, in many cases, corporate, where 
there are inefficiencies that need to be addressed, and there 
are people who maybe aren't the best. They aren't suited for 
the job they're in, and those people need to be sought out and 
told if you are not happy here, you can get a job somewhere 
else and be happy.
    Mr. Perriello. Well, we certainly will have a zero 
tolerance policy, but we also want to build on the successes.
    One of the ones that you mentioned, Mr. Boyer, and I'll 
head back to you, is the Virginia Wounded Warrior Project. And 
I certainly have been very impressed by their work, and in 
particular their ability to engage some of the younger veterans 
who have shied away in some cases from some of the traditional 
outlets. What lessons can we learn from them that might be 
something we could take to scale?
    Mr. Boyer. Collaboration. The Wounded Warrior Program is 
beginning its third year with the General Assembly providing $2 
million per year and supported by $150,000 or so per year in 
private funds. We have an executive director, but it's 
administered through--we have five regional consortia where we 
have a regional director, and the services are implemented 
through community service boards, which are already in 
existence.
    It's a collaborative effort. We have partnered with the VA. 
The VISN 6 Director sits on the Wounded Warrior Executive 
Board. The rural health teams in VISN 6 have made contacts with 
our regional directors and attended a couple events. They are 
looking for ways to join together to provide the services that 
particularly rural veterans, National Guardsmen and Reservists 
are not aware of, and many of them, you know, need them 
desperately.
    Mr. Woods. One of the things that we are doing in the DAV 
is for the Guard and the troops coming back, we have meetings 
in Richmond, meet with them when they come back, give them 
handouts, let them know what's available to them. A lot of the 
kids come back and they really don't realize what kind of 
benefits are available. So before they get out in the outlying 
areas, we try to catch them and do a brief--we give them some 
booklets, give them some phone numbers, say if they have any 
problems, contact us so we can get somebody within your area. 
Because in the outlying areas we have, in the DAV, they can 
assist them, so they don't have to worry about traveling when 
they get the information they need.
    Mr. Perriello. The good news is we have increased funding 
for the VA in general significantly over the last couple years, 
and one of the areas is rural health where we have been able to 
see this. But just like the primary care facility we talked 
about earlier, I think now has to be a time of some 
experimentation as well, because we are dealing with so many 
new factors, whether it's the new veterans coming in or, as you 
said, a generation reaching a different type of need, Korean/
Vietnam vets hitting into that aging level where some who were 
not enlisting before are coming in.
    So I think one of the things we want the capacity to do is 
to try different outreach efforts, try different collaboration 
efforts, try work with, you know, different VSOs as partners. 
And the more we can get rapid feedback from you as you have 
gone out and done repeatedly and say, hey, this is a program 
we're getting good feedback on--the CBOC is an example of that, 
where we have got overwhelmingly positive feedback from CBOC.
    So there's some real concerns, not just Ms. Tucker's, but 
in one case we have lost someone who was doing a lot of the 
mental health work, and that just sets you back in a tremendous 
way. Sometimes that's just a person needing to move on, and in 
some case that's a systemic failure. But overall people seem to 
be pleased with the direction we are going with the CBOCs. The 
same way with outreach. I just hope you will continue to do the 
diligent job you have done in letting us know in real-time, 
hey, this isn't working, we like the idea of the vans, but we 
haven't seen the vans here.
    One of the things that we spent a lot of time on last year 
was the implementation of the new Post-9/11 GI Bill, and that 
was a substantial new investment in our veterans, but it was 
also complicated because we were doing it for the first time. 
In working with the VSOs, we were able to take what could have 
been a real logistical nightmare in terms of payments and other 
things, and I think we were able to implement that relatively 
smoothly and now have about 250,000 veterans enrolled in the 
new GI Bill.
    So in the same way as we roll out some of the new rural 
health proposals and outreach, I just really appreciate the 
real-time feedback we're getting and hope to build on that and 
see areas that we need to do it and again have a zero tolerant 
strategy for those who are vigilant with our veterans.
    With that, I yield back.
    Mr. Michaud. Ms. Tucker, once again, thank you for sharing 
your story.
    I am concerned about the daily challenges that you face as 
a mother caring for your son, Ben. VA is supposed to have a 
case manager to help families maneuver through the VA health 
care system. Did your family have a case manager assigned? And 
if so, do you have any recommendations of how we can have case 
managers do a better job?
    Ms. Tucker. Okay. Over the years we did have several 
different social workers that were there to help us. At the 
very beginning, I became aware that the social worker that was 
trying to help us just could not handle what I needed her to 
do. So when we were in the Richmond VA, on Mondays, Ben and I, 
I would put him in his wheelchair, and we'd walk the halls 
looking for help, people to tell me just what do I do, because 
I had no idea. I was overwhelmed. You know, like others had 
mentioned the forms. You look at them, and you do--our eyes 
glaze over, because you don't know how you're ever going to 
fill in all those blanks, pull all of that information 
together.
    So I did occasionally, you know, run across someone that 
could really help me. Now I have two people in the VA I know I 
can go to, that can point me in the right direction, like 
Rhonda Fletcher at the Salem VA is one person, Kamisha Thornton 
at the Richmond VA another one. Those two people have been able 
to help me.
    One of the people that couldn't help me, in the beginning 
actually, when I went back to the Richmond VA, they put her in 
a management position. And I do not understand how, when she 
could not help me on a lower level, why she is now in a 
management position. You know, that's one of the problems with 
the VA. Supervision needs to be able to see that their workers 
are getting their cases handled, their jobs done.
    Mr. Michaud. You said you had several----
    Ms. Tucker. Yes, because we have moved around so much. We 
were in the Richmond VA. We dealt with Salem VA. And we've 
dealt with the Hampton VA. And every time we go to a different 
VA, you end up with a different social worker following you 
around. It's not just one person. And so sometimes you run into 
people that just cannot help you, and you know that pretty 
quickly.
    One thing that has saved me is the fact that I am a 
certified public accountant. I was chief financial officer of a 
company before I left my job to care for Ben. So I was used to 
negotiating, you know, complicated forms and organizations and 
different things like that.
    One of the horrors that I thought of as I've gone along is 
like with aging veterans that are standing there that may be 70 
years old, 80 years old, and they need help, and how are they 
going to get the help, you know, if they're not able to push 
for it, they're not able to write the payments? If they end up 
hitting a caseworker like some that I've gotten, that 
absolutely do not do their job, then they will be dead before 
they get help.
    Mr. Michaud. Other than probably simplifying the forms, 
when you did actually get Ben to the VA system, were there 
waiting times, for instance, you coming in at 10:00, and 
waiting until 2:00 or 3:00? Or were they pretty prompt in that 
area?
    Ms. Tucker. That I haven't run into, extreme waiting times. 
I haven't in the clinics. You know, sometimes they have to put 
appointments off. Like I said, with Ben, sometimes the Salem VA 
cannot provide his care. I then would have to go outside to get 
it. But waiting time for appointments has not been a huge 
problem. I've usually always had, like, a 2:00 or 11:00, not 
just a ``come in 8:00 in the morning'' type of situation.
    Mr. Michaud. Mr. Woods, in your testimony you noted the 
system between the VHA and the VBA should be redesigned. You 
further stated that there are many opportunities for VHA and 
VBA to work together. Could you expand upon that point? What 
are the missing opportunities between the VHA and VBA?
    Mr. Woods. We feel that they are missing the opportunity to 
work together. You know, even though one is providing the 
benefit and the other is providing the administrative part, if 
they can link those two things together and not have a 
disconnect where one has to get the paperwork and the other one 
has to take out a medical evaluation, if they could work 
together, pull those two things together, it would cut down the 
lead time where a veteran has to wait to get the claim back.
    We don't feel they're working close enough together. This 
person has to have it in so many days, and they have to work it 
before they get it to the other area. If they were connected 
together, we feel that would cut down a lot of the lead time, 
something they need to look at. Just our thoughts. We feel they 
need to look at that.
    Mr. Michaud. Okay. As was stated earlier on the first 
panel, and you have touched upon it, if you look within the VA 
system, with the new rules as it relates to Agent Orange, as it 
relates to post-traumatic stress disorder, look at actually 
increasing access to health care for veterans that are Priority 
8 veterans, you look at the fact that this Administration is 
sending more troops to Afghanistan, clearly there's going to be 
more of a burden upon the VA system to be able to handle this 
all at once, and on top of that, a process where we're hearing 
a lot of complaints about delays in getting, you know, 
veterans' paperwork processed in a timely manner, has any of 
the VSOs in your organizations looked at ways that the VA might 
be able to streamline the process to make it more efficient 
and--but haven't actually moved forward in that regard?
    Mr. Boyer. If I may address that, the VFW strongly believes 
that the administration is not going to make improvement in 
processing paperwork as long as that system is using pencils. 
If they go to electronic records processing with a link between 
the U.S. Department of Defense (DoD) and the VA, until they do 
that, they're not going to make headway in processing all these 
benefit claims.
    In the State of Virginia we have an automated electronic 
data processing system. It's been demonstrated. We're finishing 
the demonstration this year. We have discussed it with the VA. 
I've talked to our Congressional delegation in Virginia about 
the need for electronic data processing. Everybody agrees 
there's no momentum, nothing is happening concretely. It's 
talk, agreement, no action.
    Mr. Mitrione. We believe that this is a technology that's 
here. I mean, I know that if an individual fails to include a 
1099 miscellaneous on his income tax, the Internal Revenue 
Service definitely knows about it regardless of where it came 
from. So from the VA system, why they cannot take care of or at 
least incorporate this same kind of technology--you know, they 
may be moving in that direction. They may not be moving fast 
enough to get it done.
    Mr. Michaud. On the subject of collaboration to let our 
veterans know what they're entitled to, how closely do the VSOs 
work with the State? We've actually invited the Virginia 
Department of Veterans' Services to come testify today. They 
chose not to. Disappointing in that fact.
    But I think we could learn a lot from the State, and in 
other field hearings that we've had the State has testified. 
How do you feel that the State is doing as far as helping 
veterans move forward with their issues?
    Mr. Woods. What we have is we have 130 service officers 
throughout the Commonwealth dealing in our different chapters 
that work the cases, veterans come through. They get certified 
once a year so they know how to fill out the claims and what 
they need to send them forward. The ball is being dropped 
someplace within the system. After you send the information in, 
it's not being processed in a timely manner. We feel the 
backlog is causing that.
    But the service officers are really doing what they're 
taught to do, what information they need on the form, how to 
fill the forms out. There are so many different forms that 
you've got to go through, you've got to know how to fill them 
out. If you fill the forms out wrong, it's going to get kicked 
out. It's going to be frustrating. By having a service officer 
filling it out, you eliminate that.
    I think if we continue that process, the VSO starts doing 
what they're supposed to do, we're going to limit some of this 
backlog.
    Mr. Boyer. Mr. Chairman, if I might address that question, 
as Chairman of the Joint Leadership Council of the Veterans 
Service Organizations, I worked directly with the Virginia 
Department of Veterans' Services. And I would like to say that 
the Department of Veterans' Services has a very comprehensive 
program. We have 28 field agents scattered around the State 
whose primary purpose is to work with veterans and help them 
access the VA system. We would like to have more, but, you 
know, funding, funding is an issue.
    The Department of Veterans' Services manages the Virginia 
Wounded Warrior Program. The Executive Director works for the 
Virginia Department of Veterans' Services. And that is an 
effort that they have been pushing very, very strongly. There 
is a concerted effort within the Department to increase the 
outreach to veterans, and it's only limited by the amount of 
funds available.
    Ms. Tucker. I was just going to say that the VBA has been 
so helpful with Ben's case. If I hadn't been directed toward 
them when I did, I would have been very buried under the forms. 
It's a shame that we have so many that you have to have service 
organizations like that to help you.
    And one of my sons is currently switching to the VBA 
because the service organizations, the State that it was using, 
you know, just didn't seem to help at all, didn't seem to 
advocate on his behalf. So the VBA is going to take over his 
case now.
    Mr. Michaud. Once again, I want to thank all of you for 
coming this morning. I really appreciate your willingness to 
inform the Subcommittee on what's happening in Virginia on 
rural health care for our veterans.
    And once again, Ms. Tucker, I want to thank you for telling 
us your story, and it definitely has not fallen on deaf ears in 
this Subcommittee. I really appreciate your willingness to come 
out. I know it can't be easy. I know at times it is extremely 
frustrating being in your position, trying to take care of Ben. 
But it's always extremely frustrating on this side when we 
provide the VA with what we think are adequate resources, but 
we're still continuing to hear problems veterans have to go 
through. Hopefully, we'll be able to eventually have a system 
where, when the veterans need help, they'll get it, and they'll 
get it in a timely way.
    So once again, I want to thank this panel's willingness to 
come out this morning.
    Mr. Perriello. Thank you all.
    Mr. Michaud. We'll invite the third panel to come forward.
    Mr. Perriello. Thank you, Mr. Chairman.
    If the third panel will come up.
    Assistant Deputy Under Secretary for Policy and Planning, 
Patricia Vandenberg, who I have had the pleasure of meeting 
with by phone, but we were meeting in person earlier today for 
the first time, and we'll continue to talk with her. She is the 
Acting Director of the Office of Rural Health for the Veterans 
Health Administration, U.S. Department of Veterans Affairs. We 
are happy to have her down in the district today.
    We also have Daniel Hoffman with us, who is the Network 
Director of VISN 6, Veterans Health Administration, U.S. 
Department of Veterans Affairs; as well as Carol Bogedain, the 
Interim Director of the Salem VA Medical Center (VAMC), which I 
have had the pleasure of touring before and hope to get back to 
again, and which services many, many of the veterans in Central 
and Southern Virginia. We do split some with Richmond and 
Durham, but again, probably the bulk of the Salem area, and we 
have generally heard very positive reviews of everything going 
on over at Salem.
    So we appreciate the three of them being here today and 
look forward to your testimony.

 STATEMENTS OF PATRICIA VANDENBERG, MHA, BS, ASSISTANT DEPUTY 
 UNDER SECRETARY FOR HEALTH FOR POLICY AND PLANNING, VETERANS 
  HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
  ACCOMPANIED BY DANIEL F. HOFFMAN, FACHE, NETWORK DIRECTOR, 
  VETERANS AFFAIRS MID-ATLANTIC HEALTH CARE NETWORK, VETERANS 
INTEGRATED SERVICES NETWORK 6, VETERANS HEALTH ADMINISTRATION, 
 U.S. DEPARTMENT OF VETERANS AFFAIRS; AND CAROL BOGEDAIN, MS, 
    RD, CPHQ, FACHE, INTERIM MEDICAL CENTER DIRECTOR, SALEM 
       VETERANS AFFAIRS MEDICAL CENTER, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

           STATEMENT OF PATRICIA VANDENBERG, MHA, BS

    Ms. Vandenberg. Thank you.
    For the record, I would like to acknowledge that we have a 
Director at the Office of Rural Health, Dr. Mary Beth Skupien. 
She began her service to the VA on July 6. She is coming to us 
from the Indian Health Service, where she has served both as a 
care provider and nurse practitioner, as well as in a variety 
of administrative positions. She had a nursing practice and has 
a doctorate in public health from Johns Hopkins. So I'm 
delighted to have her on the team.
    I will continue to be actively involved in all matters 
pertaining to the Office of Rural Health and, most 
particularly, the implementation of Section 403. So we decided 
that it is most appropriate for me to be here today to address 
the Subcommittee.
    We appreciate this opportunity of you inviting us here 
today to discuss the progress the Department of Veterans 
Affairs has made in implementing Section 403 of Public Law 110-
387, as well as the VA's efforts to increase access to quality 
health care for veterans living in rural and highly rural 
communities in Virginia.
    I'm accompanied today by Mr. Daniel Hoffman, the Network 
Director, and Ms. Carol Bogedain, Interim Director of the Salem 
VA.
    Mr. Perriello. If you could move the microphone closer, 
there are some hands going up in the back.
    Ms. Vandenberg. As you know, the VA is required to conduct 
a pilot program to provide health care services to eligible 
veterans through contractual arrangements with non-VA 
providers. This statute directs that the pilot program be 
conducted in at least five VISNs. The VA has determined that 
VISNs 1, 6, 15, 18, and 19 meet the statute's requirements. 
This program will explore opportunities for collaboration with 
non-VA providers to examine innovative ways to provide health 
care for veterans in remote areas.
    Immediately after Public Law 110-387 was enacted, the VA 
established a cross-functional workgroup with a wide range of 
representatives from various offices as well as VISN 
representatives to identify issues and develop an 
implementation plan. The VA soon realized that the pilot 
program could not be responsibly commenced within 120 days of 
the laws enactment as required. In March and June of 2009, VA 
officials briefed Congressional staff on these implementation 
issues.
    VA has made notable strides in preparing for the 
implementation of Section 403 with the goal of having the pilot 
program operational in late 2010 or early 2011. Specifically, 
VA has developed an implementation plan, which contains 
recommendations made by the workgroup, analyzed our driving 
distances for each enrollee to identify eligible veterans and 
reconfigured our data systems, provided eligible enrollee 
distribution maps to each participating VISN to aid in planning 
for potential pilot sites, developed an internal request for 
proposals that was disseminated to the five VISNs, asking for 
proposals on potential pilot sites, developed an application 
form that will be used for veterans participating in the pilot 
program. And we have taken action to leverage lessons learned 
from the Healthcare Effectiveness through Resource Optimization 
pilot program, HERO, and adapt it for purposes of this pilot 
program.
    VA has assembled an evaluation team of subject matter 
experts to review the proposals from the five VISNs regarding 
potential implementation. This team will then recommend 
specific locations for approval by the Under Secretary of 
Health. We anticipate this process will be completed this 
summer.
    After sites have been selected, VA will begin the 
acquisitions process. Since this process depends to some degree 
on the willingness of non-VA providers to participate, VA is 
unable to provide a definitive timeline for completion, but 
we're making every effort to have these contracts in place by 
the fall. This would allow VA to begin the pilot program in 
late 2010 or early 2011.
    VA is developing information materials for veterans 
participating in the pilot program for non-VA providers and for 
VA employees and other affected populations so that when the 
pilot is implemented all parties will have the information they 
need to fully utilize these services. VA is committed to 
implementing the program directed by Congress and to maintain 
the quality of the care veterans receive.
    Other issues such as securing the exchange of medical 
information, which was referred to several times this morning, 
as well as verifying veterans' eligibility for this pilot 
program, coordinating care, and evaluating the success of the 
pilot program are also important priorities. And we are working 
to ensure that there is appropriate implementation in the pilot 
program.
    As was referenced by Mr. Thackston and his colleagues, I 
appreciated the opportunity to meet with Congressman Perriello 
and his staff and interested stakeholders several weeks ago. 
The prior panels this morning have addressed important issues 
facing veterans in rural communities, and I value the 
opportunity to hear their perspectives and will take insights 
learned back to the implementation of this pilot.
    Thank you again for the opportunity to discuss the status 
of the pilot program with you today.
    [The prepared statement of Ms. Vandenberg appears on p. 
76.]

             STATEMENT OF DANIEL F. HOFFMAN, FACHE

    Mr. Hoffman. Good morning, Mr. Chairman and Congressman 
Perriello. Thank you for the opportunity to share what we in 
VA's Mid-Atlantic Health Care Network are doing to reach out to 
veterans in our rural areas.
    Increasing access for veterans is one of the Secretary's 
top priorities for the Department. This has several components 
immediately relevant to rural veterans. It means bringing care 
closer to home, sometimes even into the veteran's home. It 
means increasing the quality in the care we deliver, and it 
means providing veterans-centered care in a time and manner 
that is convenient to our veterans.
    It's my responsibility to increase access for veterans in 
North Carolina, Virginia and the southeastern portion of West 
Virginia. VISN 6 encompasses more than 88,000 square miles, 53 
percent of which is rural or highly rural. The veteran 
population for our area is in excess of 1.5 million, and 
between October 1, 2009, and June 30, 2010, we have cared for 
more than 319,000 veterans.
    To meet the growing demand for health care, we have 
aggressively worked to increase capacity, we have added to or 
enhanced each of our eight medical centers, and we have grown 
from two community-based outpatient clinics less than 10 years 
ago to a current total of 17. Our plan calls for 11 more to be 
added by the end of fiscal year 2013. In all, over the next 3 
years, VISN 6 will add more than 1.5 million square feet of 
health care space for veterans. With these additional sites of 
care, more than 90 percent of our veteran population will be 
within 60 minutes of a VA health care facility.
    However, our efforts to care for veterans living in rural 
areas go beyond bricks and mortar. Our rural health teams are 
working diligently to find new and better ways to affect care 
in the rural areas. In May of 2009, VISN 6 began laying the 
foundation for what is now our rural health program. In July of 
2009, clinicians, staff and medical center directors developed 
a strategy to bring together the many resources which 
contribute to enhancing and integrating our rural health 
efforts.
    We created eight teams of professionals based out of each 
of our eight medical centers made up of pharmacists, nurses, 
social workers and others whose focus is to make VA care 
available closer to veterans' homes, and sometimes even into 
our veterans' homes. These teams are now fully staffed and are 
now currently developing and deploying strategies to enhance 
care, specifically focusing on areas they serve.
    Three of the teams representing Virginia--from Salem, 
Richmond, and Hampton--are set up outside today for veterans to 
visit. We're also reaching out to partner with and leverage the 
many programs already in existence. Our teams are working 
closely with the Virginia Wounded Warrior Program, and we are 
meeting with universities like Old Dominion, the Eastern 
Virginia Medical School and the University of Virginia and Via 
Osteopathic School to share the knowledge they have 
accumulated. Additionally, we are working with the Indian 
Health Service and local tribal councils to provide for our 
veterans of Native American heritage.
    VISN 6 has reached out to Native American veterans through 
the use of a mobile van based clinic you can see and tour 
outside. Operating out of this mobile clinic, five VA staffers 
provide primary care on five Native American reservations 
located in Virginia. Each month the clinic visits the 
Chickahominy Tribe, Eastern Chickahominy Tribe, Pamunkey Tribe, 
Upper Mattaponi Tribe, and the Rappahannock Tribe.
    In line with VA's efforts in other rural areas, we are also 
leveraging technology to strengthen our telehealth program 
designed to close the geographic gap between providers, 
specialists and patients. Currently all of our CBOCs are 
equipped with telemedicine, to bring additional services closer 
to where our veterans reside.
    One of our great success stories is the use of teleretinal 
imaging for diabetic retinopathy. This system is now up and 
running in 22 sites, and because early detection allows for 
early treatment, we have saved many veterans from going blind. 
We have also enhanced our telemental health services based out 
of the Salem VAMC. This program currently provides telemental 
health to veterans in Tazewell, Hillsville, Danville and 
Lynchburg. It will be expanded to serve the new Wytheville and 
Staunton clinics when they open. This program has served more 
than 330 veterans by offering medication evaluation and 
management, substance abuse evaluation and treatment and 
treatment for both combat and other military trauma.
    In our efforts to become the provider of choice for our 
women veterans, we have hired a women's health coordinator for 
the VISN, one for each State and one in each hospital. They are 
overseeing our progress in developing a women-friendly 
atmosphere and are working hard to get the message out that 
this is not just your grandfather's VA. We have been and will 
continue to make huge leaps forward on providing gender 
specific care in safe and comfortable environments.
    Beyond the use of telemedicine and mobile clinics we are 
also using low-tech methods like direct mail. As a trial in 
June, we mailed letters to 10,000 women veterans in West 
Virginia, inviting them to consider using the VA for their 
primary and gender specific care.
    The bottom line is that throughout VISN 6 we're working 
hard to live up to our motto: ``Excellent service, earned by 
veterans, delivered here.'' Thank you again for the opportunity 
to share what the men and woman of VISN 6 are doing to help 
improve the lives of veterans. I look forward to responding to 
any of your questions.

        STATEMENT OF CAROL BOGEDAIN, MS, RD, CPHQ, FACHE

    Ms. Bogedain. Good morning, Mr. Chairman, Congressman 
Perriello. Thank you for inviting me here today to discuss the 
programs at the Salem VA Medical Center with respect to 
outreach and care for rural veterans.
    The Salem VA Medical Center is part of VISN 6 and serves 
veterans throughout Virginia for psychiatric care and 
Southwestern Virginia for medical and surgical care. We have 
community-based outpatient clinics in Lynchburg, Danville, 
Tazewell and we have a site of care at Hillsville. And we plan 
to open VA staffed CBOC in Wytheville and Staunton in January 
of 2011. As a side note, we're having the groundbreaking for 
the Wytheville CBOC today. The Vet Center in Roanoke provides 
services to our CBOC and support counseling groups in 
consultation, and they do travel to other areas.
    The Salem VA Medical Center has several programs that 
provide services to rural veterans. Our rural health team in 
Salem began serving veterans in our catchment areas in May of 
2010, and we have 14 staff members who support this initiative, 
including both clinical and nonclinical employees. The team 
works closely with many of our other outreach programs such as 
home-based primary care, telemedicine, our women's health 
program, mental health, the OEF/OIF, and other services to 
address the needs of rural veterans. The team educates veterans 
on eligibility and enrollment and disease specific issues. They 
offer pharmacy consultations, provide blood pressure and body 
mass index screening and promotes My HealtheVet, which is the 
VA's personal electronic health record.
    We use visual aids, models and presentations and videos to 
educate the veterans for their needs. We're reaching out to 
veterans at VA, Community, VSO and other events and 
organizations. To date approximately 40 events or visits have 
occurred. There's 15 more that have been confirmed and 
scheduled and we continue to outreach.
    As part of our outreach, the team helps veterans in rural 
and VA health care. Veterans have the option of enrolling 
either face-to-face with VA staff or filling out a 10-10EZ 
Health Application Enrollment Form. We are focusing our 
outreach efforts on women, women veterans, and OEF/OIF veterans 
in particular. The rural health team is coordinating with our 
Veterans Health Clinic to educate women in rural areas.
    We have already completed training of our providers in 
gender specific care, and we'll also have additional training 
provided at the Salem VAMC for the rural health nurses by the 
Eastern Virginia Medical School. The rural health team has 
attended pre- and post-deployment events in collaboration with 
our OEI/OIF program coordinator.
    Salem VA Medical Center supports the Volunteer 
Transportation Network that runs each Thursday from 
Martinsville for veterans who have scheduled appointments at 
the Salem Medical Center. We have also recently recruited a 
volunteer driver who will operate a shuttle van from the 
Danville CBOC to meet the Martinsville van. Between October and 
mid-May, the Martinsville van travelled 4,285 miles and 
transported 112 veterans during 28 trips to the Salem VA 
Medical Center. We have ordered an additional van to be based 
in Danville to transport even more veterans.
    We also offer a range of specialty programs. Home-based 
primary care delivers primary health care in the veteran's home 
through an interdisciplinary team of VA specialists. Another 
program, telemental health, which we discussed earlier, is 
currently used in conjunction with comprehensive on-site 
services at are CBOCs to offer specialty mental health 
surfaces. We currently offer telemental health care at the 
Tazewell, Hillsville, Danville and Lynchburg CBOCs and plan to 
provide these services at the new CBOCs in Wytheville and 
Staunton.
    The Salem VA Medical Center has provided Care Coordination 
Home Telehealth to veterans since 2005. This program utilizes 
an in-home device to help VA and veterans monitor their health 
status on a daily basis.
    Congressman Perriello, in conclusion I'd like to address 
some of the concerns that you and others have raised in a 
conversation that we had last week on our conference call. We 
appreciate the opportunity to speak with you and your staff and 
to better communicate with our veterans.
    We are sending a letter to all of our veterans who use the 
Danville CBOC to explain that they can choose a medical home 
and identify which hospital they would prefer to use for 
services the clinic cannot provide. We will also work to ensure 
all Danville providers have the necessary credentialing and 
privileging at the Salem, Durham, and Richmond VA Medical 
Centers to allow our doctors to order tests, consultations, 
medications and any other services our veterans need, and that 
process has started. We will also do a better job communicating 
with the local VSOs to explain these policies and what we're 
doing to improve the care, particularly in Danville.
    Thank you for the opportunity to present the many programs 
we offer to the veterans in the Salem rural areas, and I look 
forward to answering any questions you may have.
    Mr. Michaud. Thank you, all three of you, for your 
testimony this morning. I appreciate your coming forward.
    Mr. Hoffman, you quoted the slogan that you go by. Could 
you repeat the motto again?
    Mr. Hoffman. What we decided----
    Mr. Michaud. No. Could you read your motto----
    Mr. Hoffman. Sure.
    Mr. Michaud [continuing]. Once again? I didn't know if I 
missed it or not.
    Mr. Hoffman. Starting from we created eight teams----
    Mr. Michaud. No. You said you have a motto.
    Mr. Hoffman. Oh, the motto. I'm sorry. I thought you said 
the ``model.''
    Mr. Michaud. No.
    Mr. Hoffman. ``Excellent service earned by veterans 
delivered here.''
    Mr. Michaud. You heard the testimony of the two previous 
panels. You heard Ms. Tucker's concern with her son. If I was 
evaluating based upon what you stated, I probably would have to 
fail the VA for not living up to the motto. What seems to be 
the problem.
    Words are cheap. Action is what counts. In my opinion, you 
did not live up to that motto. And as I heard from other 
veterans earlier as well, there's concern here. So what are you 
doing to live up to that motto? What resources do you need? 
Where has the VA failed you as a VISN Director? Do you want to 
respond?
    Mr. Hoffman. First, I would agree with you, we failed Ms. 
Tucker. And I would not hold that out as my example of good VA 
care. We would hope and in fact we have done very, very good 
things in the VA in a lot of cases, but that one I cannot be 
proud of. And I'm sure the people that have worked on her would 
not be proud of that as well.
    One of the things that I have heard in focus groups and 
other venues that we're taking much more seriously is--and what 
I heard from Ms. Tucker and others, is that we do have case 
managers, but we don't have just one. And you were very 
perceptive in your question, who is your case manager, and Ms. 
Tucker mentioned at least two and others over her last 5 years.
    One of the comments that came out of the focus group that 
struck me as being critical in all of this is who manages the 
case managers on behalf of veterans. I think that's something 
we need to do much better. It is, frankly, something that our 
whole medical home concept that has been recently implemented I 
think will help. We're still in the implementation stages on 
that, but essentially it sets up within the medical home, the 
medical home chosen by the veteran and their family to increase 
case management services on behalf of that veteran.
    So, to make invisible the very complex system which is VA, 
not just VHA but VBA and all of the other issues, I'd like to 
think that the money that we have received already for rural 
health will also help in that regard, just being able to make 
contact with these folks, getting them enrolled in our system 
and then being able to have the opportunity to case manage 
we'll also adopt.
    I think you also heard issues related to our information 
technology functions, and it's something that I think we think 
is very important--I know we think is very important from our 
leadership point of view, to move as quickly and with alacrity 
as possible to not only upgrade our current system which was a 
leader for a long period of time in health care, but to 
synchronize that with DoD and with the private community.
    We're actually engaged in this VISN in a pilot to do just 
that in our Hampton facility. Hampton is teaming up with DoD in 
Portsmouth and with the Bon Secours Health Care System and with 
the State of Virginia who has experience in this area. 
Hopefully that will move the process forward to pilot these 
things.
    Mr. Michaud. To give you an example, I'm going to add to 
that. Then I'll ask you a specific question. In Maine, a mill 
that I worked at filed bankruptcy, and they shut the mill down 
in East Millinocket. I did know that the different drug 
companies offered either no- or low-cost prescription drugs for 
people who qualify. What I didn't know is that there were over 
385 different types of programs within all the drug agents and 
drug companies. People had to fill out seven or eight pages in 
applications to see if they qualified for any of these specific 
programs. When Senator Snowe and I approached Pharmaceutical 
Research and Manufacturers of America (PhRMA), we asked them if 
they could simplify that. They did. The process boiled down to 
four simple questions, and the computer did the rest of the 
work.
    We heard earlier today about filling out paperwork after 
paperwork, getting denied, encountering delays. They're using 
pencils. What have you done as a VISN Director to streamline 
that process.
    I'll be asking the same question of Ms. Vandenberg as well. 
It's more than just money. It's about trying to make the 
process smoother, more efficient. Have you done anything to 
simplify the process by collaborating between VHA and VBA?
    Mr. Hoffman. Well, we do work closely with VBA. But I think 
both of us--I'm speaking for VBA and I probably shouldn't. But 
I think we both feel a little behind the technology curve. One 
of the analogies was we feel like we're digging the Panama 
Canal with a teaspoon. And all of the comments that have to do 
with upgrading our system so that we can automate and share 
records more transparently between VBA and VHA would all be 
welcomed. We can't really do that independently of the entire 
system. But we actively adopt all of the systems that are made 
available to us.
    Mr. Michaud. Even within VHA I've heard several complaints 
on setting up an appointment for a veteran. Once they get 
there, they have to wait there all day. In some cases, they 
still can't see the doctor. That's concerning, especially when 
they have to travel in Maine, for instance, 4 or 5 hours. So 
it's not only between VBA and VHA. It's within VHA as well.
    So what are you doing to make sure that veterans are not 
wasting their time to get adequate health care? Have you 
streamlined that process, or is it not a problem within VISN 6.
    Mr. Hoffman. No, I would not be so bold as to say it's not 
a problem in VISN 6. It is a problem, multiservice scheduling, 
and it's one that's frankly been brought up through our 
national leadership board to VA, national VA.
    Centralizing, coordinating scheduling is something that's 
vital for our future. We have tried our own manual work-
arounds, and it's basically a case management issue at this 
point where if a given veteran we know needs two or more 
appointments at a given location, we will try our best to try 
to get those appointments grouped in a tighter time frame, so 
if they come in the morning they don't have to stay the whole 
day. They can return home by noon.
    We don't always succeed in that, and it's not always easy, 
because we're doing it manually. You know, it's our case 
manager calling the various appointment people and trying to 
get those appointments rather than having to collate and neatly 
put together in the most economic time, economic fashion for 
our veterans.
    Mr. Michaud. Have you ever run into the situation, in 
contracting out care, where a veteran would have to travel some 
distance to get health care?
    First of all, I'll use an example I heard this past 
weekend, where a veteran had to travel 4 hours for a 15-minute 
hearing exam and ultimately couldn't get that hearing exam, and 
had to travel another 4 hours back.
    When you make your decision to contract out care for a 
veteran, are you considering the time it takes a veteran to 
actually travel to the VA facility?
    Mr. Hoffman. Yes, in short. We consider time, the acuity of 
the patient's condition--they just may flat not be able to 
travel because of distances that a healthy veteran may be able 
to travel--and the type of exam. You know, we fee out, for 
example, numerous exams, ophthalmology exams, hearing exams in 
various locations. We have even piloted and are piloting a 
teleaudiology concept which may have promise for us in the 
future for actually doing some of these exams out of our CBOCs 
so that we can give one closer to our veterans.
    Mr. Michaud. My next question is on the Veterans Equitable 
Resource Allocation model. We heard at one of our hearings from 
a former VISN director who made reference to the mothership, 
the Central Office, not giving adequate funding to the other 
medical facilities within the VISN.
    I'll use Maine again as an example. When Congress increased 
the boundary reimbursement for our veterans, what it cost VA 
Togus for reimbursement rates is anywhere between $5 million 
and $6 million. However, they received from the mothership 
about $1.5 million. So therefore, they're running in the red.
    So the problem I have, and my question to you is, are you 
providing the adequate resources for the different facilities 
within VISN 6, or are you forcing them to live within their 
means, meaning that ultimately they cannot hire nurses or must 
restrict what services they can provide, whether that is 
contracting out care or other services.
    Mr. Hoffman. That's a great question. There's probably not 
a network director or a director that would say that they have 
all the resources that they need. So, by definition, we live 
within constrained resources. Both at the VISN level and the 
medical center level, if you ask any one of my directors, I 
think they would confess that they have to watch their budgets 
very, very carefully and make tough choices. And whether 
that's--it will never be with any travel. That's a given. But 
it will be somewhere in the whole continuum of health care 
services. We do our best to allocate appropriately to each 
facility based on where the veterans are and their acuity of 
care needed.
    Mr. Michaud. Ms. Vandenberg, I have several questions for 
you as well. I think you remember that Congress is very lenient 
anytime there's a new Secretary onboard. Because they're new, 
we give them the flexibility to grow into the position.
    Secretary Shinseki has been there a year and a half, and I 
think it's important for the VA and for the Secretary to start 
delivering services. And my concern, as you can imagine, is 
going to be about the pilot program, which I will ask you a 
specific question about. I will be reading a quote that you 
gave us when you testified before our Committee. As I said 
earlier, it's more than money. It's about doing things in a way 
that provides better services. We heard from panel two about 
the need for VHA and VBA to work more collaboratively together. 
I gave you an example of a cumbersome process with a lot of 
different drug companies.
    What is VHA doing to help streamline that process so it 
will help with the delays? I agree with what the Secretary is 
doing on Agent Orange, PTSD, and increasing access for priority 
veterans. The President is escalating the war in Afghanistan by 
sending more troops over there. Therefore, they're going to 
come back and need more services. My big concern is that the 
workload is going to increase exponentially within VHA and VBA.
    What are you doing to help streamline that process? Is 
there a way you can simplify it similar to what PhRMA did with 
the prescription drug issue?
    Ms. Vandenberg. Thank you for that question. As you are no 
doubt aware, we have had a very systematic approach to system 
redesign within the Veterans Health Administration for a number 
of years now, and I think we can demonstrate very significant 
progress in improving throughput in our clinics as well as 
enhancing efficiency in our inpatient services.
    Recently, we have begun to team up with VBA to look at 
processes where we interface with VBA, in particular the whole 
set of steps that it takes to do compensation and pension exams 
and the Disability Evaluation System pilot in particular. So we 
have a high level commitment at this point to collaborate 
systematically with VBA to look at select processes and attempt 
to streamline them.
    I'd be happy to give you further information on the record. 
To follow up, I didn't come prepared today to talk about this 
extensively, but I can tell you unequivocally that we are 
collaborating with VBA in bringing the vast network of tools 
and resources that we have used within VHA to enhance 
efficiency and streamline the processes.
    With regard to Section 403 implementation, after our April 
hearing we went back and reviewed the law, and the 
interpretation that came from that is that the law reads, and I 
quote, that ``the pilot be carried out within areas selected by 
the Secretary for the purposes of the pilot program in at least 
five Veteran Integrated Service Networks.'' We interpreted this 
statutory language to mean that it was permissible for VA to 
implement the pilot program within specific areas.
    I understand that that continues to be a concern to you, 
sir, and I look forward to the opportunity to brief you and 
other Members of the Subcommittee and other Members of Congress 
and your staff in more detail as to the analysis that we have 
conducted with regard to the requirements that we would face if 
the pilot program is implemented on a VISN-wide basis.
    Mr. Michaud. The CBO requested from the VA certain 
information when the legislation was passed. One of the 
questions that they asked was the number of total patients 
within those VISNs who are going to be affected by this 
legislation. For VISN 6, 267,189 is the number of total 
patients that were going to be affected by this legislation. 
When they did the fiscal note, they came up with the estimate. 
I believe it was $100 million. The intent was for full VISN 
participation.
    When you were before the Subcommittee earlier, I want to 
quote your comments in regards to that. You stated, and I 
quote, ``So I'm just wanting to acknowledge that I hear you. I 
further appreciate the intent and just practically speaking 
obviously we are going to honor the intent. We are obviously 
going to go back and apprise the Under Secretary of Health of 
the need for us to think more broadly and make whatever 
adjustments are necessary then in the next steps of the 
process.'' So in looking out for fiscal year 2011 we expected, 
as I mentioned earlier, to spend at least $100 million on this 
pilot. Now that we are going to go back and reset our 
parameters, we may need to amend that estimate.
    I guess my question then is, when did the VA reach the 
decision that the implementation of the pilot program is only 
going to be in selected areas? When was that decision made? 
Since, clearly, your testimony at the last hearing indicates 
you were going to go back and reassess it, and you would 
probably have to come up with a different estimate for cost. 
When did you make that decision?
    Ms. Vandenberg. That decision----
    Mr. Michaud. Who made that decision, as well? When and who?
    Ms. Vandenberg. That decision is still pending in the 
Department at this point. We have revisited the requirements of 
the law. We have reevaluated the implications of VISN-wide 
implementation both from an economic standpoint as well as from 
the contracting standpoint, and that decision is still under 
consideration.
    Mr. Michaud. Well, my other question is all about access to 
quality care. We heard earlier today from Mr. Chapman from 
Southwest Virginia Community Health Systems. If you look at the 
needs of our veterans in rural areas, in a lot of areas 
community health centers are located, where we need that help.
    What is the VA doing to focus on contracting with community 
health centers that want to participate, or accommodate 
veterans in those regions who want to participate? What are you 
doing to reach out to them?
    I can see a huge problem when you look at Agent Orange, 
PTSD, Priority 8 veterans, escalation of the war in 
Afghanistan. It's not going to get easier for the VA, it's 
actually going to get harder. And, quite frankly, those that 
are going to take the brunt of the frustration over VA not 
being able to provide adequate services in a timely fashion to 
our veterans in rural areas, will be the VA employees in those 
regions. And that's very unfortunate, because I think in the 
past, VA employees have taken a lot of criticism primarily 
because they have not received adequate funding from our 
previous administration or Congress.
    This Committee and Congress have been very generous in 
trying to meet the needs of VA, but we can't meet the needs of 
VA if we're not given the proper information or if VA is not 
implementing the laws as they are intended to be implemented. 
And I can go into the nursing home issue, as well, where VA did 
something totally different from the intent of the law on 
reimbursement for nursing homes.
    Ms. Vandenberg. With regard to community health centers in 
particular, in our VA planning process we have identified the 
location of those resources and have communicated that 
information as part of the planning process to the network 
directors in the annual planning exercise. Our planning 
approach is a top-down, bottom-up. And, therefore, we have 
afforded the network directors the opportunity to identify what 
resources within their VISN would optimally meet the 
requirements that they have for providing care to veterans, and 
so there have been a number of collaborative efforts.
    The situation that was cited earlier is one that I am 
somewhat familiar with, having convened our Veterans Rural 
Health Advisory Committee in Johnson City. And we heard during 
the course of that recent meeting in March a review of that 
circumstance.
    So there is no prohibition to using community health 
centers at this point in time, and your observation that we 
might need to do something more systematic is one that I will 
take back to the Under Secretary.
    Mr. Michaud. There might be no prohibition, but the 
prohibition is going to come when Mr. Hoffman has to live 
within his budgetary needs. I want to make sure that Mr. 
Hoffman and other VISN directors and medical facility directors 
are able to provide the services that they need for their 
veterans. And that's where the problem is going to be.
    If we have to provide more resources, that's one issue, but 
if we are not told of what's out there, the problem that we are 
facing as elected officials with jurisdiction over VA is to see 
how we can change the system to make it work for our veterans 
so that we will not have to hear stories from Ms. Tucker about, 
going through what she had to go through with Ben. That's what 
we are all here for, and I know that's what you're here for, as 
well.
    The other issue is to make sure that what legislation we do 
pass is implemented in the way that it was intended to be 
implemented. If it isn't, then we're going to hear complaints 
from veterans.
    We want to work with you. We want to make sure that you 
have the resources available. But we also want you to work with 
us and let us know where I believe we can make changes. I'm 
getting to a point now where we might want to look at other 
ways to deliver services, such as asking the U.S. Department of 
Health and Human Services to bring forward a proposal where our 
veterans can go to them directly to access health care, because 
we're starting to hear more and more concerns within the VA 
system. And with the increased need for veterans' health care 
because of Agent Orange, PTSD, and expansion of Priority 8 
enrollment, it's going to get worse and not better unless we 
can actually streamline that particular process.
    We want to be able to take care of the problems before they 
become too severe. And, ultimately, when you look at the 
increase in the amount of suicides, not only within the 
veterans community but also within the active military, it is 
increasingly too great. We want to be able to provide Mr. 
Hoffman with the resources that he needs. He needs to have the 
resources so he can distribute them in a way that's fair and 
equitable, but also, streamlining the process is going to be, I 
think, extremely important as well.
    Mr. Perriello.
    Mr. Perriello. Thank you, Mr. Chairman.
    First, Ms. Bogedain, thank you for being on the call and 
for the responsiveness. We have, as you know, had a largely 
positive response to the CBOC in Danville. We've had an 
overwhelmingly positive response to Salem.
    Again, we want a zero tolerance policy there for where 
problems arise. But one of the confusions as we do develop some 
of these new programs like the CBOC is the question of, does 
that mean that I have to switch my specialty care from one 
hospital to another? I think that has been a barrier for some 
people participating in what seems to be a step in the right 
direction.
    So I just want to commend you for a rapid response, and 
we'll continue to follow up with you on that and other concerns 
that we hear about with the hospital, and again, we have been 
really enjoying a rapid response and open line of communication 
with you.
    Ms. Vandenberg, you know, I was thinking about this old 
``Saturday Night Live'' skit, while Chairman Michaud was 
talking, where Jon Lovitz is playing a movie agent advising an 
old war film actor, and the war film actor keeps saying, 
``Well, maybe I made too many of these war movies.'' And Jon 
Lovitz says, ``I guess you have.'' He says, ``Well, tell me 
what you really think.'' He says, ``Well, you know, I think 
it's time to hang it up.'' He says, ``What are the reviews 
saying?'' ``Well, the reviews say you're the worst actor I've 
ever seen, and now I get 10,000 letters a day saying the 
same.'' ``So tell me where I stand really.''
    And I think that the point here is that sometimes there are 
two interpretations of a law, and sometimes it seems clear to 
me that there's just a breakdown of communication or something 
people don't want to hear.
    In this case, through the multiple hearings that we've had, 
it seems clear to me--and I am new to politics--that the 
Committee feels very strongly that this is a pilot program that 
we want to test and test as broadly as possible to see and we 
believe that's coming from the grassroots up from communities. 
And it seems that the VA has taken every opportunity to try to 
crush, delay, and minimize this plan.
    Now, this is a situation where the VA may be right and 
Congress may be wrong, and I offer you this proposal: There is 
no easier group to blame than Congress. So if this is something 
that goes forward and does not work, I think it will not be 
difficult for the VA to say it's Congress's fault. We're 
clearly on the record believing in this program. If, however, 
it succeeds, no one ever believes what we do works anyway, and 
the Administration, and more importantly, the VA will be able 
to claim very aggressively the success of this program.
    I really do believe this is something where, again, we may 
be wrong, but I think our intent is very clear, which is that 
we believe it's right. We believe that accessing more primary 
care in these areas is a positive thing. What I feel like we've 
tried to do is put forward the most positive cases that we can 
find.
    Now, I think that's often the case out of what you might 
call colloquial interest for Members of Congress, but out of 
all the communities that I could represent, I do my due 
diligence, and I look at the ones that I think can sustain it 
versus ones that are flash-in-the-pan ideas and have that 
response.
    So I guess, you know, to play what's turning into a bit of 
a bad-cop, good-cop scenario, it seems like we're offering you 
an opportunity for something where the downsides can all fall 
on us, the upsides can go to the Administration. And the 
question is, you know, at the end of the day, what is the 
reason not to try a larger number of these within the VISNs 
that already qualify if--or try to run a pilot where the goal 
is to figure out if this works, not to figure out how to make 
the case against it? Why would we not try a broader set of data 
points to have in the study?
    Ms. Vandenberg. I'm glad to see the direction you took in 
the beginning when you were talking about the old actor. I 
thought, ``Oh, goodness, we're getting very personal here.''
    Mr. Perriello. No, I was not directing to you.
    Ms. Vandenberg. I'm just teasing.
    All I can say today is that I hear you loud and clear, and 
I will take this message back to the Under Secretary and to the 
Secretary.
    Last Thursday I was part of the team briefing the Secretary 
on a range of issues on access, was focused on access, and the 
work was done in my Office for Policy and Planning, and it's an 
issue that we are and will continue to give extensive 
consideration. So I hear you. I will take the message back 
tomorrow.
    Mr. Perriello. We appreciate that. I also want to commend 
Secretary Shinseki. I think the thing at the VA, first of all, 
there's obviously just a lot of day-to-day things going on with 
the uptick, not only the transition, but the uptick in demand. 
But I think what he has tried to do in his leadership style is, 
excuse me, to take big problems and try to check them off one--
not one at a time, but definitely have a focus.
    I know in the first year, getting the new GI Bill 
implemented and implemented well was a huge focus. And I think 
it was an unbelievable accomplishment, given how quickly that 
was implemented. People say, you know, that the public sector 
can't do that, but I think the fact that the--the general put 
so much into it--our Committee was following it--really was, 
again, a big accomplishment.
    And I know that his focus has been the backlog since then, 
among other--veteran homelessness, jobs and other things. But 
the issue of the backlog--and we have tried to take a big chunk 
of that on, with moving Agent Orange funding forward and doing 
some of the investigations and other things.
    I think when it comes to the issue of rural health, we 
already have a lot of pieces on the table that suggest we are 
already taking a big swing at the bat on this. When you look at 
the CBOC starting to take off, when you look at some of the 
things we have done in terms of telemedicine and other areas, I 
think, you know, if you start to put that together, you really 
are looking at something we can be really proud of looking back 
in a couple of years. I think there's so many people that want 
to do this right, and it's our belief that this can be a very 
significant component of that.
    Again, we don't know at the outset for sure what's going to 
work. We believe that the new challenge is so big with the 
changing demographics of our veterans that we're going to need 
to try four or five things, what combination of telemedicine, 
CHC, primary care through private-sector vendors, CBOCs, 
bumping up our hospital care, what combination of those things 
will meet the challenge.
    So I appreciate that you understand the intent as you did 
in the April hearing. We really hope that this is something 
that we can look at again and champion as a success and not 
just be up here, you know, expressing our frustration. But, 
again, it is something where we feel like our intent is clear. 
And I do have a place near and dear in my heart for the 
facility in South Boston. There's no question about it. My bias 
is clear. But I also think it's indicative of a larger issue, 
which is that we believe there are opportunities like that 
around, and that it would be a shame to delay or hold off on 
that.
    So we appreciate your continuing conversation with us and 
look forward to hopefully have a very positive resolution to 
this specific and general case.
    I yield back.
    Mr. Michaud. Let me once again thank this panel for coming 
forward. I look forward to working with you.
    Hopefully you heard loud and clear the concerns the two 
previous panels brought forward, and you can look at ways to 
work collaboratively to help streamline that process. I know a 
lot of the issues relate to the technology, but the bottom 
line, I know for me as a Member of Congress, is to make sure 
that our veterans get the health care that they need when they 
need it, and I know that's what the VA hopes to do as well. We 
look forward to working with you so we can do what's right for 
the men and women who serve in the military and put their lives 
on the line each and every day for this great Nation of ours.
    So I want to thank Ms. Vandenberg, for coming forward 
today, and I look forward to working with you.
    If there are no other questions, I will adjourn the 
hearing.
    Thank you very much. I want to thank all the veterans and 
everybody in the audience for coming as well. Thank you.
    [Whereupon, at 12:10 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    The Subcommittee on Health will now come to order. I would like to 
thank everyone for attending this hearing, especially the veterans who 
are with us today. I would also like to express my sincere gratitude to 
the Bedford County Board of Supervisors for their hospitality in 
hosting this hearing.
    Today's hearing would not have been possible without Mr. 
Perriello's tireless advocacy for our veterans living in Virginia. He 
is a welcomed member of the Subcommittee on Health for Veterans' 
Affairs who brings new energy and enthusiasm for tackling the unique 
challenges facing our rural veterans.
    As a Congressman who represents rural communities of Maine, Mr. 
Perriello and I have a shared interest in ensuring that our rural 
veterans receive the care that they deserve. Our veterans, whether they 
live in rural Maine or rural Virginia, face common challenges. Most 
notably, access to care is an issue where veterans live many miles and 
hours from the closest VA medical facility. Given this challenge, it is 
important that our rural veterans have access to such tools as 
telemedicine, telehealth, and the VA's new pilot program to provide 
enhanced contract care.
    This year, we held several important hearings focused on rural 
health care. For example, this past April, we held a hearing on VA's 
implementation of the enhanced contract care pilot program. To our 
surprise, we learned of VA's plans to create a pilot within a pilot 
program, where only those veterans in select communities within VISNs 
1, 6, 15, 18, and 19 would have access to enhanced contract care. At 
this hearing, we clearly conveyed Congress's intent for VA to implement 
this pilot program VISN-wide. Unfortunately, we were just informed a 
few days ago that VA does not plan on honoring Congress's intent and 
will only implement the pilot program in select locations within the 
five VISNs. I am deeply concerned by these recent developments and look 
forward to hearing from the VA today on this issue.
    Next, in June of this year, we held a hearing on innovative 
wireless health technology solutions as a way to help overcome rural 
health care challenges. At this hearing, we heard from the Director of 
the Rural Development Network of the University of Virginia Health 
System, who provided poignant testimony on the unique needs of the 
veterans of Appalachia and the importance of innovations in 
telemedicine and wireless mobile health sensors and applications.
    Again, I'd like to thank Mr. Perriello for inviting us here today 
and I appreciate this opportunity to hear directly from our veterans of 
central and southern Virginia about their local health care needs. I 
look forward to the testimonies of our witnesses today.

                                 
   Prepared Statement of Major General Carroll Thackston, USA (Ret.),
              Mayor, South Boston, VA, and Former Adjutant
                 General, Virginia Army National Guard
    Good morning ladies and gentlemen. I am Carroll Thackston and I am 
the Mayor of South Boston, Virginia. I have served over ten years as 
both Vice-Mayor and Mayor of our town which numbers 8,500 in 
population. I am also a retired Major General, United States Army, 
having served for over 40 years, the last 4\1/2\ years as the Adjutant 
General of the Virginia National Guard.
    I served on active duty for over six years, but spent 35 years in 
the National Guard. With this background, I have a good understanding 
of National Guard operations, goals and objectives, and the problems, 
current and future, facing the National Guard.
    My main focus this morning will be about the National Guard and its 
probable impact on the Department of Veterans' Affairs. As you are 
aware, the Total Force Policy has been in effect since post-Vietnam and 
treats the three components of the Army and Air Force--the Regular 
forces, the National Guard and the Reserves as a single force. Unlike 
the impact of Vietnam veterans on the VA system, the total integration 
and increased reliance on the combat and combat support units of the 
National Guard throughout the 90's and the War on Terror creates a 
whole new dynamic for Veterans' Affairs.
    Before I discuss some of my concerns about the Guard and its 
increasing impact on the VA, I would like to tell you about our local 
efforts to help the veterans of Halifax County and immediate nearby 
counties. For the past three years several of us have worked with a 
small group of local Halifax veterans, primarily Vietnam veterans, to 
establish a primary care facility in South Boston to serve local area 
veterans. We have met many times and traveled many miles in pursuit of 
our goal. At this point, we are aggressively seeking designation as a 
rural locality under the VA's Enhanced Contract Care Pilot Program. If 
successful, the Halifax Regional Hospital's new Primary Care Facility 
located in South Boston will serve as a pilot project site for contract 
care within VISN 6. Our group has met numerous times with Congressman 
Perriello, his staff, and VA representatives. We traveled to Washington 
and were able to meet with Secretary Shinseki, and most recently 
participated in a lengthy teleconference that included Deputy Assistant 
Undersecretary Vandenberg and numerous VA staffers. In January of this 
year, Dr. Roger Browne, a member of our group, testified during the 
Roundtable Discussion of the Committee on Veterans' Affairs on 
``Meeting the Unique Health Care Needs of Rural Veterans.'' Dr. 
Browne's credentials as a specialist in internal medicine who has 
treated Halifax County veterans for over 30 years and his personal 
experience as Brigade Surgeon for the 198th Light Infantry Brigade in 
Vietnam in 1968 have provided our group with the leadership and 
credibility to clearly identify the quality primary health care our 
veterans need and deserve. At the finish line, we hope to have our new 
and modern Primary Care Center in South Boston operating as a VA 
primary care contractor providing all Halifax County veterans, both old 
and young, Regular forces or Guard and Reserve, with the quality 
primary medical care that they have earned and are entitled to, both 
legally and morally. There were 1,127 veterans in Halifax County 
enrolled in the VA system at the end of fiscal year 2009. There are 
2,954 civilian veterans in Halifax County according to the most recent 
census data. We want all of them participating in the VA health system, 
and we want a local facility that is convenient for them and their 
families. And we want to insure that our growing population of veterans 
that are returning from current tours of active duty are assimilated 
back into their home communities with the assurance that convenient, 
quality VA medical care is there for them.
    As a former Adjutant General of the Virginia National Guard, I have 
deep concerns about the coming impacts to the VA system as a result of 
the extensive use of National Guard combat and combat support units 
during Operations Iraqi Freedom and Operation Enduring Freedom in 
Afghanistan. During my tenure as Adjutant General, in spite of actively 
seeking overseas operations for our ten National Guard Divisions, the 
Guard was more or less relegated to Homeland Security and domestic 
crises. That is not the situation the Guard finds itself in post 9-11.
    In Virginia, we have 7,838 members currently assigned to the Army 
National Guard which is 102% of its authorized strength. Since 9-11, 
8,862 Army National Guard personnel and over 700 Air National Guard 
personnel have been deployed. Eighty-one (81) Purple Hearts have been 
awarded to Virginia Guardsmen and ten (10) Guardsmen have been killed 
in action. There are currently 630 Virginia Army National Guard and 
Virginia Air National Guard on active duty.
    On the national scene, the total number currently on active duty 
from the Army National Guard and Army Reserve is 90,144; Navy Reserve, 
6,354; Air National Guard and Air Force Reserve, 16,457; Marine Corps 
Reserve, 4,917; and the Coast Guard Reserve, 787. This brings the total 
National Guard and Reserve personnel currently activated to 118,659, 
including both units and individual augmentees (DoD News Release 7-14-
10--National Guard (in Federal Status) and Reserve Activated as of July 
13, 2010)
    These figures are current as of July 13th. When you consider the 
continuing participation in the war efforts since 2001, the total 
number of National Guard and Reserve members is substantial.
    So, in conclusion, when we consider the huge influx of citizen 
soldier veterans created by the integration of Guard and Reserve forces 
by the Total Concept Policy and the prosecution of extensive combat 
operations in the Middle East, there is an enormous workload headed for 
the Department of Veterans Affairs.
    When you consider the demands being put on the Department of 
Veterans Affairs by that intense combat environment and multiple tours 
of duty, combined with the effort to increase VA medical care 
eligibility for veterans, I believe the VA will be required to expand 
its network of health care facilities to meet those increased demands. 
News reports last week indicate that the VA is adopting new rules 
regarding post-traumatic stress disorder that will, in my opinion, 
drastically increase the clinical workload for the VA. Reports cite a 
2009 Rand Corporation estimate that ``nearly 20 percent of returning 
veterans, or 300,000, have symptoms of PTSD or major depression.'' It 
will be interesting to see those estimates updated to reflect the new 
rules announced last week.
    The education our group has received in pursuing a contract primary 
care facility for Halifax County has clearly enlightened us on the 
tremendous strides the VA has made since the mid-1990's with the 
establishment of the VISN network and CBOCs, or Community Based 
Outreach Clinics.
    We are absolutely convinced that the VA will need to rely on the 
numerous professional, and highly qualified, private-sector medical 
facilities to meet the coming demand for VA medical health care. 
Expanding the CBOC system may be prudent and wise, but the full 
utilization of contract medical facilities such as the one in South 
Boston will be essential to meeting those demands--both on-time and on-
cost. Our research has shown considerable savings in time and fuel by 
veterans using more convenient and accessible primary care locations. 
Only through an aggressive primary care program that is structured to 
include all qualified veterans will the VA be able to cultivate a 
climate of preventive medicine and early detection of serious 
illnesses. The VA Medical Center will always be the bedrock of VA 
medical care to take care of the most serious medical problems of our 
veterans and the VISN/CBOC system is a proven winner in our opinion. 
Contract primary care using existing private sector facilities is going 
to be critical to the VA. We in South Boston and Halifax County are 
ready to show you the way.
    Thank you. May I answer any questions.

                                 
            Prepared Statement of Howard Chapman, Executive
      Director, Southwest Virginia Community Health Systems, Inc.,
         and Member, Virginia Community Healthcare Association

 Utilizing Community Health Centers as a Vehicle for Increasing Access 
to Primary Care for Veterans Through the Rapid Activation of Community 
                    Based Outpatient Clinics (CBOCs)

                           EXECUTIVE SUMMARY
    PROPOSAL: This paper proposes the use of individual community 
health centers, or organized networks of community health centers, to 
serve as a vehicle for increasing access to primary care for Veterans. 
In this model, community health centers would function as Community 
Based Outpatient Clinics (CBOCs) as defined by the Department of 
Veterans Affairs. This model is based on a strong collaborative 
relationship between the Health Resources and Services Administration's 
Bureau of Primary Health Care and the Department of Veterans Affairs.

Summary Overview

    In May 2004, the Department of Veterans Affairs issued its final 
version of its Capital Asset Realignment for Enhanced Services (CARES) 
Report. The CARES process was ``initiated in 1998 to provide veterans, 
Congress and the American people with a 20-year plan to provide the 
infrastructure the VA will need to provide 21st Century veterans with 
21st Century medical care.'' \1\
---------------------------------------------------------------------------
    \1\ Chapter 1--Statement of Secretary, CARES Report, May 2004.
---------------------------------------------------------------------------
    This Report calls for VA systemwide improvements in the use of 
vacant space, modernization, operating costs, as well as increasing 
access to primary care from 73 percent to 80 percent for all eligible 
\2\ veterans. In addressing the need for increased access to primary 
care, the CARES Commission originally identified the addition of 250 
Community Based Outpatient Clinics,\3\ which would be strategically 
located throughout the country. These CBOCs would be in addition to the 
existing inventory of both staff model and contracted CBOCs that have 
been operating since 1998.
---------------------------------------------------------------------------
    \2\ According to the Veterans Administration Primary Care Access 
Guidelines.
    \3\ CBOCs are outpatient primary care access points that are 
generally located in areas of high concentration of veterans 
populations, and are 1-2 hours driving time from regionally located VA 
Medical Centers.
---------------------------------------------------------------------------
    The final Report prioritized 156 CBOCs out of the originally 
proposed 250 locations for activation by Calendar 2012.
    A crossmatch analysis comparing the 156 prioritized CBOC locations 
with current \4\ BPHC grantees indicates that there are approximately 
256 BPHC grantees that could potentially provide access to primary care 
to 100 percent of the 156 prioritized CBOC locations identified in the 
2004 CARES Report. \5\
---------------------------------------------------------------------------
    \4\ Cross match conducted August 2004 and includes all BPHC Web 
site posted grantees including community health centers (CHC), migrant 
health centers (MHC), health center networks (ISDI), health care for 
the homeless (HCH), FQHC Look-a-Likes (FQHCLA), healthy communities 
access program (HCAP), and healthy schools healthy communities (HSHC) 
grantees.
    \5\ Cross match analysis does not take into account any increase in 
community health centers as a result of President Bush's Initiatives I 
or II.

---------------------------------------------------------------------------
Rationale

    There are a multitude of rationales supporting a community heath 
center--VA CBOC collaboration in addition to the most compelling 
resource rationale given above:

          The goal of the CBOC program to increase access to 
        primary care for its Veterans is consistent with the mission of 
        community health centers and the President's Initiative.
          Community health centers offer the wide range of 
        services that meet or exceed the VA's requirements for CBOCs 
        including primary care, laboratory, radiology, mental health, 
        and women's services.
          Veteran patient population health demographics are 
        consistent with the patient health demographics of community 
        health center patients and the program's efforts to further 
        develop disease collaboratives.
          Community health centers are well suited to meet the 
        CBOC Performance Measures, as established by the VA, in the 
        areas of JCAHO accreditation, travel distance, mental health, 
        patient satisfaction, etc.
          There is a growing community health center commitment 
        to health information technology, high speed internet 
        connectivity, and an electronic health record which is 
        consistent with the Veterans Administration's commitment to the 
        Computerized Patient Record System (CPRS).
          Community health centers are organized in BPHC/HRSA 
        funded networks that can provide the infrastructure and 
        expertise in information technology, contracting and care 
        management.

    The purpose of this document is to organize the experiences, 
requirements, capacities, and issues that could impact the successful 
use of community health centers in serving the primary care needs of 
our veterans.
           Community Health Centers as Vehicles For Increased
                  Access to Primary Care for Veterans
Background of the CBOC--VA Staffed vs. Contracted

    From 1995 to 1998, the Department of Veterans Affairs approved more 
than 230 Community-Based Outpatient Clinics (CBOCs). By the end of FY 
98, there were 139 CBOCs providing health care to veterans with the 
number of CBOCs per Veterans Integrated Service Network (VISN) ranging 
from one to 16.
    The predominate staffing model for these early CBOCs was based on 
the use of VA employees who practiced in VA owned or leased facilities. 
During this development period, the VA also began issuing Request for 
Proposals on a competitive basis in order to contract with existing, 
community based primary care providers in private practice. Some of the 
early RFPs were actually awarded to academic medical centers that had 
concurrent contractual relationships with the regional VA Medical 
Center for graduate medical education training programs. By April 1998 
only 26 of the existing 139 CBOCs were contracted CBOCs.

Current BPHC Grantees with CBOC Contracts

    There are approximately 13 community health centers with CBOC 
agreements across the United States as of August 2004. Eleven of these 
agreements are direct agreements between the individual health center 
and the local VA Medical Center. Two of the Virginia health centers 
participate with the VA as CBOCs through a network master agreement 
with the statewide health center owned network. The use of organized 
networks as a contracting vehicle has broad applicability, especially 
in the areas of pricing, contracting, contract management, compliance, 
data collection, reporting, and quality improvement.

Description of Need and Authority--2004 CARES Report \6\
---------------------------------------------------------------------------
    \6\ Excerpted from May 2004 CARES Report, Chapter 2, pages 6-8

    As recommended by the CARES Commission, the VA completed a rigorous 
re-examination of its forecasting Model by expanding the enrollment 
base period, completing a lower bound sensitivity analysis, and making 
Model improvements. These changes resulted in several recommendations 
regarding facilities, operating costs, and access to primary care, 
specifically as it concerns the Community Based Outpatient Clinic 
program.
    [The following is excerpted from May 2004 CARES Report, Chapter 2. 
Pages 6-8.]
    Commission Recommendations: The CARES Commission made several 
recommendations for enhanced access to veterans' health care through 
Community-Based Outpatient Clinics (CBOCs). Recognizing the need to 
apply uniform criteria and consistent national standards, the 
Commission reaffirmed that final decisions regarding the establishment 
of new CBOCs should remain under the purview of the Under Secretary for 
Health and the Secretary. Under that national framework, the Commission 
made several additional recommendations about how VA should prioritize 
CBOCs.
    The Commission found that the prioritization methodology . . . 
disproportionately disadvantaged veterans living in rural areas that 
are underserved and lack appropriate access to care. They also sought 
flexibility for VISNs to relieve space deficits at parent facilities by 
adding new sites of care. Finally, the Commission recommended VA 
improve the efficiency of operations at existing sites and supply basic 
mental health services at all CBOCs.
    Secretary's Response and Implementation: The VA will continue its 
ongoing efforts to meet national standards or access to care for our 
Nation's veterans by establishing new sites of care through CBOCs. The 
Commission made several positive recommendations regarding CBOCs, and 
VA will act to ensure they are met. To that end, VA revised its 
national criteria for establishment of CBOCs to include emphasis on the 
importance of access to care for rural veterans, use of CARES travel 
guidelines to assess access to care, the availability of mental health 
services, and the flexibility for VISNs to relieve space deficits at 
crowded parent facilities by moving care to a nearby outpatient 
setting.
    These actions complement existing CBOC criteria that include a 
focus on caring for Priority 1-6 veterans, ensuring that VISNs have 
necessary funds to operate new sites, developing well conceived 
business plans before implementing new sites, ensuring new CBOCs will 
increase access to care, and other factors. Further, VA will continue 
to explore opportunities to improve management of existing CBOCs 
through more effective staffing, expanding hours of operation, and 
examining opportunities to augment services where appropriate. VA will 
proceed with development of new CBOCs through CARES and will prioritize 
clinics that meet specific criteria.

    Priority criteria include CBOCs that:

        1.  Are in markets that have large numbers of enrollees outside 
        of access guidelines and are below VA national standards for 
        primary care access;
        2.  Are in markets that are classified as rural or highly rural 
        and are below VA national standards or primary care access;
        3.  Take advantage of VA/DoD sharing opportunities;
        4.  Are associated with the realignment of a major facility; 
        and
        5.  Are required to address the workload in existing 
        overcrowded facilities.

    These priorities reflect determination to produce more equitable 
access to VA services across the country, particularly in rural and 
highly rural areas where there are often limited health care options. 
They also reflect the Department's ongoing commitment to strengthening 
sharing opportunities with the Department of Defense.
    The 156 priority CBOCs listed at the end of this response will be 
implemented by 2012 pending availability of resources and validation 
with the most current data available. This list reflects VA's 
priorities for planning based upon the most current information. As VA 
proceeds in implementing CARES and as it engages in future planning, 
the locations of these CBOCs may change, but the priorities will remain 
constant. VA will enhance access to care in underserved areas with 
large numbers of veterans outside of access guidelines and in rural and 
highly rural areas. VA also will enable overcrowded facilities to 
better serve veterans and will continue to support sharing with DoD. 
These principles will remain priorities even if management strategies 
to meet them evolve as new data and information becomes available. 
Recognizing that resources are not available to open all of these 
clinics immediately, VA will manage implementation of CBOCs by applying 
the revised CBOC criteria within the existing National CBOC Approval 
Process.
    These priorities reflect determination to produce more equitable 
access to VA services across the country, particularly in rural and 
highly rural areas where there are often limited health care options, 
ensure a careful and considered implementation that mandates VISNs 
develop sound business plans, ensures national criteria are met, and 
that resources are available to provide the quality of care veterans 
expect from the Department. Resource requirements that must be in place 
to open new CBOCs include the capacity to manage specialty referrals 
and inpatient needs of new populations.
    These priorities do not prohibit VISNs from pursuing other CBOC 
opportunities identified in the DNCP. VISNs will be able to propose any 
CBOC in the DNCP for activation; however, they must be able to 
demonstrate their ability to open priority clinics on schedule before 
they can open a clinic that is outside of the priority criteria. VISNs 
will immediately begin preparation of proposals for development of 
CBOCs for this year.
    [End of excerpt.]

Testimony--Veterans Affairs Under Secretary for Health

    In his testimony before the Subcommittee on Health, House Committee 
on Veterans Affairs on June 27, 2006, then VA Under Secretary of 
Health, Dr. Jonathan Perlin recognized the value of community health 
centers by acknowledging the potential for collaboration:

         ``The VA continues to look for ways to collaborate with 
        complementary Federal efforts to address the needs of health 
        care for rural veterans . . . . VA services are complemented by 
        the services of community health centers (CHCs), which are 
        local, non-profit, community-owned health care providers 
        serving low income and medically underserved communities. For 
        nearly forty years, this national network of health centers has 
        provided primary care and preventive services to communities in 
        need. Most centers try to arrange specialty care for clients 
        with hospitals and individual health providers.

         As of January 2006, more than 1,000 CHCs provide health care 
        to community, migrant and homeless veterans and operate in more 
        than 3,600 communities in every state and territory. Over 
        37,000 health care professionals work in areas designated as 
        underserved or experiencing acute provider shortages. Three 
        hundred sixty-one (361) CHCs are located greater than sixty 
        minutes away from a VHA access point and are providing care to 
        rural veterans.

         As VA continues to look for ways to enhance access to health 
        care for rural veterans, targeted partnerships with CHCs to 
        meet specific, locally defined, health care needs in rural 
        locations may provide an additional service delivery option to 
        the array of practices already deployed by VA medical 
        facilities. VHA will consider current policies and next steps 
        that would assist VISNs and facilities to explore this 
        option.''

Basis for Collaboration

    Community health centers are uniquely positioned to meet the needs 
of the Veterans Administration in providing increased access to primary 
care for its Veterans.

         Current Collaboration between the Department of Health and 
        Human Services (HHS) and Department of Veterans Affairs--On 
        February 25, 2003, the Department of Health and Human Services 
        and the Department of Veterans Affairs entered into a 
        Memorandum of Understanding (MOU) to encourage cooperation and 
        resource sharing between the Indian Health Service (IHS) and 
        Veterans Health Administration (VHA). Five mutual goals were 
        established in the MOU (www.vha.ihs.gov). There are current 
        successful examples of increased access to health care under 
        this MOU.

         Available Inventory of Community Health Centers--The current 
        inventory of community health center grantees within those 
        programs supported by the Bureau of Primary Health Care are 
        operating in all 156 priority locations identified in the CARES 
        Report for CBOC activation. Activation of these 156 CBOCs would 
        increase access to primary care for eligible Veterans to the 80 
        percent level targeted by the Veterans Administration. 
        Activation of additional CBOCs within BPHC grantee operations 
        has the potential to exceed the 80 percent target levels for 
        primary care access.

         Compliance with VA Quality Standards--Community health centers 
        are committed to becoming accredited by the Joint Commission 
        and are supported by the Bureau of Primary Health Care in 
        achieving this accreditation. This accreditation standard is 
        consistent with the Veteran Administration Medical Centers' 
        accreditation efforts.

         Commitment to Information Technology--Community health centers 
        are increasing their focus and capacity to acquire electronic 
        health records, integrate disease registries, implement 
        telemedicine solutions, and improve the overall quality of care 
        provided to its patients through measurable outcomes. This 
        growing commitment to information technology is being fueled by 
        several factors including the successful acquisition, 
        implementation and support of health information technology 
        within a health center controlled network.

         Experience as a Contracted CBOC--Although somewhat limited in 
        number, there are specific, successful examples of existing 
        community health centers acting as a CBOC through the 
        competitive awarding of a CBOC contract. These contracts have 
        been awarded to either individual health centers or to a health 
        center controlled network. These community health center based 
        CBOCs can provide real time information on the experiences in 
        serving veterans in a CBOC model, financing, utilization of 
        services, use of the VA's version of an electronic health 
        record (CPRS), and overall contract compliance.

         Veteran's Administration Commitment to Collaboration--The 
        CARES Report clearly states the VA's commitment to collaborate 
        with the Department of Defense in meeting the goals of the 
        Report. This model is based on the assumption that the VA would 
        extend their willingness to collaborate with community health 
        centers as described in Dr. Perlin's testimony previously 
        discussed, as well as allow for a similar collaboration as 
        described in its MOU with the Indian Health Service.

Benefits to the Veterans Administration

        1.  Readily accessible facilities and staffing for the 
        activation of planned CBOCs.
        2.  Simplified contracting processes which could decrease the 
        activation costs of new CBOCs.
        3.  Improved patient care for veterans through existing 
        community health center disease management programs and other 
        enabling services.
        4.  Improved veteran patient satisfaction through the increased 
        accessibility of primary care.
        5.  Improved veteran patient satisfaction through the ability 
        of community health center CBOCs to serve not only the veteran, 
        but the veteran's family members for primary care regardless of 
        their ability to pay for services.
        6.  Improved veteran patient satisfaction with the provision of 
        culturally sensitive health care services.
        7.  Decreased reliance on VA resources for support of 
        information technology interfacing between community health 
        centers and the CPRS system.

Benefits to the Community Health Centers

        1.  Increased patient base with an accompanying revenue source.
        2.  Improved provider satisfaction with the increased 
        professional educational opportunities available to VA medical 
        staff.
        3.  Contracting, disease management, information technology and 
        financial management activities do not have to be developed and 
        managed with new community health center resources, if these 
        activities are housed within an existing health center network 
        organization.
        4.  Improved standing in the community via increased 
        interaction with veteran organizations such as VFW, AMVETS, 
        etc.

Considerations for a Health Center--Department of Veterans Affairs CBOC 
        Model

    THE MODEL--The proposed ``model'' advocates for a high level of 
formalized collaboration between the Department of Health and Human 
Services and the Department of Veterans Affairs allowing community 
health centers to be considered the ``primary option'' for locating and 
activating a CBOC according to the requirements set forth by the 
Veterans Administration. This collaboration would include an agreed 
upon process to allow ``qualified and ready'' BPHC grantee community 
health centers \7\ to be designated as CBOCs and provide those Scope of 
Services currently required by the Department of Veterans Affairs. 
Community health centers would have to meet all operating requirements 
of the CBOC program and be held to the same performance standards as 
existing contracted CBOCs.
---------------------------------------------------------------------------
    \7\ The reference throughout this paper to community health centers 
is based on current experience and does not imply that other federal 
grantee organizations could not serve as a CBOC site.
---------------------------------------------------------------------------
    There are numerous issues that would need to be addressed in order 
to successfully implement a community health center/Department of 
Veterans Affairs CBOC collaboration. Many of these issues concerning 
existing Federal contracting laws, acquisition rules, intergovernmental 
agency cooperation, Federal budgets, etc. are outside the scope of this 
document.
    These issues notwithstanding, the following considerations could be 
explored based on current community health center CBOC experiences:

          Currently, CBOC RFPs and contracts are developed, 
        issued, and awarded at the individual VA Medical Center or VISN 
        level. The RFP system is fragmented and is based on individual 
        VA Medical Center/VISN schedules and budgets. They are governed 
        by a competitive bidding process. Consideration: Create a 
        collaborative contract environment that provides BPHC grantees 
        first right of refusal for announced CBOCs. Only those 
        community health centers that are deemed ``ready'' may 
        participate in the contracting process (see below).
          Contracts for CBOCs between VISNs may vary in Scope 
        of Services, and other terms and conditions of an agreement. 
        Consideration: A national community health center CBOC RFP 
        could be developed that would minimize the variability in 
        contract documents and decrease the cost of contracting.
          There are varying degrees of willingness within the 
        VA system to accommodate an outside organization's ability to 
        interface with the CPRS system. Consideration: A Memorandum of 
        Agreement could be developed between HHS and Department of 
        Veterans Affairs that lays the groundwork for ongoing 
        cooperation in the area of information technology, or the CBOC 
        program in general, similar to that of the IHS.
          Community health centers may be willing to become a 
        CBOC and become excited about the opportunity without a 
        realistic assessment of their capacity to serve veterans. 
        Consideration: A standard readiness assessment could be 
        developed and conducted at community health centers in order to 
        properly prepare to accommodate veterans. This may require 
        technical assistance resources.
          Community health centers may not have the 
        sophistication required to properly analyze the requirements of 
        a CBOC RFP including the scope of services, financial 
        management, contract compliance, etc. Consideration: Technical 
        assistance resources could be identified by the BPHC or NACHC 
        to serve interested community health centers in support of 
        these contracting and financial requirements in order to ensure 
        success.
          Mental health in the primary care setting is an 
        important issue for both the VA and community health centers. 
        Often times, there is an expectation for CBOCs to provide 
        mental health services, although the actual Scope of Services 
        re: mental health varies from filling out an assessment form to 
        actual staffing requirements. In some instances, however, the 
        VA has mental health resources that they are willing to provide 
        in a CBOC facility to serve its veterans even though that 
        facility is a contracted CBOC for primary care. Consideration: 
        In those contracted CBOC locations where the VA has a mental 
        health resource available to see veterans, explore a ``reverse 
        contract'' whereby the community health center can use that VA 
        mental health resource for all of the patients being seen at 
        the community health center. Adjust the contractual 
        reimbursements accordingly.
          The May 2004 CARES Report makes no reference to any 
        alternative methodology for implementing CBOCs. The Report 
        relies on existing VA policies and procedures for activating a 
        CBOC and only references collaboration with the Department of 
        Defense on a limited basis, mostly for facilities changes. 
        Consideration: Offer an Addendum to the CARES Report that is 
        based on a broader view of collaboration with other Federal 
        agencies that share a common purpose i.e. the BPHC's mission of 
        increasing access to primary care.

Conclusion

    The purpose of this paper was to make an initial attempt at 
identifying the potential for increasing access to primary care for 
veterans through the use of community health center contracted CBOCs. 
It is not meant to be an all-inclusive discussion of the issues nor an 
attempt to limit the collaborative opportunities to one group of 
federally supported grantees.

Contact Information

    Chief Executive Officer
    Community Care Network of Virginia
    6802 Paragon Place, Suite 630
    Richmond, Virginia 23230

                                 
                  Prepared Statement of Kevin Trexler,
                 Division Vice President, DaVita, Inc.
    Mr. Chairman and distinguished Members of the Subcommittee, I am 
grateful for the opportunity to provide testimony on behalf of DaVita. 
I am Kevin Trexler, Division VP of DaVita. I manage more than 80 
dialysis clinics in Virginia, DC, and Maryland. My career path has also 
included six years as a deployed Navy-trained advanced degreed nuclear 
Submariner, working closely with various military and other 
intelligence agencies.
    DaVita is a leading provider of dialysis services in the United 
States. We treat more than 117,000 patients each week in more than 
1,500 centers, which represents nearly one-third of patients with End 
Stage Renal Disease--or ESRD--in the United States. We are also a 
recognized leader in achieving excellent clinical outcomes, 
consistently demonstrating outcomes that are among the best when 
compared to national averages. We have a proven track record of success 
in providing the best possible patient care through our innovative 
approach to collaborating with our many partners. At DaVita we also 
recognize the value in supporting the concept of community and 
especially those who serve and have served in the military. DaVita 
employs over 800 Veterans, as well as many active duty, guard and 
reserve troops. We have a long tradition of honoring those teammates at 
DaVita who have served, and are serving, as well as their families at 
our annual nationwide meeting.
    DaVita is privileged to care for more than 2,000 of our nation's 
Veterans in our dialysis clinics across the country. Because VA's own 
network of dialysis facilities is not sufficient in capacity or 
geographic scope to care for many thousands of the Veterans with ESRD, 
we and other dialysis providers deliver dialysis treatments in 
Veterans' communities when VA cannot provide reasonable access or lacks 
the in-house capability to provide this life-saving treatment. More 
than 20 percent of those Veterans in rural Virginia have no alternative 
treatment options within 20 miles. We consider ourselves a partner of 
VA and are committed to providing excellent quality, exceptional 
clinical performance, and outstanding customer service to all these 
Veterans whom we serve.
    Our testimony today addresses the Subcommittee's interest in 
understanding the quality of and access to dialysis care provided to 
Veterans in rural and underserved areas.
    Veterans receiving dialysis treatment are frail patients often with 
multiple illnesses. They cannot survive without dialysis or kidney 
transplants. Thus, patient access to care is critical. Patients receive 
three treatments per week, every week of the year, each one requiring 
four hours of staff-assisted care. Moreover, the treatment requires a 
highly skilled workforce including a dietitian, a social worker, and 
other ancillary service providers, as well as the use of high tech 
medical equipment and supplies. Dialysis treatments are dependent on 
high-cost pharmaceuticals--including one key drug that is still under 
patent and has no generic, less expensive alternatives. Both the 
provision of the treatments and the financial aspects of dialysis 
treatments are unique.
    Veterans with ESRD who live in rural or underserved areas often 
have no other treatment options within many miles. Any disruption to a 
Veteran's reasonable accessibility of a dialysis center will lead to 
longer travel times for their dialysis treatments, which, in turn, can 
have a significant impact on health outcomes. A study published in the 
April 2008 American Journal of Kidney Diseases found that patients 
traveling more than 60 minutes each way for dialysis treatments had 
significantly higher mortality levels and a lower health care quality 
of life.
    Like many rural health care providers, DaVita's ability to receive 
sustainable reimbursement is critical to ensuring that access to care 
is preserved. The economics of the dialysis industry are very fragile, 
particularly in facilities that serve rural areas. The average rural 
dialysis clinic operates at a loss. Nearly 90 percent of patients are 
Medicare or Medicaid beneficiaries, and these reimbursements are 
insufficient to cover the cost of the treatments. Given the 
insufficiency of Medicare reimbursement, the dialysis industry relies 
on a unique ``social contract'' in which other payors subsidize the 
Medicare rates to ensure adequate access to care for all patients.
    Here in Virginia, we provide care to Veterans through VA-
established negotiated contracts. During the last 10 months, VA has 
awarded negotiated contracts with a number of dialysis providers 
throughout the country, covering most areas in which Veterans are 
authorized to receive Purchased dialysis care treatments. These 
contracts, if maintained, will continue to provide mutually agreed-
upon, sustainable reimbursement. The VA, and not providers, will 
ultimately decide if these contracts continue for the complete five-
year duration. The VA has not assured providers that these contracted 
rates will remain in effect, which results in the industry concern 
about VA's commitment to maintain existing contracts.
    DaVita recognizes and supports VA's goal to standardize 
reimbursement for the purchase of non-VA provided health care services 
and to reduce its costs in a way that would not threaten veterans' 
access to care. DaVita believes that there is a way to achieve cost 
savings and standardization of payments, while concurrently improving 
the health status of Veterans with ESRD who are authorized by VA to 
receive their dialysis and kidney-related care in the community. Since 
last fall we have proposed to VA that they implement a patient-
centered, integrated care management dialysis program for these 
extremely sick Veterans. The result would be:

          avoidance of rural clinic closures,
          improvement in the health status of Veteran dialysis 
        patients, and
          the creation of a patient-centered approach for 
        managing the health of Veterans with kidney disease.

    It is important to consider that dialysis is only about a third of 
the total cost of care for these extremely sick Veterans; the majority 
of costs come from avoidable ER visits and hospital stays, and other 
costs due to infections and missed treatments. An integrated care 
management program would focus on key interventions, such as the 
placement of fistulas for dialysis access, which have proven to reduce 
the instances of hospitalizations for patients. This not only results 
in improved health and quality of life for Veterans, but would also 
reduce VA's overall Purchased Care costs for these patients.
    In its recently released Broad Agency Announcement, the VA included 
a request for industry to submit proposals related to the VA Innovation 
Initiative. VA is seeking solutions from the health care industry that 
would improve the provision of dialysis care in community clinics and 
in Veterans' homes. We are delighted that VA has reached out to the 
kidney care provider community and will submit our proposal for 
consideration before the end of the month. Because DaVita understands 
that investments in prevention and coordination of care leads to 
improved outcomes and lower total costs, our proposed coordinated care 
program promotes patient-centered care for veterans with ESRD who have 
been authorized to receive Purchased Care. This integrated care 
management program will combine lab, pharmacy and medication therapy 
management, vascular access care, vaccinations, case management and 
access to diet and nutrition counselors and nephrologists. The program 
will promote utilization of and coordination with VA services where 
possible, and will collect and provide clinical data to VA through 
Electronic Medical Record technology when possible or in another format 
if VA prefers. VA currently does not receive clinical data from 
providers in the Purchased Care Program.
    In addition, DaVita has expertise in providing and remotely 
monitoring dialysis care and treatments in patients' homes that would 
be of particular benefit to patients in rural areas. For instance, in-
home biometric monitoring will allow us to monitor a patient's key 
health data in a remote setting. If an abnormal value is recorded an 
alert will be sent to one of our nurses who can either call or video 
conference with the patient to determine what medical actions are 
needed. This allows us to get real-time data without sending a nurse to 
the house. This system will also allow us to provide educational 
materials and reminders--including medication reminders, appointment 
reminders, etc--to the patient and care givers.
    We also have the ability to take advantage of mail order or in-
center delivery of medications so patients do not have to make extra 
trips to the VA or local pharmacy.
    An integrated approach would be beneficial in many ways. Patients 
in similar programs, such as ongoing Medicare pilots, have experienced 
increased quality of life, greater satisfaction with the care they 
receive, and higher levels of engagement in their own care. In 
addition, they have benefited from preventive care measures such as 
immunization, lower rates of infection, greater compliance with 
medication therapy regimens, and lower hospitalization rates. VA is 
known for its progressive approach to health care delivery, and the 
Department can maintain this same approach with dialysis care for 
Veterans in the Purchased Care Program by implementing an integrated 
care management initiative that benefits both patients and taxpayers. 
As you may know, VA is moving to a patient-centered medical home 
approach for all VA facilities. This would be the first step in the 
Purchased Care Program to mirror what VA intends to accomplish within 
VA facilities in the next two years.
    On behalf of DaVita, I would like to thank you for your interest in 
the care that we provide to Veterans and for your commitment to 
ensuring that Veterans in rural areas continue to receive the quality 
of and access to the care they have earned. We are grateful to the 
Subcommittee for your leadership in seeking new ways to promote quality 
care for all Veterans and especially the unique population of Veterans 
with kidney disease whom we serve.
    I would be happy to answer any questions you may have.

                                 
               Prepared Statement of Michael F. Mitirone,
           Commander, Department of Virginia, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to submit The American Legion's 
views on this pressing issue concerning the quality of health care 
provided to veterans in rural areas and in particular those in rural 
Virginia.
    The American Legion, a long time advocate for America's veterans 
and their families, has noted the change in demographics of veterans 
and also the recent trend of veterans moving to rural and extremely 
rural areas of this nation. Even with that conscious decision, these 
veterans have earned the right to receive access to ``The Best Care 
Anywhere.'' The Veterans' Health Administration (VHA) has endeavored to 
provide the required patient services, particularly gender-specific 
services, regardless of location, but there is still much to be done. 
The American Legion has passed a national resolution supporting 
enhancements to VHA's Rural Health Care programs to ensure veterans 
receive the timely and quality health care they have earned, regardless 
of where the veteran chooses to live.
    The American Legion's primary health care evaluation tool is a 
program called ``A System Worth Saving.'' This Task Force, first 
established in 2003, annually conducts site visits at VA Medical 
Centers nationwide to assess the quality and timeliness of VA health 
care. In preparing for these visits, The American Legion team 
researches General Accountability Office (GAO) reports, VA's Office of 
Inspector General (VAOIG) reports, and news articles relating to 
potential breakdowns in a system that we consider, ``The Best Care 
Anywhere.'' This task force, we believe, is valuable on a national 
level to identify trends and improvements made in the VA Health Care 
System, as well as identify local issues and areas for improvements.
    During the 2010 ``System Worth Saving'' Task Force visits to 32 VA 
Medical Centers across the country, a commonly repeated theme regarding 
rural areas was the shortage and turnover of personnel, especially 
nurses and personnel with specialty training. One of the reasons 
reported during Task Force visits for turnover and shortage is a lack 
of competitive compensation.
    Of the 23.4 million veterans in this country, nearly eight million 
veterans are enrolled in the VA Health care system, of which 
approximately three million are from rural areas. Rural veterans 
comprise about 40 percent of all enrolled veterans, or one of out of 
every three enrolled veterans. For many of the three million veterans 
living in rural areas, access to health care remains problematic, as 
they simply live too far away from the nearest VA Medical Center or 
Community Based Outpatient Clinic (CBOC). VA defines urban, rural and 
highly rural veterans with the following definitions: urban: any 
enrollee located in a census area defined as urbanized; rural: 
enrollees not designated as urban; highly rural: those enrollees 
defined as rural and reside in counties with less than seven 
individuals per square mile. Only two-thirds of rural and highly rural 
veterans enrolled in the health care system received VA medical 
services in FY 2008. Unfortunately, for many this means that rural 
veterans cannot see a doctor or a health care worker to receive the 
care that they need due to their geographical limitations. Given these 
barriers, it is no surprise that our rural veterans have poorer health 
outcomes compared to the general population.
    In VHA's Office of Rural Health Strategic Plan for 2010-2014, VA's 
strategic goals are to: improve rural access and quality of care, 
enhance technologies, improve research studies and analyses, improve 
education and training, improve collaboration of service options and 
recruiting and retaining medical professionals. VA provides care to 
more than 5.5 million veterans each year at over 1,100 locations, 
including inpatient hospitals and CBOCs. Demographic shifts and changes 
in where veterans live call for continued realignment of the delivery 
system with the needs of all veterans enrolled in mind. One of the 
continued challenges for VA is determining the locations to build a 
major medical center or where it is more feasible to construction 
CBOCs, contract services, or telehealth programs.
    Men and women from geographically rural and highly rural areas make 
up a disproportionate share of servicemembers and comprise about one-
third (31.9) of the enrolled Veterans who served in Operation Enduring 
Freedom and Operation Iraqi Freedom (OEF/OIF); many of these 
servicemembers are returning to their rural communities. This is due to 
the high number of Reserve Component servicemembers who deploy from and 
return to their hometowns. This trend of veterans returning to rural 
communities will continue and VA must ensure that it is prepared to 
meet the increased demand for rural health care services.
    The VA relies heavily on the CBOCs to serve the rural veteran 
populations. For example, the Marion VA Medical Center in Illinois has 
seven CBOCs located in Illinois, Indiana, and Kentucky that provide 
services to veterans in 52 counties in three states. Currently there 
are 42,000 veterans enrolled in rural CBOCs. The challenge of rural 
health care is a national issue. According to the National Rural Health 
Association (NRHA), many of the issues are a result of population size, 
age structure, health risk factors, economic development, ethnic 
composition, technology, and mix of health care providers, all 
impacting the health care needs of rural veterans and how they access 
health care services.
    The American Legion conducted a site visit at the Salem VA Medical 
Center in Salem, VA in FY 2004, and at that time patients traveled an 
average of 80 miles and waited 30 minutes for specialty care. In FY 
2009, there were 23,169 unique users veterans in the Salem VA Medical 
Center catchment area with 33,094 enrolled. The rural area of Bedford 
is approximately 30 miles from the nearest CBOC and 80 miles away from 
the Salem VA Medical Center. Bedford, Virginia has 1,524 veterans 
enrolled with only 770 users. There is currently one veteran in 
Bedford, VA that is enrolled in the Home Based Primary Care program and 
eight veterans that reside in Bedford, VA enrolled in the Care 
Coordination Home Telehealth program. The most common fee basis service 
for veterans living in the rural areas of Virginia is physical therapy 
and neurosurgery. There is an assigned Rural Health Team that provides 
outreach and patient education to veterans.
    Another example of the difficulty to service rural and highly rural 
veterans is the Sheridan VA Medical Center in Wyoming and whose closest 
CBOC is 9 hours away. Some of the issues at this and other VAMCs are 
that when the roads are affected by rain or snow, the VA Medical 
Center's Volunteer Transportation Network vans are unable to go pick up 
veterans for their appointments. In some cases, travel times are nearly 
20 hours each way to pick up a veteran and the veteran and volunteer 
driver must sleep in a homeless shelter each way on the trip. Also, 
many veterans who live in rural areas of the United States do not wish 
to make the long and tedious drive to the VAMC, even if a volunteer 
driver is willing to take them. Some veterans have gone over 30 years 
without seeing their primary care provider, but decide to see a doctor 
when it is usually too late, such as when cancer or other serious 
medical conditions worsen.
    At some VA facilities unique approaches are being developed for 
assisting veterans and their caregivers. At the Iron Mountain Veteran 
Affairs Medical Center in Michigan, management reported that they do 
not have an adult day center because of the rural density. The VA is 
developing a voucher program so family and friends are able to receive 
payment and training to take care of their veterans. This will allow 
the veteran to be able to stay out of the VAMC and get the best care 
possible.
    The American Legion applauded Congress and the Administration's 
passage of the Caregivers and Veterans Omnibus Health Services Act this 
year. One of the provisions in the law is to increase housing and 
transportation assistance for veterans living in rural communities. In 
addition, under VA's current mental health strategic plan mental health 
services have been expanded to primary care settings in VAMCs and 
CBOCs, something The American Legion has called for. The American 
Legion continues to urge VA to improve access to quality primary and 
specialty health care services using all available means at their 
disposal for veterans living in rural and highly rural areas. Veterans 
should not be penalized or forced to travel long distances to access 
quality health care because of where they choose to live.
    Mr. Chairman, while VA is making continued improvements to the 
access and delivery of health care to rural veterans, more still needs 
to be done. We commend the committee for holding this field hearing in 
our community to witness firsthand some of the challenges we and other 
rural veterans continue to face across America today.
    Mr. Chairman and Members of the Committee that concludes my 
testimony.

                                 
          Prepared Statement of Daniel Boyer, Post Commander,
         Grayson Post 7726, VFW Past State Commander, Veterans
                  of Foreign Wars of the United States
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
    It is my honor to be here today to represent members of the 
Veterans of Foreign Wars of the United States here in Bedford and 
around our wonderful state of Virginia.
    I come before you with profound gratitude for what the VA is 
striving to achieve on behalf of our veterans. No agency or department 
is perfect, and yet I know that with the support of the Congress and 
this committee, the VA is making strides forward and is working 
diligently to care for all generations of veterans.
    With these thoughts in mind I would like to address the rural 
health care challenges we are facing here in southwest Virginia.
    Access to VA services in rural areas is always a primary concern, 
and that is no different in our region. From my hometown of Galax, VA, 
we have the Salem VA hospital that is approximately 100 miles to the 
north. Also located in our region is the Johnson City, Tennessee, VA 
hospital that is approximately 125 miles to the West. Either of these 
can be quite a journey, particularly when a veteran has two non-
contiguous appointments. It can be a frustrating process for a veteran 
to travel long distances for multiple appointments spread throughout 
the day. We are very thankful for our Community-Based Outpatient Clinic 
(CBOC) in Hillsville, and we believe that the addition of a second CBOC 
in Marion, although limited to three days a week, will provide even 
greater assistance. There is clearly a need for the VA to open more 
clinics in rural areas, and the onus is on VA to find solutions for our 
veterans whether it be through additional private contracting, private-
public partnerships, collaboration at multiple levels of government, or 
other creative means to make sure veterans are getting the care they 
deserve.
    Another area that will potentially improve access to care is 
Telehealth. The VFW believes this is a major opportunity to improve 
health care outcomes, particularly in rural communities. Though there 
are privacy issues and technological limitations that must be 
addressed, they should not delay any expansion of telehealth services. 
The House Veterans' Affairs Subcommittee on Health recently held a 
hearing that spent considerable time discussing rural broadband and 
wireless expansion, and we encourage the committee to continue 
expanding the body of evidence that clearly supports a robust 
telecommunications infrastructure in our rural communities.
    We are also concerned that many cases of Traumatic Brain Injury 
(TBI) are not being properly diagnosed. We are obviously playing catch-
up in our understanding of TBI, and access to medical professionals who 
can properly diagnose TBI is a problem nation-wide. As you might 
imagine, veterans living in rural communities are especially vulnerable 
to misdiagnoses and ill-suited treatment, and the VA needs to make sure 
a sufficient network of doctors is in place to take what we are 
learning and put it to use in these communities. Moreover, post-
diagnosis treatment can be time-consuming and can hinder efforts to 
treat rural veterans suffering with TBI. This is a serious issue that 
the VA and this committee need to tackle head on.
    Closely tied to TBI is our concern with proper diagnosis and 
treatment of mental health conditions. We applaud VA for raising 
awareness on mental health issues and for working to reduce the stigma 
attached to seeking mental health treatment. We urge the Congress 
provide continuous oversight of VA mental health programs to ensure the 
need for counseling and other types of treatment is being met here and 
in all the rural areas of the country. At the Salem, VA, facility alone 
nearly 2,500 veterans have received diagnoses that may be caused by 
PTSD. One concrete step that could be taken to ensure all veterans who 
struggle with mental health conditions receive timely and professional 
care is to staff our rural CBOCs to provide inpatient mental health 
counseling and other specialty services.
    Specifically, strong outreach and education programs will be 
necessary to help eliminate the stigma of mental illness and other 
barriers that dissuade many from seeking care. We also need meaningful 
post-deployment health assessments that will incentivize servicemen and 
women to provide honest responses so that can receive appropriate kinds 
of care and secure benefits they have earned. Routine examinations 
should include mental health assessments. VA staff should be fully 
competent to identify warning signs, should be aware of all available 
programs, and should fully utilize them.
    Suicide among our veterans is a national priority and it is 
certainly a rural issue as well. Veterans who live in rural communities 
often have limited health care access. Having the resources needed to 
combat the isolation is critical. The VA's suicide hotline is an 
effective tool for those who call, but we should work to ensure every 
veteran who is at the end of their rope knows there is a helping hand. 
Again, it comes back to outreach. These programs must be visible in the 
everyday lives of veterans. We know this is especially challenging in 
highly rural areas and we hope the VA will redouble their efforts with 
regard to rural outreach--not only for the suicide prevention hotline, 
but for all their programs.
    One way the VA is reaching out to address these and other issues is 
through the Mobile Vet Centers (MVCs) that are literally going to where 
our rural vets live and work, ensuring access to services are provided 
where it is needed. However, it is with some dismay that I tell you I 
have not seen one or heard of one being in our community. With that in 
mind, the VFW hopes that the VA is devoting proper time and attention 
to evaluating the success of the MVCs and considering adding additional 
resources if there is a demand for more Mobile Vet Centers.
    In rural areas, simple word of mouth is still one of the primary 
ways information is distributed and the VA should not overlook hometown 
newspapers, local VSO chapters, and other means tailored to our older 
veterans. Though they should employ e-mail alerts, social media, and 
other electronic means to reach out, they should not expect this to 
reach every generation of veteran. We want to be a resource for the VA 
to reach rural veterans, and the potential to boost outreach by using 
VFW posts and those of other Veteran Service Organizations cannot be 
overstated. Another helpful opportunity for collaboration would be to 
use local VFW posts to conduct local screenings and wellness events. 
Just because a Mobile Vet Center is not available that shouldn't mean 
the VA can't send a doctor or other medical professionals to a rural 
area. Speaking on behalf of the VFW here in Virginia, if the VA sends 
us a doctor, we can supply the patients and the physical space needed 
to screen for mental illnesses and TBI along with other physical 
conditions such as glaucoma, hearing, diabetes, and other illnesses. 
Such opportunities would provide a platform for further collaboration 
and would be a positive contact with rural communities where there is 
no VA presence. Everyone benefits when mutually interested parties work 
together, and we hope that the VA would take seriously the many 
benefits of increased cooperation with the VSO community.
    The Independent Budget said it best when it stated that `health 
workforce shortages and recruitment and retention of health-care 
personnel are a key challenge to rural veterans' access to VA care and 
to the quality of that care'. The VA must aggressively train future 
clinicians to meet the unique challenges rural veterans face. The VA 
already has existing partnerships with over a hundred schools of 
medicine in the United States. To not apply them, and expand upon them 
if needed, would essentially squander this vast resource. We cannot 
allow that to happen.
    The VFW is also concerned that the men and women who serve in our 
Guard and Reserve are not fully utilizing the VA benefits that they 
have earned. Demobilizing members of the Reserve Component are often so 
preoccupied with thoughts of family and home that they fail even to 
mention existing health conditions, not to mention ones that will 
certainly develop down the road as a result of their service. Local VFW 
Posts often fund and facilitate going away and coming home parties for 
Guard and Reserve units. We have successfully used these events to 
boost morale and to offer assistance with their VA paperwork through 
the Virginia Department of Veterans Service, and will continue to 
support our returning warriors through these events and other outreach 
efforts.
    Finally, I would like to bring attention to the successes of our 
Virginia Wounded Warrior Program. Rural veterans are a primary target 
population of the Virginia Wounded Warrior Program. I hear and know 
very positive things about the program. We hope that the VA will 
continue to look at this hallmark state program and redouble their 
efforts to work with all layers of government--local, state, and other 
federal entities--to provide an integrated, total solution for not just 
our wounded warriors, but for all who have served, and their families.
    Mr. Chairman, I again thank you for the honor to present our 
priorities to you. I would be happy to answer any questions that you or 
the members of the Committee may have.
                                 
            Prepared Statement of Clarence Woods, Commander,
           Department of Virginia, Disabled American Veterans
    Mr. Chairman, Ranking Member Brown and Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) 
Department of Virginia to testify at this oversight hearing of the 
Committee focused on the Department of Veterans Affairs (VA) and the 
health care needs of rural veterans in the Commonwealth of Virginia. As 
an organization of 1.2 million service-disabled veterans, rural health 
is an extremely important topic for DAV, and we value the opportunity 
to discuss our views. Also, as requested by Mr. Perriello, a Member of 
this Subcommittee, we are incorporating in this statement the 
particular concerns of our Department of Virginia (following on page 6 
of this statement).
    As a partner organization in the Independent Budget (IB) for Fiscal 
Year (FY) 2010, DAV believes that after serving their nation in 
uniform, veterans should not experience neglect of their health care 
needs by VA simply because they live in rural or remote areas far from 
major VA health care facilities. The delegates to our most recent 
National Convention, held in Denver, Colorado, August 22-25, 2009, 
again passed a longstanding resolution on improving health care for 
veterans living in rural or remote areas.
    In the IB, we have detailed pertinent findings dealing with rural 
health care, disparities in health care, rural veterans in general, and 
the circumstances of newly returning rural servicemembers from 
Operations Enduring and Iraqi Freedom (OEF/OIF). Unfortunately those 
conditions remain relatively unchanged:

          Rural Americans face a unique combination of factors 
        that create disparities in health care not found in urban 
        areas. Only 10 percent of physicians practice in rural areas, 
        despite the fact that one-fourth of the U.S. population lives 
        in these areas. State offices of rural health identify access 
        to mental health care and concerns for stress, depression, 
        suicide, and anxiety disorders as major rural health 
        concerns.\1\
---------------------------------------------------------------------------
    \1\ L. Gamm, L. Hutchison, et al., eds. Rural Healthy People 2010: 
A Companion Document to Healthy People 2010, vol. 2, College Station, 
Texas: Texas A&M University System Health Science Center, School of 
Rural Public Health, Southwest Rural Health Research Center, 2003. 
www.mentalhealthcommission.gov/reports/FinalReport/downloads/
downloads.html
---------------------------------------------------------------------------
          Inadequate access to care, limited availability of 
        skilled care providers, and stigma in seeking mental health 
        care are particularly pronounced among residents of rural 
        areas.\2\ The smaller, poorer, and more isolated a rural 
        community is, the more difficult it is to ensure the 
        availability of high quality health services.\3\
---------------------------------------------------------------------------
    \2\ President's New Freedom Commission on Mental Health, Achieving 
the Promise: Transforming Mental Health Care in America, July 2003
    \3\ Institute of Medicine, NIH, Committee on the Future of Rural 
Health Care, Quality through Collaboration: The Future of Rural Health, 
The National Academies Press, 2005.
---------------------------------------------------------------------------
          Nearly 22 percent of our elderly live in rural areas; 
        rural elderly represent a larger proportion of the rural 
        population than the urban population. As the elderly population 
        grows, so do the demands on the acute care and long-term-care 
        systems. In rural areas, some 7.3 million people need long-
        term-care services, accounting for one in five of those who 
        need long-term care.\4\
---------------------------------------------------------------------------
    \4\ L. Gamm, L. Hutchison, et al., eds., Rural Healthy People 2010: 
A Companion Document to Healthy People 2010, vol. 3, College Station, 
Texas: Texas A&M University System, Health Science Center, School of 
Rural Public Health, Southwest Rural Health Research Center, 2003.

    Given these general conditions of scarcity of resources, it is not 
surprising or unusual, with respect to those serving in the U.S. 
---------------------------------------------------------------------------
military and to veterans, that----

          There are disparities and differences in health 
        status between rural and urban veterans. According to the VA's 
        Health Services Research and Development office, comparisons 
        between rural and urban veterans show that rural veterans 
        ``have the worse physical and mental health related to quality 
        of life scores. Rural/Urban differences within some Veterans 
        Integrated Service Networks (VISNs) and U.S. Census regions are 
        substantial.''
          More than 44 percent of military recruits, and those 
        serving in Iraq and Afghanistan, come from rural areas.
          More than 44,000 servicemembers have been evacuated 
        from Iraq and Afghanistan as a result of wounds, injuries, or 
        illness, and tens of thousands have reported readjustment or 
        mental health challenges following deployment.
          Thirty-six percent of all rural veterans who turn to 
        VA for their health care, have a service-connected disability 
        for which they receive VA compensation.
          Among all VA health care users, 40.1 percent (nearly 
        2 million) reside in rural areas, including 79,500 from 
        ``highly rural'' areas as defined by VA.
     Veterans Rural Health Resource Centers are Key Proponents of 
                              Improvements
    In August 2008, VA announced the establishment of three Veterans 
Rural Health Resource Centers (VRHRCs) for the purpose of improving 
understanding of rural veterans' health issues; identifying their 
disparities in health care; formulating practices or programs to 
enhance the delivery of care; and, developing special practices and 
products for implementation VA system-wide. According to VA, the Rural 
Health Resource Centers will serve as satellite offices of ORH. The 
centers are sited in VA medical centers in White River Junction, 
Vermont; Iowa City, Iowa; and, Salt Lake City, Utah.
    The concept underlining their establishment was to support a strong 
ORH presence with field-based offices across the VA health care system. 
These offices are charged with engaging in local and regional rural 
health issues in order to develop potential solutions that could be 
applied nationally in the VA, including building partnerships and 
collaborative relationships--both of which are imperative in rural 
America. These satellite offices of ORH and their efforts, along with 
those of VISN rural health coordinators, can validate the importance of 
the work and extend the reach of ORH in Veterans Health Administration 
(VHA), to reinforce the idea that the ORH is moving VA forward using 
the direct input of the needs and capabilities of rural America, rather 
than trying to move forward alone from a Washington DC central office.
    Currently, these Centers are under temporary charters, and 
recipient of centralized funding not exceeding five years. The nature 
of that arrangement has had unintended consequences on the Centers, 
including problematic recruitment and retention of permanent staff to 
conduct their work. We have been informed that all staff appointments 
to the VRHRCs are consequently temporary or term appointments, rather 
than permanent career positions, because of reluctance on the part of 
the host VA medical centers to be placed in the position of needing to 
absorb these personnel costs when Central Office funding ends. If the 
concept of field-based rural health satellite offices is to be 
successful and sustained, the Centers need permanency of funding and 
staff.

Further Beneficiary Travel Increases are Needed

    In the FY 2009 Appropriations Act, Congress provided VA additional 
funding to increase the beneficiary travel mileage reimbursement 
allowance authorized under section 111 of title 38, United States Code, 
and intended to benefit certain service-connected and poor veterans as 
an access aid to VA health care. VA consequently announced payment of 
the higher rate, at 41.5 cents per mile. While we appreciate this 
development and applaud both Congress and the VA for raising the rate 
considerably, 41.5 cents per mile is still significantly below the 
actual cost of travel by private conveyance, and provides only limited 
relief to those who have no choice but to travel long distances by 
automobile for VA health care. This challenge is particularly acute in 
frontier states, and in rural Virginia and other States, where private 
automobile travel is a major key to health care access.

Telehealth_A Major Opportunity

    The DAV and our partners in the IB believe that the use of 
technology, including the World Wide Web, telecommunications, and 
telemetry, offer VA a great but still unfulfilled opportunity to 
improve rural veterans' access to VA care and services. We note that 
this Subcommittee held a hearing on June 24, 2010, in Washington, on 
the topic of ``overcoming rural health care barriers: use of innovative 
wireless health technology solutions.'' While DAV was not asked to 
testify at that particular hearing, we have reviewed and appreciate the 
testimonies of other witnesses, and we subscribe to the broad-based use 
of telemetry, new monitoring technologies, and the internet to help 
relieve burdens in access to VA health care being borne by veterans in 
rural and remote areas. We trust the Subcommittee will be using its 
findings from the hearing to further its oversight of VA in the use of 
telehealth and related technologies in rural America.
    The IB veterans service organizations (IBVSOs) understand that VA's 
intended strategic direction in rural care is of necessity to enhance 
noninstitutional care solutions. VA provides home-based primary care as 
well as other home-based programs, and is using telemedicine and 
telemental health--but on a rudimentary basis in our judgment--to reach 
into veterans' homes and community clinics, including Indian Health 
Service facilities and Native American tribal clinics. Much greater 
benefit would accrue to veterans in highly rural, remote and frontier 
areas if VA were to install general telehealth capability directly into 
a veteran's home or into a local non-VA medical facility that a rural 
veteran might easily access, versus the need for rural veterans to 
drive to distant VA clinics for services that could be delivered in 
their homes or local communities. This enhanced cyber-access would be 
feasible into the home via a secured Web site and inexpensive computer-
based video cameras, and into private or other public clinics via 
general telehealth equipment with a secured internet line or secure 
bridge.
    Expansion of telehealth would allow VA to directly evaluate and 
follow veterans without their needing to personally travel great 
distances to VA medical centers. VA has reported it has begun to use 
internet resources to provide limited information to veterans in their 
own homes, including up-to-date research information, access to their 
personal health records, and online ability to refill prescription 
medications. These are positive steps, but we urge VA management to 
coordinate rural technology efforts among its offices responsible for 
telehealth, rural health, and Information Technology offices at the 
Department level, in order to continue and promote these advances, but 
also to overcome privacy, policy and security barriers that prevent 
telehealth from being more available in a highly rural veteran's home, 
or into already-established private rural clinics serving as VA's 
partners in rural areas.

The ORH: A Critical Mission

    As described by VA, the mission of the ORH is to develop policies 
and identify and disseminate best practices and innovations to improve 
health care services to veterans who reside in rural areas. VA 
maintains that the office is accomplishing this by coordinating 
delivery of current services to ensure the needs of rural veterans are 
being considered. VA also attests that the ORH will conduct, 
coordinate, promote, and disseminate research on issues important to 
improving health care for rural veterans. With confirmation of these 
stated commitments and goals, the DAV concurs that the VHA would be 
beginning to incorporate the unique needs of rural veterans as new VA 
health care programs are conceived and implemented; however, the ORH is 
a relatively new function within VA Central Office (VACO), and it is 
only at the threshold of tangible effectiveness, with many challenges 
remaining. Given the lofty goals, we remain concerned about the 
organizational placement of the ORH within the VHA Office of Policy and 
Planning rather than placing it closer to the operational arm of the VA 
health care system, and closer to the decision points in VHA executive 
management. Having to traverse the multiple layers of the VHA's 
bureaucratic structure could frustrate, delay, or even cancel 
initiatives established by this staff office. We also note that, 
executive direction within the office itself has been problematic, and 
that VA has experienced chronic difficulty in recruiting a permanent 
director of the office. We have been advised that a new director of ORH 
has been retained and assumed office on July 1, 2010.
    We continue to believe that, rural veterans' interests would be 
better served if the ORH were elevated to a more appropriate management 
level in VACO, perhaps at the Deputy Under Secretary level, with staff 
augmentation commensurate with these stated goals and plans. We 
understand that recently the grade level of the Director of ORH was 
elevated to the Senior Executive Service. We appreciate that change but 
grade levels of Washington-based executives, do not necessarily 
translate to enhanced outcomes and better health for rural veterans.

Rural Health Coordination at the Grassroots

    The VHA has established VA rural care designees in all its VISNs to 
serve as points of contact and liaisons with the ORH. While DAV 
appreciates that the VHA designated the liaison positions within the 
VISNs, we remain concerned that they serve these purposes only on a 
part-time basis, along with other duties as assigned. We believe rural 
veterans' needs, particularly those of the newest generation of war 
veterans, are sufficiently crucial and challenging that they deserve 
full-time attention and tailored programs. Therefore, in consideration 
of other recommendations dealing with rural veterans' needs put forward 
in this statement as well as in the IB, we urge VA to establish at 
least one full-time rural liaison position in each VISN and more if 
appropriate, with the possible exception of VISN 3 (urban New York 
City).

Outreach Still Needs Improvement

    We note Public Law 110-329, the Consolidated Security, Disaster 
Assistance, and Continuing Appropriations Act, 2009, approved on 
September 30, 2008, included $250 million for VA to establish and 
implement a new rural health outreach and delivery initiative. Congress 
intended these funds to build upon the successes of the ORH by enabling 
VA to expand initiatives such as telemedicine and mobile clinics, and 
to open new clinics in underserved and rural areas.
    Outreach Clinics are established to extend access to primary care 
and mental health services in rural and highly rural areas where there 
is not sufficient demand or it is otherwise not feasible to establish a 
full-time Community-Based Outpatient Clinic (CBOC) by establishing a 
part-time clinic. Ten Outreach Clinics were funded in fiscal year 2008, 
and 30 in fiscal year 2009. While the potential impact would affect 
over 997,000 rural and highly rural enrollees that reside within areas 
that VA serves, only 2,250 patients were seen by the end of fiscal year 
2009.
    Without question, section 213 of Public Law 109-461 could be a 
significant element in meeting the health care needs of veterans living 
in rural areas, especially those who have served in Afghanistan and 
Iraq. Among its features, the law requires VA to conduct an extensive 
outreach program for veterans who reside in rural and remote areas. In 
that connection, VA is required to collaborate with employers, state 
agencies, community health centers, rural health clinics, Critical 
Access Hospitals (as designated by Medicare), and local units of the 
National Guard to ensure that returning veterans and Guard/Reserve 
members, after completing their deployments, can have ready access to 
the VA health care and benefits they have earned by that service. Given 
this mandate is more than three years old, DAV urges VA's recently 
created National Outreach Office in the Office of Intergovernmental 
Affairs, Office of Public and Intergovernmental Affairs to move forward 
on this outreach effort--and that outreach under this authorization be 
closely coordinated with VA's ORH to avoid duplication and to maintain 
consonance with VA's overall policy on rural health care.
    To be fully responsive to this mandate, VA should report to 
Congress the degree of its success in conducting effective outreach, 
and the result of its efforts in public-private and intergovernmental 
coordination to help rural veterans. We note VA is required to develop 
a biennial plan on outreach activities and DAV has had the opportunity 
to review the December 1, 2008, VA biennial outreach activities report 
to Congress. Clearly VA is conducting numerous outreach activities to 
veterans of all eras and has a special emphasis on veterans of OEF/OIF. 
However, we note the report lacks an overarching strategic plan as well 
as any parameters or statistical evidence to determine whether outreach 
efforts, individually or collectively, are achieving the desired 
results. Strategic planning is essential for successful business 
operations and a full understanding of the veteran population is an 
important element in providing education and outreach.

Virginia-Specific Concerns

    As requested by Mr. Perriello's office, we wanted to provide the 
Subcommittee our local and regional perspectives and concerns on rural 
health care in the Commonwealth of Virginia.
    Rural health initiatives are centrally funded by the VISN for only 
two years. Our DAV Department of Virginia is concerned that VA medical 
center directors will not support them once this protected, and 
``fenced'' funding is stopped, or that they might be tempted to ``rob 
Peter to pay Paul'' within the medical centers by utilizing funds 
needed by other VA programs and applying them to the rural initiatives. 
We believe that rural initiatives should remain centrally funded and 
not be made to compete with other medical center programs.
    Sick and disabled veterans in Virginia have been waiting patiently 
for years to see new VA CBOC being opened in our rural areas. We 
currently have two approved CBOC projects that are taking far too long. 
Each of these CBOCs is now more than a year overdue in opening. Efforts 
are not made to open new CBOCs expeditiously and projected opening 
dates are usually delayed by a bureaucratic system. Also, for those 
that are open (in Alexandria, Bristol, Charlottesville, Danville, 
Fredericksburg, Harrisonburg, Hillsville, Lynchburg, Norton, Tazewell, 
Virginia Beach, and Winchester), VA space planning needs improvement. 
In our experience, VA's planning configuration does not include making 
space available for the occasional visiting clinician but only for 
authorized permanent Full Time Employee Equivalence (FTEE.) When 
visiting clinicians come to these clinics to provide services (in 
mental health, podiatry, and other specialties), either they often have 
nowhere to see their patients, or space for them is very cramped. VA 
space planners need to do a better job of providing for itinerant 
providers within CBOC space configurations. Allowing more space than 
needed by permanent staff also provides us an opportunity to expand 
services sooner rather than having to wait additional years for clinic 
construction projects after the need is identified.
    We believe CBOCs need to provide more services on site in order to 
obviate veterans' needing to travel long distances to major VA medical 
centers for services they cannot receive in CBOCs. The DAV Department 
of Virginia believes this problem can be solved by VA's building 
``super-CBOCs,'' or larger and more extensive outpatient facilities in 
rural areas.
    We have noted that VHA is now working on ``systems redesign'' 
(reforming VHA as the new ``Medical Home''). We believe this kind of 
logic could be applied to a VHA-VBA system redesign. We believe there 
are many opportunities between VHA and VBA to work together, but they 
are being missed.

While Popular, Privatization Is Not a Preferred Option

    Section 216 of Public Law 110-329 requires the Secretary to allow 
veterans residing in Alaska and enrolled for VA health care to obtain 
needed care from medical facilities supported by the Indian Health 
Service or tribal organizations, if an existing VA facility or 
contracted service is unavailable. It also requires participating 
veterans and facilities to comply with all appropriate VA rules and 
regulations, and must be consistent with Capital Asset Realignment for 
Enhanced Services. In addition, Public Law 110-387, the Veterans' 
Mental Health and Other Care Improvements Act of 2008, directs the 
Secretary of Veterans Affairs to conduct a three-year pilot program 
under which a highly rural veteran who is enrolled in the system of 
patient enrollment of the VA, and who resides within a designated area 
of a participating VISN may elect to receive covered health services 
through a non-VA health care provider at VA expense. The act defines a 
``highly rural veteran'' as one who (1) resides more than 60 miles from 
the nearest VA facility providing primary care services, more than 120 
miles from a VA facility providing acute hospital care, or more than 
240 miles from a VA facility providing tertiary care (depending on 
which services a veteran needs); or (2) otherwise experiences such 
hardships or other difficulties in travel to the nearest appropriate VA 
facility that such travel is not in the best interest of the veteran. 
During the three-year demonstration period, the act requires an annual 
program assessment report by the Secretary to the Committees on 
Veterans' Affairs, to include recommendations for continuing the 
program.
    DAV's concerns regarding the use of non-VA purchased care are the 
unintended consequences for VA, unless carefully administered. Chief 
among these is the diminution of established quality, safety, and 
continuity of VA care for rural and highly rural veterans. It is 
important to note that VA's specialized health care programs, 
authorized by Congress and designed expressly to meet the specialized 
needs of combat-wounded and ill veterans, such as the blind 
rehabilitation centers, prosthetic and sensory aid programs, 
readjustment counseling, polytrauma and spinal cord injury centers, the 
centers for war-related illnesses, and the national center for post-
traumatic stress disorder, as well as several others, would be 
irreparably impacted by the loss of veterans from those programs. Also, 
the VA's medical and prosthetic research program, designed to study 
and, hopefully, cure the ills of injury and disease consequent to 
military service, could lose focus and purpose were service-connected 
and other enrolled veterans no longer physically present in VA health 
care programs. Additionally, title 38, United States Code, section 
1706(b)(1) requires VA to maintain the capacity of its specialized 
medical programs and not let that capacity fall below the level that 
existed at the time when Public Law 104-262 was enacted in 1996. 
Unfortunately, some of that capacity has dwindled.
    We believe, VA must maintain a ``critical mass'' of capital, human, 
and technical resources to promote effective, high-quality care for 
veterans, especially those with sophisticated health problems such as 
blindness, amputations, spinal cord injury, or chronic mental health 
problems. Putting additional budget pressures on this specialized 
system of services without making specific appropriations available for 
new rural VA health care programs may only exacerbate the problems 
currently encountered.
    In light of the escalating costs of health care in the private 
sector, to its credit, VA has done a remarkable job of holding down 
costs by effectively managing in-house health programs and services for 
veterans. While some service-connected veterans might seek care in the 
private sector as a matter of personal convenience, as a result of 
enactment of vouchering and privatization bills, they would lose the 
many safeguards built into the VA system through its patient safety 
program, evidence-based medicine, electronic health record, and bar 
code medication administration. These unique VA features culminate in 
the highest quality care available, public or private. Loss of these 
safeguards, ones that are either generally not available in private 
sector systems or only partially so, would equate to diminished 
oversight and coordination of care, and ultimately may result in lower 
quality of care for those who deserve it most.
    In general, current law places limits on VA's ability to contract 
for private health care services in instances in which VA facilities 
are incapable of providing necessary care to a veteran; when VA 
facilities are geographically inaccessible to a veteran for necessary 
care; when medical emergency prevents a veteran from receiving care in 
a VA facility; to complete an episode of VA care; and for certain 
specialty examinations to assist VA in adjudicating disability claims. 
VA also has authority to contract to obtain the services of scarce 
medical specialists in VA facilities. Beyond these limits, there is no 
general authority in the law (with the exception of the new 
demonstration project described above) to support broad-based 
contracting for the care of populations of veterans, whether rural or 
urban.
    The DAV urges this Committee and the VA ORH to closely monitor and 
oversee the functions of the new rural pilot demonstration project from 
Public Law 110-387, especially to protect against any erosion or 
diminution of VA's specialized medical programs and to ensure 
participating rural and highly rural veterans receive health care 
quality that is comparable to that available within the VA health care 
system. Especially we ask VA in implementing this demonstration project 
to develop a series of tailored programs to provide VA-coordinated 
rural care (or VA-coordinated care through local, state or other 
federal agencies) in the selected group of rural VISNs, and to provide 
reports to the Committees on Veterans' Affairs of the results of those 
efforts, including relative costs, quality, satisfaction, degree of 
access improvements, and other appropriate variables, compared to 
similar measurements of a like group of rural veterans in VA health 
care. To the greatest extent practicable, VA should coordinate these 
demonstrations and pilots with interested health professions' academic 
affiliates. We recommend the principles of our recommendations from the 
``Contract Care Coordination'' section of the IB be used to guide VA's 
approaches in this demonstration and that it be closely monitored by 
VA's Rural Veterans Advisory Committee. Further, we believe the ORH 
should be designated the overall coordinator of this demonstration 
project, in collaboration with other pertinent VHA offices and local 
rural liaison staff in VHA's rural VISNs selected for this 
demonstration.

VA's Readjustment Counseling Vet Centers: Key Partners in Rural Care

    Given that 44 percent of newly returning veterans from OEF/OIF live 
in rural areas, DAV believes that these veterans, too, should have 
access to specialized services offered at VA's Vet Centers. Vet Centers 
are located in communities outside the larger VA medical facilities, in 
easily accessible, consumer-oriented facilities highly responsive to 
the needs of local veterans. These centers present the primary access 
points to VA programs and benefits for nearly 25 percent of veterans 
who receive care at the centers. This core group of veteran users 
primarily receives readjustment and psychological counseling related to 
their military experiences. Building on the strength of the Vet Centers 
program, VA should extend its current pilot program for mobile Vet 
Centers that could help reach veterans in rural and highly rural areas 
where there is no other VA presence.

VA Should Stimulate Rural Health Professions

    Health workforce shortages and recruitment and retention of health 
care personnel (including clinicians) are a key challenge to rural 
veterans' access to VA care and to the quality of that care. The Future 
of Rural Health report recommended that the federal government initiate 
a renewed, vigorous, and comprehensive effort to enhance the supply of 
health care professionals working in rural areas. To this end, VA's 
deeper involvement in education in the health professions for future 
rural clinical providers seems appropriate in improving these 
situations in rural VA facilities as well as in the private sector. 
Through VA's existing partnerships with 103 schools of medicine, almost 
28,000 medical residents and 16,000 medical students receive some of 
their training in VA facilities every year. In addition, more than 
32,000 associated health sciences students from 1,000 schools, 
including future nurses, pharmacists, dentists, audiologists, social 
workers, psychologists, physical therapists, optometrists, respiratory 
therapists, physician assistants, and nurse practitioners, receive 
training in VA facilities.
    We believe these relationships of VA facilities to health 
professions schools should be put to work in aiding rural VA facilities 
with their health personnel needs. Also, evidence shows that providers 
who train in rural areas are more likely to remain practicing in rural 
areas. The VHA Office of Academic Affiliations, in conjunction with 
ORH, should develop a specific initiative aimed at taking advantage of 
VA's affiliations to meet clinical staffing needs in rural VA 
locations. The VHA office of Workforce Recruitment and Retention should 
execute initiatives targeted at rural areas, in consultation with, and 
using available funds as appropriate from, the ORH. Different paths to 
these goals could be pursued, such as the leveraging of an existing 
model used by the Health Resources and Services Administration (HRSA) 
to distribute new generations of health care providers in rural areas. 
Alternatively, VHA could target entry level workers in rural health and 
facilitate their credentialing, allowing them to work for VA in their 
rural communities. Also, VA could offer a ``virtual university'' so 
future VA employees would not need to relocate from their current 
environments to more urban sources of education. While, as discussed 
above, VA has made some progress with telehealth in rural areas as a 
means to provide alternative VA care to veterans in rural America, it 
has not focused on training future clinicians on best practices in 
delivering care via telehealth. This initiative could be accomplished 
by use of the virtual university concept or through collaborations with 
established collegiate programs with rural health curricula. If 
properly staffed, the VRHRCs could serve as key ``connectors'' for VA 
in such efforts.
    Consistent with our HRSA suggestion above, VA should examine and 
establish creative ways to collaborate with ongoing efforts by other 
agencies to address the needs of health care for rural veterans. VA has 
executed agreements with the Department of Health and Human Services 
(HHS), including the Indian Health Service and the HHS Office of Rural 
Health (ORH) Policy, to collaborate in the delivery of health care in 
rural communities, but we believe there are numerous other 
opportunities for collaboration with Native American and Alaska Native 
tribal organizations, state public health agencies and facilities, and 
some private practitioners as well, to enhance access to services for 
veterans. The ORH should pursue these collaborations and coordinate 
VA's role in participating in them.
    The IB for FY 2009, had expressed the concern that rural veterans, 
veterans service organizations, and other experts needed a seat at the 
table to help VA consider important program and policy decisions such 
as those described in this statement, ones that would have positive 
effects on veterans who live in rural areas. The IBVSOs were 
disappointed that Public Law 109-461 failed to include authorization of 
a Rural Veterans Advisory Committee to help harness the knowledge and 
expertise of representatives from federal agencies, academic 
affiliates, veterans service organizations, and other rural health 
experts to recommend policies to meet the challenges of veterans' rural 
health care. Nevertheless, we applaud the Secretary of Veterans Affairs 
for having responded to the spirit of our recommendation to use VA's 
existing authority to establish such an advisory committee. That new 
federal advisory committee has been appointed, has held formative 
meetings, and has begun to issue reports to the Secretary. We are 
pleased with the progress of the advisory committee and believe its 
voice is beginning to influence VA policy for rural veterans in a very 
positive direction.

Summary and Recommendations

    DAV and our partner organizations in the IB believe VA is working 
in good faith to address its shortcomings in rural areas, but still 
faces major challenges. In the long term, its methods and plans offer 
rural and highly rural veterans potentially the best opportunities to 
obtain quality care to meet their specialized health care needs. 
However, we vigorously disagree with proposals to privatize, voucher, 
and contract out VA health care for rural veterans on a broad scale 
because such a development would be destructive to the integrity of the 
VA system, a system of immense value to sick and disabled veterans and 
to the organizations that represent them. Thus, we remain concerned 
about VA's demonstration mandate to privatize services in selected 
rural VISNs, and will continue to closely monitor those developments.
    With these views in mind, DAV makes the following recommendations 
to the Subcommittee and also to the VA, where applicable:

      VA must ensure that the distance veterans travel, as well 
as other hardships they face, be considered in VA' s policies in 
determining the appropriate location and setting for providing direct 
VA health care services.
      VA must fully support the right of rural veterans to 
health care and insist that funding for additional rural care and 
outreach be specifically appropriated for this purpose, and not be the 
cause of reduction in highly specialized urban and suburban VA medical 
programs needed for the care of sick and disabled veterans.
      The responsible offices in VHA and at the VA Departmental 
level, collaborating with the ORH, should seek and coordinate the 
implementation of novel methods and means of communication, including 
use of the World Wide Web and other forms of telecommunication and 
telemetry, to connect rural and highly rural veterans to VA health care 
facilities, providers, technologies, and therapies, including greater 
access to their personal health records, prescription medications, and 
primary and specialty appointments.
      We recommend a further increase in travel reimbursement 
allowance commensurate with the actual cost of contemporary motor 
travel. The existing gap in reimbursement has a disproportionate impact 
on veterans in rural and frontier states.
      The ORH should be organizationally elevated in VA's 
Central Office and be provided staff augmentation commensurate with its 
responsibilities and goals.
      The VHA should establish at least one full-time rural 
staff position in each VISN, and more if needed.
      VA should ensure that mandated outreach efforts in rural 
areas required by Public Law 109-461 be closely coordinated with the 
ORH. VA should be required to report to Congress the degree of its 
success in conducting effective outreach and the results of its efforts 
in public-private and intergovernmental coordination to help rural 
veterans.
      Additional mobile Vet Centers should be established where 
needed to provide outreach and readjustment counseling for veterans in 
highly rural and frontier areas.
      Through its affiliations with schools of the health 
professions, VA should develop a policy to help supply health 
professions clinical personnel to rural VA facilities and practitioners 
to rural areas in general.
      Recognizing that in some areas of particularly sparse 
veteran population and absence of VA facilities, the VA ORH and its 
satellite offices should sponsor and establish demonstration projects 
with available providers of mental health and other health care 
services for enrolled veterans, taking care to observe and protect VA's 
role as coordinator of care. The projects should be reviewed and guided 
by the Rural Veterans Advisory Committee. Funding should be made 
available by the ORH to conduct these demonstration and pilot projects, 
and VA should report the results of these projects to the Committees on 
Veterans' Affairs.
      Rural outreach workers in VA's rural CBOCs should receive 
funding and authority to enable them to purchase and provide 
transportation vouchers and other mechanisms to promote rural veterans' 
access to VA health care facilities that are distant from these 
veterans' rural residences. This transportation program should be 
inaugurated as a pilot program in a small number of facilities. If 
successful as an effective access tool for rural and highly rural 
veterans who need access to VA care and services, it should be expanded 
accordingly.
      At highly rural VA CBOCs, VA should establish a staff 
function of rural outreach worker to collaborate with rural and 
frontier non-VA providers, to coordinate referral mechanisms to ease 
referrals by private providers to direct VA health care when available 
or VA-authorized care by other agencies when VA is unavailable and 
other providers are capable of meeting those needs.

    Mr. Chairman, this concludes DAV's statement. I would be pleased to 
address questions from you or other Members of the Committee.
                                 
  Prepared Statement of Lynn Tucker, Museville, VA (Veteran Caregiver)
    My name is Lynn Tucker. I am here to testify on behalf of my son 
Private First Class Benjamin Tucker, a lifelong resident of the rural 
community of Museville in the 5th Congressional District of Virginia. 
Ben enlisted in the United States Marine Corps in May 2004. Ben served 
for 22 months before tragedy struck in the form of a dirt bike accident 
leaving him with a traumatic brain injury. Ben is classified by the 
Veterans Administration as 100-percent disabled. I am here to testify 
on behalf of Ben's two brothers, Corporal Jonathan Tucker and Lance 
Corporal Clayton Tucker, who served two tours as Marines in Iraq. They 
suffer from the effects of repeated IED and RPG blasts and the deaths 
of many friends. I am also here to testify on behalf of all veterans 
needing care from the VA. My testimony today is based as a caregiver to 
Ben, who lives at home in Museville.
    Ben's story reveals what should be our concerns for all veterans, 
particularly those representing rural areas; the concerns are: access 
to primary and specialty care, effective and efficient communication 
within the VA and approval and remittance of payments from the VA for 
medically related items and services. Problems in any of these areas 
affect rural veterans like Ben, Jonathan and Clay by limiting medical 
choices, causing travel hardships, and contributing to an overall 
breakdown in the quality of care and life. What we all need to remember 
here is that these individuals, and all veterans, made a commitment to 
serve and to protect our liberties without knowledge of the ultimate 
outcome.
    Access to primary and specialty care is imperative for all veterans 
and especially difficult for rural veterans. For Ben who requires 
frequent specialized care, this is quite a challenge. Ben lives 45 
minutes from the Danville CBOC, 1 hour and 15 minutes from the Salem 
VA, and 3 hours from the Richmond VA. Only the Richmond VA can provide 
all the different types of care Ben needs and is the least accessible.
    In October 2006 Ben returned home after almost a year in hospitals 
and was totally dependent for all his care as he had no voluntary 
movement and was fed by a gastric tube. He was eligible for 15 hours 
weekly with the VA Home Health Aide Program. Due to his rural location, 
locating and retaining certified nursing assistants with the selected 
VA vendor was often impossible. Months would pass with no nursing help 
and no help from the VA in locating a vendor with nurses willing to 
drive the extra distance for a rural client. Just this last year we 
were able to retain a reliable and caring nurse through the VA when a 
new vendor was selected. With Ben's monthly VA disability payments 
another CNA was employed after a period of 4 months with no nursing 
help. Overall low payroll compensation with the added expense of 
additional driving discourages CNA's from accepting rural clients.
    Ben has a Codman shunt in his brain to drain excess fluid and 
requires care from a neurosurgeon. The Salem VA does not have a 
neurosurgeon; therefore, Ben has continued to see a Roanoke 
neurosurgeon practicing with Carilion Hospitals. Getting approvals for 
appointments is so time consuming, we have stopped applying for 
approval of routine visits and use Ben's Medicare Insurance and pay the 
balance remaining. This practice is not an appropriate solution for 
veterans and conveys that the VA does not have an appropriate system in 
place to care for their own. Many veterans' families that our family is 
associated with express concerns about waiting for approval and 
appointments with primary care doctors and specialists. Per two VA 
clinic staffers in Salem, with the intake of more veterans from Iraq 
and Afghanistan, this situation is growing worse by the day. Do VA 
administrators understand this situation?
    Effective communication is a barrier for veterans seeking care and 
necessary assistive equipment. Communication between VA staffers within 
the administration often results in long delays or unnecessary denials. 
During the summer of 2006 Ben applied for the grant to help pay for a 
custom wheelchair van. This request was submitted to the Roanoke 
Regional VA office. The form was passed along through the VA from 
person to person until somewhere a copy was made and the copy was 
passed along instead of the original. After several weeks, inquiries 
were made of the VA on Ben's behalf with no results. It was not until 
the family actually traced the path of the grant form, with the help of 
Kay Austin of the Paralyzed Veterans of America, that it was determined 
the form was in fact on the desk of a VA employee where it had laid for 
2 months. The employee stated the original was needed, but had not 
tried to locate the original or call for a new original. Then Ms. 
Austin faxed a new form and a second completed copy was delivered 
personally to the VA employee.
    Veterans often have to wait for needed medications to be refilled. 
Just this past month, Ben needed renewal on a medication that took over 
12 days to resolve. The CBOC in Danville received my request by fax and 
the receipt was confirmed by a nurse. Three of the medications arrived 
in the mail, but the one in question was not on Ben's prescription list 
in My HealththeVet. I called the CBOC and left a message on the nurse 
line. No one called. Inquiries confirmed the message was retrieved off 
the voice mail, but no action was taken. Finally the nurse called to 
say we needed to contact Richmond for an approval. In all it took 12 
days for the CBOC to tell me to call Richmond. Consider this: if you 
needed medication for your hypertension would you be willing to forgo 
that for 12 days? Is that not harmful to your health? Living in a rural 
area with the nearest pharmacy 30 minutes away and the nearest VA 
pharmacy an hour and 15 minutes away, this problem is compounded. 
Simple communication would have alleviated the wasted time, energy, and 
driving to fill this prescription.
    In September 2008, a bath sling was requested for Ben by the 
Richmond VA physical therapy department to the Richmond VA prosthetics 
department. A picture and an Internet link were provided to the 
employee. After months, many calls, and e-mails with the link again, 
three improper slings were delivered. Calls were made to the Guldmann 
vender in Texas for the sling attempting to provide Ben with the needed 
equipment. After calling the Guldmann headquarters and being given 
information for Guldmann MidAtlantic, on March 4, 2009 the correct bath 
sling was delivered overnight for free by Guldmann MidAtlantic after 
hearing the difficulty of trying to procure the sling for Ben. A 
veteran in a rural location cannot easily travel to a VA center and 
resolve issues in person. VA employees must respond to e-mails and 
calls and act appropriately to resolve the issue at hand. Veterans 
should not spend days, weeks, or months waiting by the phone.
    During 2008 a recumbent stepper was requested to the Salem VA by a 
physical therapist for Ben. Ben was taken to the Salem VA and evaluated 
by a doctor who approved the request. After months, calls were made 
about the equipment and found the request had never reached the 
prosthetics department. Shortly the Salem VA called explaining Ben 
needed the evaluation he had already completed. The doctor never 
entered the evaluation into the computer and never forwarded the 
request to the prosthetics department. Once this issue was resolved and 
several months passed, calls were made checking the progress of the 
request again and discovered it was denied. The Danville CBOC was 
notified but no one notified us. Efforts were made to begin tracking 
the documentation to determine why the request was denied. The VA 
employee who denied the request was very exasperated and actually said, 
``Why am I in the middle of this?'' The employee could not grasp why he 
had to defend his decision nor could he present procedural or policy 
issues relating to the denial. After a lengthy discussion debating the 
need for the equipment due to Ben's rural location and physical 
condition, the request was approved and the equipment delivered.
    Payments from the VA for medical services or equipment outside the 
VA system are slow to nonexistent, and this situation traps the veteran 
between the VA and the outside vendor. After Ben's van was delivered 
November 13, 2006, the VA owed a payment to the dealer it had already 
approved. After several weeks the dealer contacted Ben's family asking 
for help in obtaining the payment from the VA. Phone calls were made 
seeking this payment to no avail. Several weeks later the dealer 
requested the payment from Ben. The payment for the van finally reached 
the dealer on February 20, 2007, 3 months after delivery of the van to 
Ben.
    The van is not the only example of poor payment practices, Ben 
currently has collections against him for medical bills the VA agreed 
to pay. At first we paid some of the bills ourselves until realizing 
this wasn't an exception, but the norm. A great deal of time has been 
spent tracking many payments with the hospital and the VA not willing 
to communicate with each other. Currently all collection calls are 
referred to the VA
    Ben was referred for physical therapy at the Carilion Clinic in 
Rocky Mount. During one of his appointments I was called to the front 
desk because the center did not have the authorization number to pay 
for his therapy. It was necessary to contact the VA from the front desk 
of the facility in order that Ben could complete his appointment. 
Otherwise, Ben or his family would have had to agree to pay for the 
therapy.
    Ben spent almost 5 months in 2006 at Craig Hospital in Colorado 
after we paid over $14,000.00 to have him flown medically. On his 
return trip home, the VA agreed to pay for the flight because it was 
necessary for him to be evaluated by the Salem VA before returning 
home. On the day before the flight, the air ambulance company asked for 
a credit card number because the VA could not locate who approved 
payment for the flight. Once again, many phone calls were made adding 
to an already tense situation.
    In May 2006, my husband and I sat in a meeting with the Richmond VA 
after Ben was discharged by the marines in April. Ben was an active 
duty marine for 22 months, 2 months short of eligibility for VA 
coverage, with no TRICARE insurance, and his VA claim not processed. 
The VA employee wanted to know how the bill of approximately $40,000.00 
per month was to be paid if Ben continued to stay in the polytrauma 
unit. With no help from the VA, we investigated and obtained cobra 
insurance with TRICARE for Ben and the VA was paid.
    As a taxpayer and citizen of the United States of America it is 
striking how we take for granted the lives of those who voluntarily put 
theirs on the line. Ben, Jonathan, Clay, and all veterans enlisted 
without knowledge of the outcome. They made a commitment to their 
country. Where is their country now? Where will our country be when all 
the veterans return from Iraq and Afghanistan? Will they too be 
burdened with forms, phone calls, red tape, and delays? Will they too 
be turned away and not cared for? We cared to send them.
                                 
          Prepared Statement of Patricia Vandenberg, MHA, BS,
  Assistant Deputy Under Secretary for Health for Policy and Planning,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good Morning, Mr. Chairman and Members of the Committee. Thank you 
for inviting us here today to discuss the progress the Department of 
Veterans Affairs (VA) has made in implementing section 403 of Public 
Law (PL) 110-387, as well as VA's efforts to increase access to quality 
health care for veterans living in rural and highly rural counties in 
Virginia. I am accompanied today by Mr. Daniel Hoffmann, Network 
Director for the VA Mid-Atlantic Health Care Network (Veterans 
Integrated Service Network, or VISN 6), and Ms. Carol Bogedain, Interim 
Director for the Salem VA Medical Center. My testimony today will 
discuss VA's work in implementing the pilot program required by section 
403 of PL 110-387 and our local efforts in the area.

Section 403 of Public Law 110-387

    Public Law 110-387, Section 403 requires VA to conduct a pilot 
program to provide health care services to eligible veterans through 
contractual arrangements with non-VA providers. The statute directs 
that the pilot program be conducted in at least five VISNs. VA has 
determined that VISNs 1, 6, 15, 18 and 19 meet the statute's 
requirements. This program will explore opportunities for collaboration 
with non-VA providers to examine innovative ways to provide health care 
for veterans in remote areas.
    Immediately after Public Law 110-387 was enacted, VA established a 
cross-functional workgroup with a wide range of representatives from 
various offices, as well as VISN representatives, to identify issues 
and develop an implementation plan. VA soon realized that the pilot 
program could not be responsibly commenced within 120 days of the law's 
enactment, as required. In March and June 2009, VA officials briefed 
Congressional staff on these implementation issues.
    VA has made notable strides in implementing section 403 of PL 110-
387, with the goal of having the pilot program operational in late 2010 
or early 2011. Specifically, VA has:

          Developed an Implementation Plan, which contains 
        recommendations made by the Workgroup on implementing the pilot 
        program;
          Analyzed driving distances for each enrollee to 
        identify eligible veterans and reconfigured its data systems;
          Provided eligible enrollee distribution maps to each 
        participating VISN to aid in planning for potential pilot 
        sites;
          Developed an internal Request for Proposals that was 
        disseminated to the five VISNs asking for proposals on 
        potential pilot sites;
          Developed an application form that will be used for 
        veterans participating in the pilot program; and
          Taken action to leverage lessons learned from the 
        Healthcare Effectiveness Through Resource Optimization pilot 
        program (Project HERO) and adapt it for purposes of this pilot 
        program.

    VA has assembled an evaluation team of subject matter experts to 
review the proposals from the five VISNs regarding potential pilot 
sites. This team will then recommend specific locations for approval by 
the Under Secretary for Health. We anticipate this process will be 
complete this summer. After sites have been selected, VA will begin the 
acquisitions process. Since this process depends to some degree on the 
willingness of non-VA providers to participate, VA is unable to provide 
a definitive timeline for completion, but VA is making every effort to 
have these contracts in place by the fall. This would allow VA to begin 
the pilot program in late 2010 or early 2011.
    VA is developing information materials for veterans participating 
in the pilot program, for non-VA providers, for VA employees, and for 
other affected populations so that, when the pilot is implemented, all 
parties will have the information they need to fully utilize these 
services. VA is committed to implementing the program directed by 
Congress and to maintaining the quality of care veterans receive. Other 
issues, such as securing the exchange of medical information, verifying 
veterans' eligibility for this pilot program, coordinating care, and 
evaluating the success of the pilot program, are also important 
priorities and VA is working to ensure their appropriate implementation 
in the pilot program.
    VA notes that section 308 of Public Law 111-163, which was signed 
by the President on May 5, 2010, amends the requirements of Public Law 
110-387 section 403 regarding the ``hardship'' eligibility exception 
and the mileage standard.

Local Initiatives

    As noted previously, VISN 6 was selected as one of the Networks 
that will participate in the pilot program required by section 403 of 
PL 110-387. VISN 6 has identified potential locations for consideration 
for the pilot program.
    Separately, in fiscal year (FY) 2009, VISN 6 received approval and 
funding from VA's Office of Rural Health for three programs to improve 
access for veterans in rural Virginia. These included a program to 
improve effective communication and improving health literacy; a rural 
women veterans health care program; and additional mental health 
substance abuse coordination. VISN 6 immediately began implementing 
these efforts in the summer of 2009, and all VA medical centers in VISN 
6, including the Salem VA Medical Center, are benefiting from this 
continuing process. The programs are specifically targeted to assist 
veterans residing in rural and highly rural counties.
    The first project is designed to help VA conduct outreach to 
veterans living in rural and highly rural areas and improve health 
literacy. We will accomplish this through several strategies. First, we 
are identifying veterans with common characteristics or conditions, 
such as chronic obstructive pulmonary disease, diabetes, or congestive 
heart failure, and we are providing personal or group education on 
their health care needs in areas easily accessible to our veterans. 
This may occur in a Veterans Service Organization facility, a Vet 
Center, or a community-based outpatient clinic (CBOC). Second, we are 
conducting patient prescription reviews with the aim of improving 
communication and coordination between each veteran and his or her 
clinical pharmacist and provider. When veterans better understand the 
health care decisions their providers are making, they can be a more 
effective partner in making those decisions. We are also expanding the 
use of VA's online personal health record, My HealtheVet and enhancing 
self-care programs for chronic disease. To better support these 
initiatives, VISN 6 recently established rural health teams, which 
consist of rural health coordinators, clinical pharmacists, registered 
nurses, social workers, medical support assistants, program support 
assistants, and drivers. The hiring process for unfilled positions in 
the VISN 6 rural health teams is almost complete; all positions have 
been recruited and are pending final personnel actions. The teams are 
providing regular updates to VISN leadership and are implementing 90 
day action plans they developed in May. Each VA medical center in the 
VISN has received funding to support these outreach and access efforts. 
In total, VISN 6 received $4.89 million for this project.
    The second project supported by VA's Office of Rural Health is a 
rural women veterans health program. This program is designed to help 
increase the number of providers in rural or highly rural areas who are 
proficient, skilled and knowledgeable in caring for women veterans. We 
have trained at least one provider in this program at each VISN 6 CBOC 
and medical center; as of the beginning of July 2010, 150 providers 
total have already been trained, and 150 more will be trained before 
the end of this fiscal year. The program will also focus on improving 
health literacy and the overall health education of women veterans. 
VISN 6 received $1.92 million for this effort.
    The final project supported by VA's Office of Rural Health is a new 
effort to support additional mental health substance abuse 
coordination. This program is designed to provide mental health 
services including substance abuse treatment for veterans in rural or 
highly rural areas through contracts with community partners to 
increase access to these services. Our contracting officials are 
finalizing this proposal and we expect to begin obligating funds by the 
end of the fiscal year. VISN 6 received approximately $2 million for 
this program.
    Last month, between June 15 and 17, 2010, VISN 6 held a Network-
wide meeting that provided our rural health teams with goals, 
objectives and strategic direction. The meeting allowed the teams to 
learn more about tele-medicine, home-based primary care programs, 
women's health programs, the impact of post-traumatic stress disorder 
(PTSD) and traumatic brain injury (TBI) on veterans and their families, 
and the various partner programs offered by local governments in North 
Carolina and Virginia. This information sharing is critical to 
effective implementation of our outreach and access strategies for 
veterans in this area.
    In summary, these efforts are part of a larger plan by VISN 6 to 
improve access to quality health care for veterans in rural and highly 
rural areas. The principles of this approach include engaging community 
providers and leaders; VA is here to complement their programs, not 
compete. Indeed, in fiscal year (FY) 2010 through June, the Salem VA 
Medical Center has disbursed more than $15 million for fee-basis 
appointments, while the Richmond VAMC has disbursed just under $15 
million for fee-basis appointments; across all of VISN 6, more than 
$178 million has been disbursed through fee-basis care.
    We also need to educate and engage veterans and their families, and 
focus on common health issues among our veterans. Finally, quality 
health care and positive health outcomes are strongly associated with 
improved screening and health maintenance and compliance. These 
programs support the strategic goals of the Office of Rural Health. By 
improving health literacy and empowering our veterans to become full 
partners in their health care decisions, we can deliver the quality 
care our veterans have earned.

Conclusion

    Thank you again for the opportunity to discuss the status of the 
pilot program required by section 403 of PL 110-387 and the work VA is 
doing to improve access for veterans in rural Virginia. My staff and I 
look forward to answering your questions.
                                 
        Statement of Chris A. Lumsden, Chief Executive Officer,
            Halifax Regional Health System, South Boston, VA
    Halifax Regional Health System (HRHS) is non-profit, community 
owned and locally governed organization located in South Boston, 
Virginia. We are a fully integrated health care provider serving over 
100,000 residents over a five county area in southern Virginia. Beyond 
our 173-bed acute care hospital, we own and operate two nursing homes, 
and Alzheimer's facility, a home health care and hospice agency, and 
four primary care clinics in our service region. We have approximately 
125 doctors on staff and employ about 1,200 people at HRHS.
    The newest primary care clinic, Halifax Primary Care (HPC), was 
opened in South Boston in July of 2007. In June, 2009, HPC moved into a 
new 10,000 square foot state-of-the-art clinic here in town. The clinic 
is currently staffed by five physicians and one mid-level extender with 
a support staff of fifteen clinical and clerical employees. The 
facility was designed for easy expansion as additional doctors are 
recruited and more patients are served from this area.
    HRHS and HPC fully support the efforts to provide convenient high 
quality medical care to all veterans residing in our service region. If 
we meet the criteria and can fulfill the standards required as a 
provider of medical services to the veteran population, HPC would 
consider it an honor and a privilege to help better serve such a 
distinguished constituency of patients. We have been working closely 
with the local Veteran's Clinic Steering Committee and hope that South 
Boston is approved as veterans primary care site. It will certainly 
help those veterans who now must now travel long distances for these 
type services.

                                 
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