[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON DRAFT LEGISLATION, `THE VETERANS INTEGRATED
MENTAL HEALTH CARE ACT OF 2013;' DRAFT LEGISLATION, `THE DEMANDING
ACCOUNTABILITY FOR VETERANS ACT OF 2013;' H.R. 241; H.R. 288; H.R. 984;
AND H.R. 1284
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, MAY 21, 2013
__________
Serial No. 113-19
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVE P. ROE, Tennessee JULIA BROWNLEY, California,
JEFF DENHAM, California Ranking Minority Member
TIM HUELSKAMP, Kansas CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio GLORIA NEGRETE MCLEOD, California
VACANCY ANN M. KUSTER, New Hampshire
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
__________
May 21, 2013
Page
Legislative Hearing On Draft Legislation, `The Veterans
Integrated Mental Health Care Act Of 2013;' Draft Legislation,
`The Demanding Accountability For Veterans Act Of 2013;' H.R.
241; H.R. 288; H.R. 984; and H.R. 1284......................... 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health.............. 1
Prepared Statement of Hon. Benishek.......................... 34
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on
Health......................................................... 3
Prepared Statement of Hon. Brownley.......................... 35
Hon. Jeff Miller, Chairman, Full Committee on Veterans' Affairs.. 4
Prepared Statement of Chairman Miller........................ 35
WITNESSES
Hon. Dennis Ross, U.S. House of Representatives, (FL-15)......... 6
Prepared Statement of Hon. Ross.............................. 37
Hon. Brett Guthrie, U.S. House of Representatives, (KY-02)....... 7
Prepared Statement of Hon. Guthrie........................... 38
Mark Edney, MD, FACS, Member, Legislative Affairs Committee and
Urotrauma Task Force, American Urological Association.......... 15
Prepared Statement of Mr. Edney.............................. 39
Michael O'Rourke, Assistant Director of Government Relations,
Blinded Veterans Association................................... 17
Prepared Statement of Mr. O'Rourke........................... 41
Adrian Atizado, Assistant National Legislative Director, Disabled
American Veterans.............................................. 18
Prepared Statement of Mr. Atizado............................ 46
Alex Nicholson, Legislative Director, Iraq and Afghanistan
Veterans of America............................................ 20
Prepared Statement of Mr. Nicholson.......................... 49
Alethea Predeoux, Associate Director, Health Analysis, Paralyzed
Veterans of America............................................ 22
Prepared Statement of Ms. Predeoux........................... 51
Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary
for Health, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 27
Prepared Statement of Dr. Jesse.............................. 53
Accompanied by:
Susan Blauert, Deputy Assistant General Counsel, U.S.
Department of Veterans Affairs
STATEMENTS FOR THE RECORD
The American Legion.............................................. 54
Department of Veterans Affairs, Office of the Inspector General.. 56
Military Officers Association of America......................... 58
Veterans of Foreign Wars......................................... 60
VetsFirst/United Spinal Association.............................. 62
Wounded Warrior Project.......................................... 63
QUESTIONS FOR THE RECORD
Letter To: Hon. Dan Benishek, Chairman, Subcommittee on Health,
From: Paralyzed Veterans of America (PVA)...................... 67
Questions From: Hon. Dan Benishek, Chairman, Subcommittee on
Health......................................................... 67
Inquiry From: Hon. Julia Brownley, Ranking Minority Member,
Subcommittee on Health......................................... 69
LEGISLATIVE HEARING ON DRAFT LEGISLATION, `THE VETERANS INTEGRATED
MENTAL HEALTH CARE ACT OF 2013;' DRAFT LEGISLATION, `THE DEMANDING
ACCOUNTABILITY FOR VETERANS ACT OF 2013;' H.R. 241; H.R. 288; H.R. 984;
AND H.R. 1284
Tuesday, May 21, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Huelskamp, Wenstrup,
Brownley, Ruiz, Negrete McLeod, Kuster.
Also Present: Representative Miller.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. Benishek. Good morning. The Subcommittee will come to
order.
Thank you all for joining us today as we begin to discuss
six legislative proposals aimed at strengthening the health
care and services we provide to our honored veterans through
the Department of Veterans Affairs.
The six bills on our agenda this morning are draft
legislation, The Veterans Integrated Mental Health Care Act of
2013; draft legislation, The Demanding Accountability for
Veterans Act of 2013; H.R. 241, The Veterans Timely Access to
Health Care Act; H.R. 288, The CHAMPVA Children's Protection
Act of 2013; H.R. 984, to direct the Department of Defense to
establish a task force on urotrauma; and H.R. 1284, to provide
for coverage under VA's Beneficiary Travel Program for certain
disabled veterans for travel for certain special disabilities
rehab.
These bills seek to address a number of important issues
facing our veterans. I expect today's hearing to encompass a
highly detailed and thorough discussion of the potential
merits, challenges, and implications of each proposal before
us.
I look forward to working with the Ranking Member, the bill
sponsors, and my Subcommittee colleagues to fully evaluate
these proposals and ensure that we advance meaningful and
appropriate legislation to fulfill the promise we made to our
veterans.
My bill, the Demanding Accountability for Veterans Act, is
intended to address the pervasive lack of action taken by VA
based on their own agreed upon timelines for remediation of
issues and recommendations included in VA inspector general
reports.
Currently, the IG tracks open recommendations on their Web
site and in their semi-annual report to Congress, the latest of
which show that there were 177 total open reports and 1,140
total open recommendations. Of those, 33 reports and 93
recommendations had remained open for more than one year.
My bill would require the IG to make a determination on
whether VA is making significant progress on implementing VA's
own agreed upon action plan and timeline to implement the
recommendations made by the IG in a report concerning public
health or patient safety.
Under the bill, if the IG determines that significant
progress has not been made, the IG would be required to notify
the committees and the secretary of the department's failure to
respond appropriately.
Following notification, the secretary will be given 15 days
to submit the names of each VA manager responsible for taking
action to the IG. In turn, the secretary would be required to
properly notify each responsible manager of the issue requiring
action, direct that manager to resolve the issue, and provide
him or her with appropriate counseling and a mitigation plan.
The secretary would also be required to include in the
responsible manager's performance review an evaluation of
actions in response to a relevant IG report and prohibit the
individual from receiving a bonus or other performance award
for failure to take action.
The goal of this legislation is simple; to create a culture
within VA where problems that go unresolved are unacceptable.
Far too often, I have seen serious issues that the IG has
identified go unaddressed by the department. Such inaction is
intolerable where the care and services provided to our
veterans is concerned. And it is well past time for those at VA
who are responsible for implementing needed changes to be held
accountable for their work.
I am hopeful that The Demanding Accountability for Veterans
Act is the first step in ensuring that they are.
I would be happy to answer questions my colleagues may have
on the bill and listen to the views of all of our witnesses.
To that end, I would like to thank all the sponsors for
taking the time to speak with us about their proposals today. I
am grateful for each for their leadership and advocacy efforts
on behalf of our veterans and their families.
I would also like to thank our veteran service organization
partners and other stakeholders, both those who will testify
here this morning and those who submitted statements for the
record for their valuable input.
I am also grateful to the VA for being here to provide the
department's views on these important proposals.
With that, I now yield to Ranking Member Brownley for any
opening statement she may have.
[The prepared statement of Hon. Benishek appears in the
Appendix]
OPENING STATEMENT OF HON. JULIA BROWNLEY
Ms. Brownley. Thank you, Mr. Chairman, and thank you for
providing the full schedule today that includes six bills
before us that address some of the unique needs of our Nation's
honored veterans' population.
The bills pertain to a variety of areas that affect the
lives of veterans every day and this Subcommittee has conducted
many oversight hearings to understand the problems and then fix
them.
The first two bills on today's agenda including one of your
proposals, Mr. Chairman, are pieces of draft legislation to
address mental health concerns and increasing accountability at
the VA.
The next bill, H.R. 241, The Veterans Timely Access to
Health Care Act, was introduced by Mr. Ross of Florida and
pertains to timely, organized, and scheduled visits to VA
medical facilities.
H.R. 288, The CHAMPVA Children's Protection Act of 2013,
sponsored by Mr. Michaud, Ranking Member of the Full Committee,
would amend the maximum age for children to obtain medical care
under CHAMPVA from 23 to 26 and effectively reflect The Patient
Protection and Affordable Care Act enacted in 2010.
I will speak further on this bill during the first panel.
Next, H.R. 984 introduced by Mr. Guthrie of Kentucky would
direct the Secretary of Defense to establish a national task
force on urotrauma.
And, finally, my bill, H.R. 1284, The Veterans Medical
Access Act, would provide better access for blind and severely
disabled veterans who need to travel long distances to obtain
care at a special rehabilitation center.
Oftentimes, blind and catastrophically-disabled veterans
choose not to travel to VA medical centers for care because
they cannot afford the cost associated with that travel.
Currently, the VA is required to cover the cost of
transportation for veterans requiring medical care for service-
connected injuries.
H.R. 1284 would extend those travel benefits to a veteran
with vision impairment, a veteran with spinal cord injury or
disorder, or a veteran with double or multiple amputations
whose travel is in connection with care provided through a
special disabilities rehabilitation program of the VA.
Our disabled veterans have already made the greatest of
sacrifices and I firmly believe, as I am sure everyone here in
this Committee hearing today believes, that no veteran should
be denied needed medical care.
I thank all of the Members for their thoughtful legislation
and I want to thank you, Mr. Chairman, for including my bill
here today.
Thank you, and I yield back my time.
[The prepared statement of Hon. Brownley appears in the
Appendix]
Mr. Benishek. Thank you, Ms. Brownley.
I would now like to welcome our first panel to the witness
table. At the dais we have our Chairman, a well-respected and
well-established leader for our veterans, to discuss his draft
legislation, The Veterans Integrated Mental Health Care Act of
2013.
We also have my friends and colleagues, Dennis Ross,
Representative of Florida's 15th congressional district; and
Brett Guthrie, Representative of Kentucky's 2nd congressional
district. Brett is also a West Point grad and a veteran of the
army's 101st airborne division. I would like to thank him for
his service in uniform.
Thank you all for being here this morning. It is a pleasure
having you and I will yield this time for the Chairman for his
testimony.
STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you very much, Mr. Chairman.
It is great to be here today, with you the Members of the
Subcommittee on Health, Representatives from the VSOs that have
joined us and other interested stakeholders and audience
members. I appreciate the opportunity to discuss my draft bill,
The Veterans Integrated Mental Health Care Act of 2013.
Two weeks ago yesterday, I spent the day in Atlanta with
many members of the Georgia delegation to discuss inpatient and
contract mental health program mismanagement issues at the
Atlanta Department of Veterans Affairs Medical Center.
This visit occurred after the VA inspector general issued
two reports which found that failures in management,
leadership, oversight, and care coordination at the Atlanta
VAMC contributed to the suicide deaths of two veteran patients
and the overdose deaths of two others.
Now, alarmingly, the IG found that approximately four to
five thousand veteran patients fell through the cracks and were
lost in the system after the Atlanta VAMC failed to adequately
coordinate or monitor the care they received under VA's
contracts with community mental health providers.
I wish that I could say that the issues in Atlanta are an
isolated aberration. Unfortunately, that would be far from the
truth. Rather, the Atlanta story is just the latest in a tragic
series of incidents highlighting serious and systematic
deficiencies plaguing the provision of mental health care to
at-risk veterans through the VA health care system.
Since 2007, VA's mental health care programs, budget, and
staff have increased significantly, yet the numbers of veterans
taking their own lives has remained stagnant for the past 12
years, with 18 to 22 veteran suicide deaths per day since 1999
according to VA's own records.
I could go on, but the bottom line of this is that the one
size fits all path to mental health care that the department is
on is failing the veterans most in need of its services. And
the time to act is now.
I have been and will certainly continue to be a strong and
supportive advocate of VA taking action to hire staff and
address the continued failures of mental health care provided
within its own walls.
However, it has become abundantly clear through the data
that I have discussed this morning, through committee oversight
in this room, through numerous IG and Government Accountability
Office reports, and through the personal accounts of the
veteran constituents that call my office and the offices of my
colleagues on a daily basis, to ask for help that VA cannot
cope with the magnitude of mental health needs our veterans
experience in a bureaucratic vacuum with the normal VA business
as usual approach.
In order to truly maximize mental health care access for
today's veterans, VA has got to embrace an approach to care
delivery that treats veterans where and how they want to be
treated, not just where and how VA wants to do the treatment.
Some have said this could undermine VA health care as we
know it, but nothing could be further from the truth. This is
not about supplanting the VA health care system. It is about
supporting that very system.
To truly address and resolve the breakdown in the provision
of mental health care services to veteran patients, VA has got
to adopt an integrated, coordinated care delivery model for
mental health care.
Most importantly, VA has got to adopt a mental health care
delivery model that is truly veteran-centric, one that meets
and cares for veteran patients where they are, treats the
entirety of their concerns with supportive and timely wrap-
around services, and recognizes and respects their unique
circumstances, goals, and health care needs throughout their
lives as a veteran.
That is why I have proposed the draft Veterans Integrated
Mental Health Care bill that is before us this morning. It
would take the first important step to help veterans in need,
whether those services are provided in or outside of VA
facilities.
Specifically, the draft would require VA to provide mental
health care to an eligible veteran who elects to receive such
care at a non-VA facility through a care coordination contract
and with a qualified entity and require such entity to meet
specific performance metrics regarding the quality and
timeliness of care and exchange relevant clinical information
with the VA.
It would ensure that existing mental health care resources,
both those found within the VA facilities and those provided to
veterans through fee-basis care, are managed effectively.
It would also ensure that the care provided to veteran
patients in need of mental health services is timely and that
it is convenient and coordinated from the initial point of
contact throughout the recovery process.
I understand that some veteran service organizations have
expressed concern about waiting until VA rolls out its own new
contract care initiatives. And while I appreciate and I
understand and respect those views, I look forward to working
closely with them to address those concerns, but the time for
waiting is over.
Last year, the IG found that more than half of the veterans
who go to VA seeking mental health care services wait 50 days
on average to receive an initial evaluation.
This year, the IG found that thousands of Georgia veterans
had fallen through giant cracks in the system and may or may
not have received the care that they so desperately needed. We
cannot wait to see what next year brings.
When a veteran is in need of mental health care services,
the difference of a day or a week or a month can be the
difference between life or death, contentment or continued
struggle. The time to act is now.
I look forward to working hand in hand with Committee
Members, our VSO partners, and other stakeholders to strengthen
the language in this draft bill and address any issues that may
be raised during the Subcommittee's discussion this morning.
I appreciate you holding this hearing, Mr. Chairman, and
for your hard work and steadfast leadership of the Subcommittee
on Health. I yield back.
[The prepared statement of Hon. Jeff Miller appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Chairman.
I look forward to hearing from the VSOs about your
legislation and it certainly is timely.
With that, I will yield to Mr. Ross, my colleague. Thank
you.
STATEMENTS OF HON. DENNIS ROSS, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF FLORIDA; HON. BRETT GUTHRIE, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF KENTUCKY
STATEMENT OF HON. DENNIS ROSS
Mr. Ross. Thank you, Mr. Chairman, and thank you, Ranking
Member Brownley and the Committee, for allowing me to testify
on behalf of legislation I have introduced entitled The
Veterans Timely Access to Health Care Act.
America's veterans are the backbone of the freedom and
prosperity that this country has enjoyed for over 200 years. We
owe them a debt that we can never truly repay.
Unfortunately, across the country and across Florida's 15th
congressional district, veterans continue to encounter
unacceptable problems and delays receiving appointments from
the Veterans Administration for essential medical and specialty
health care needs.
For instance, the VA has set a goal to provide an initial
medical health examination within 14 days from the time a
veteran contacts a VA medical provider to schedule a
consultation. They claim, the VA claims to have met this goal
with a 95 percent success rate.
However, an inspector general report in 2012 published,
greatly contradicts these claims. In fact, the IG report
determined that the VA met its goal only 49 percent of its
time.
As Chairman Miller pointed out, for example, more than
184,000 veterans waited approximately 50 days to receive
critical mental health evaluations, not treatment, just the
formal evaluation. This is a disgrace to our veterans and
something that should not be tolerated.
Additionally, Chairman Mike Coffman of the Subcommittee on
Oversight and Investigations held a hearing on March 14th, 2013
to examine patient wait times at VA medical facilities. Sadly,
the Chairman revealed that according to VA documents, at least
two veterans died last year from diseases while waiting for a
medical consultation at the VA.
That is why I am proud to have introduced H.R. 241, The
Veterans Timely Access to Health Care Act. This legislation
supported by the Military Officers Association of America and
the Retired Enlisted Association will ensure that veterans
seeking primary and specialty care from a VA medical facility
receive an appointment within 30 days period.
This legislation also contains a number of detailed
reporting requirements so that Congress may better track the
VA's progress. And if the VA discovers they are not meeting
their goals and the mandated 30-day access to care, it is my
hope that they will reach out to Congress before the reports
are filed so that we can work together to meet the needs of our
Nation's brave and courageous veterans.
We are all on the same team here with the same goal of
providing timely, high-quality health care to our veterans.
However, this legislation will go a long way in ensuring
veterans' critical needs like those needs of the more 184,000
veterans who waited over 50 days for initial mental health
screening. We want to make sure they no longer slip through the
cracks.
It will also prevent the unnecessary loss of life of those
veterans in need of medical care and consultation.
Moving forward, I would like to work with this Subcommittee
to strengthen this legislation potentially including additional
access to care standards. Today, this legislation is a first
step to hold the VA accountable.
Thank you, Mr. Chairman, and I yield back the balance of my
time.
[The prepared statement of Hon. Ross appears in the
Appendix]
Mr. Benishek. Thank you Representative Ross. I appreciate
your words.
Brett, why don't you just go ahead with your testimony as
well?
STATEMENT OF HON. BRETT GUTHRIE
Mr. Guthrie. Thank you, Mr. Chairman.
And good morning, Ranking Member Brownley and colleagues.
I come before you today as both a Member of Congress and a
former army officer to thank you for your past support of this
issue and continued work that we need to move forward.
As you may know, genitourinary trauma or simply urotrauma
is a class of wounds that literally hits below the belt.
Urotrauma accounts for wounds to the kidneys, reproductive
organs, and urinary tract organs. These injuries are some of
the most common and debilitating suffered by our veterans from
IED detonations and have long-lasting physical and
psychological impacts.
Urotrauma is one of the signature wounds of the IED and now
accounts for one-eighth of all injuries suffered by our troops
in Afghanistan. Unfortunately, the most recent data available
suggests that this figure is still rising even after nearly
doubling in incidence between 2009 and 2010.
I know we are in the veterans committee today, but by way
of background, let me paraphrase Department of Defense report
to Congress titled Genital Urinary Trauma In The Military and
the army's surgeon general's report entitled Dismounted Complex
Blast Injury.
According to these papers, urotrauma on today's battlefield
exceeds incident rates of all prior conflicts by at least 350
percent and, yet, the DoD under secretary for Personnel and
Readiness concedes that urotrauma injury is not part of the
standards of pre-deployment training for U.S. military surgeons
and nurses and that existing infrastructure for tracking these
casualties is not sufficient to assess the long-term prognosis
of GU trauma injuries.
This lack of adequate infrastructure is exacerbated by the
inherent complications of transitional care from DoD to VA
where most victims will receive treatment for the remainder of
their lives.
Let me say that this is not my view that the VA or DoD are
ignoring urotrauma. To the contrary. I believe that many
skilled professionals are hard at work on the issue, but, as is
often the case in government, their efforts are divided, un-
integrated, and because of this less effective.
By my tally, there are six government agencies currently
working on urotrauma and while I am heartened that this
research is occurring, I am discouraged that there seems to be
little dialogue or centralization of information.
Put simply, we are not learning from experience and if we
are, we are learning too slowly. And that is why I introduced
H.R. 984, a bill that I have authored with the help of
practicing urologists who have cared for wounded warriors in
Iraq and Afghanistan.
This bill would unite public and private resources to
address the growing problem that is urotrauma. I would like to
highlight two specific opportunities for improved care that are
within the Committee's jurisdiction.
First, the existing infrastructure to track urotrauma
patients is not sufficient. We need the research infrastructure
to facilitate urotrauma outcomes research and corresponding
follow-up with DoD and most critically after transition to the
VA.
Unfortunately, one thing I have heard time and again is
that the joint theater trauma registry, which tracks
approximately 16,000 trauma victims, lacks the specificity of
detail needed to accomplish this end. VA, DoD, and health care
providers need a better platform to coordinate care across a
lifetime for our wounded warriors.
Related to this is a second issue I would like to focus on,
transition of care. Rather than mincing words, I will quote the
American Urologists Association Urotrauma Task Force directly.
It is clear to those urologists in DoD who care for our
soldiers with complex urotrauma that the transition to the VA
is currently fraught with barriers. These barriers include
deficits of communication of the detailed medical and surgical
history of injured servicemembers from DoD physicians to VA
physicians.
Another problem continues to be GU injured soldiers within
the VA system being cared for in locations where access to
expertise in GU trauma is lacking.
One solution to this problem would be designated care
coordinators to urotrauma victims. These coordinators would
need access to DoD and VA health information and guide our
wounded warriors toward existing centers of excellence and
polytrauma care.
However, as a Member of Congress, I am not wedded to a
single solution to this or any other improvement to urotrauma
care. That is why 984 allows for a big tent solution. As DoD
has said in writing, we need inter-service and interagency
relationships to facilitate aggressive, innovative, and
relevant translational and outcomes-based clinical research.
And that is what this does. It brings together VA, DoD,
HHS, surgeon generals of all of our Armed Services and civilian
expertise to create a plan to care for our wounded warriors
from the point of injury to their final resting place decades
from now.
I urge this Committee to continue the work it has already
done to further our care for these wounded warriors in
suffering these effects, and I yield back my time.
[The prepared statement of Hon. Guthrie appears in the
Appendix]
Mr. Benishek. Thank you very much, Representative Guthrie.
I will now yield again to the Ranking Member, Ms. Brownley,
to speak on H.R. 288.
Ms. Brownley. Thank you, Mr. Chairman.
H.R. 288, The CHAMPVA Children's Protection Act of 2013,
was introduced by Mr. Michaud, Ranking Member of the Full
Committee. Thank you for including it in today's agenda.
Dating back to 1973, the CHAMPVA program was established to
provide health care services to dependents and survivors of
certain veterans. It is designed to provide care in a manner
similar to that of DoD's TRICARE program in that it is a fee-
for-service program that provides reimbursement for medical
care provided by the private sector.
Individuals who are eligible for CHAMPVA are the dependents
of certain living and deceased veterans who were rated
permanently and totally disabled for a service-connected
disability, died from a service-connected disability, or died
while on active duty which was not due to personal misconduct.
As we are all aware, The Patient Protection and Affordable
Care Act requires health plans and health insurance issuers
that offer dependent coverage to extend this coverage until the
adult child turns 26 years of age.
The fiscal year 2011 National Defense Authorization Act
provided DoD with the authority to extend TRICARE coverage to
age 26 as well. However, this provision has yet to apply to
CHAMPVA.
H.R. 288 would extend that same coverage to CHAMPVA
beneficiaries. It is a simple fix that would ensure that our
veterans' families are able to receive health care commensurate
with the rest of the Nation.
And I thank you, Mr. Chair, and I yield back the balance of
my time.
Mr. Benishek. Thank you, Ms. Brownley.
I am going to yield myself five minutes for a few questions
concerning the legislation and maybe you all can answer a
couple of points that I have.
Mr. Ross, thanks for your interest in ensuring that our
veterans have timely access to care. As you know, care delayed
is care denied.
Some concerns have been raised about H.R. 241 that would
establish in law a single measure of timeliness. I am looking
forward to the opportunity to work with you on this legislation
to achieve your goal, which I think is to ensure that veterans
have a clear expectation that they will receive timely care and
that the VA will be held accountable.
But there is some concern I have about one standard. There
are different types of issues that come up. For example, the
mental health timeliness issue may be different than a routine
appointment.
Can you respond to these questions that I came up with----
Mr. Ross. Yes, sir.
Mr. Benishek. --when I read your legislation?
Mr. Ross. Thank you, Chairman.
And I agree with you. I think, you know, we are trying to
impose one standard of 30 days. When the VA says that they now
do it within 14 days, we know they do not meet that standard.
What we are trying to do is assess the situation. We know
we have a problem. We are trying to get to the solution by
putting in initially a 30-day maximum period of time by which
the appointment must be given and then having the assessment
thereafter of a report from the secretary that is due to
Congress that would show how many appointments were really made
within 30 days, how many in excess of 30, how many in excess of
six months.
From that data, we should be able to then decide what is
the appropriate standard for appointments. But I use this
legislation as a step, the first step in trying to recognize
that we have a problem in providing adequate and necessary
health care in an expeditious fashion.
And so while I am not seeking that 30 days should be the
standard, it is a starting point to assess where the problems
are and then hopefully take corrective action based on the
information we get back from the secretary.
Mr. Benishek. All right. Okay. Is there any enforcement
mechanism about this or is this the beginning?
Mr. Ross. Mr. Chairman, sadly there is not any enforcement.
I say sadly because in most of these regulatory issues we have
little enforcement ability with the agencies that we deal with.
And I think that one of the things, I would really enjoy
working with this Committee, is trying to find an enforcement
mechanism.
I think once we identify what the solution should be in
terms of the appropriate access to care standard depending on
the diagnosis or for that matter just the initial evaluation,
then I think we can look at what the enforcement should be for
their failure to do so.
I mean, for something that would be, you know, like a
physical soft tissue injury, there may not be as great of
enforcement penalties, if it was something more of a severe
mental health condition or something that requires exigent
medical care and treatment at the time.
Mr. Benishek. Thank you.
Mr. Ross. Thank you.
Mr. Benishek. Mr. Guthrie, you know, I am excited that you
brought this up here because I am a trauma surgeon myself and I
got to meet with some of the great urologists that provide
urotrauma care. And I just want to commend your efforts to get
this thing going here.
I know that this bill would unite public and private
resources to address the growing problem in urotrauma.
What is being done in that area to currently make the
private and public sector work together?
Mr. Guthrie. Well, one of the great examples of that is
that one of the people that brought this to my attention is a
physician, who you are going to hear from in the second panel,
who is in private practice, but was deployed forward with the
national guard, so experienced it firsthand and sees it back
now, back home in country.
And so what we are hoping to do there, what I am not seeing
is the DoD and VA are dealing with this. As I mentioned in my
testimony, they are dealing with it through several different
categories. And what we are trying to do is unite it. So we do
have private research with public research.
I think one example that sort of fits, I mean, in Boston in
the marathon blast, I think the trauma surgeons there had been
trained with some Israeli surgeons and it just happened that
they had that special training at that time and undoubtedly
saved lives.
And so what can happen through the military and bringing
private sources together can be replicated to help people, not
just military folks, but that is what the focus is, try to
bring everybody together from both sides, whether you are DoD
employed or you are in private practice or private research.
Mr. Benishek. Well, I know that it is going to be a
challenge for our veterans who want to go home and, yet, in
their hometown or their local VA may not have an expert
urologist trained in urotrauma and that a task force to address
that issue, I think, is a great idea and coordinating care
nationally to get the best taking care of this.
Mr. Guthrie. The biggest thing I think can come out of this
is actually that because our guys have gotten really good
unfortunately at training because they see it in Landstuhl and
here.
But when our soldiers go home to live out the rest of their
lives, I think that is what is so important for this Committee
to focus on. They are not going to be in Walter Reed or in
Landstuhl for the rest of their lives. They are going to be
home and that is what we need to focus on.
Mr. Benishek. Thank you.
Mr. Guthrie. Thanks for that comment.
Mr. Benishek. I will yield now to the Ranking Member, Ms.
Brownley, if she has any questions.
Ms. Brownley. I do not have any questions at this time.
Thank you.
Mr. Benishek. Mr. Wenstrup.
Mr. Wenstrup. No questions.
Mr. Benishek. Ms. Kuster.
Ms. Kuster. Thank you, Mr. Chairman, and thank you for
convening this hearing.
I think these are critical issues for us to be dealing
with. And I commend you and Ms. Brownley for your leadership on
this.
And thank you to our colleagues.
Both of these issues, I think, are critical and I just want
to lend my support. I do not have any particular questions. You
have been very informative and the testimony is very helpful.
But I just want to say that we appreciate you coming
forward. Thank you for service. And please know that on both
sides of the aisle here on the Veterans Committee, these are
bipartisan, nonpartisan issues that we want to work with you on
and work with the VA and the VSOs and make sure that our troops
get the care that they need.
And I am particularly reading the testimony. The confluence
of the mental health issues with the complex trauma issues, I
think, is the lesson, sadly, that we will all learn from the
last 12 years is that from what I hear back in my district in
New Hampshire, the impact, the cumulative impact on the family
structure.
And I think about the urotrauma issues and I think about
more women getting into the military and seeing combat and what
the long-term implication is for that for our society.
So I just commend you and I would like to work with you and
work with the chair and the Ranking Member on this Committee
and just say that I think it is really significant work that we
are doing.
Thank you. I yield back the balance of my time.
Mr. Benishek. Thank you, Ms. Kuster.
Mr. Huelskamp, do you have any questions for the panel?
Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate my
colleagues for bringing these proposed bills before the
Committee.
I had a couple questions and wanted to see what your
thoughts were, particularly first for Congressman Ross.
Recently, the Committee reviewed a report from the OIG
about, I think it was entitled Reported Outpatient Wait Times,
and what was disturbing to me was some evidence that certain
facilities either had an unusual definition of what the wait
time was or actually potentially falsified the data.
And I found that very concerning, especially when we talk
about the need, and I agree with you, to set a standard by
which they will reach. But when we found cases or the OIG found
cases where they went in on the day they actually had their
appointment, went in, says, okay, that was the wait time, the
day they came in rather than the time they applied.
Any thoughts on that and response from, you think, from the
Department of Veterans Affairs when we have these kind of
things occurring?
Mr. Ross. Thank you, Mr. Huelskamp.
You know, every specialty, medical specialty has practice
protocols by which there is a recommended course of treatment
and rehabilitation depending on the diagnosis.
And while not having a single standard is going to work in
terms of getting in to see the health care provider that they
see, I think what is important is that we make sure that we
collect the data appropriately as to when the first request is
made until their first evaluation and then subsequent follow-
ups can be offered.
But I think that what we are trying to do is recognize that
we have a problem here and I think that a lot of it has been
covered up and the issue is a lot worse than what we know it to
be.
So, again, I would ask to work with this Committee so that
we can have some enforcement mechanisms in there to not only
hold the Veterans Administration accountable, but also to make
sure that those that are collecting the data are doing it
appropriately and accurately.
Mr. Huelskamp. I appreciate that. I think that is
absolutely essential and to create legislation or ways to hold
the VA accountable, particularly for those that it aims to
serve.
And, Brett, comment for you or question. I serve a very
rural district. I am sure you understand that. I was actually
visiting with a veteran who was in Syracuse, Kansas and this
was about a year ago. And he had noted where he was instructed
by the VA to make, I think it was a 260-mile, 261-mile one-way
trip.
And he made the round trip three times in ten days and he
said, you know, Congressman, the care they wanted me to get,
and it was not urology, it was another type of care, I could
have got that in my local hospital and the VA would not allow
that to happen.
And, by the way, just five days ago, the local hospital
announced they could be shutting their doors.
And one issue I have had is, well, how can we make certain
that whether on the care that you mention and the care
Congressman Ross mentions, they can get that close to home, not
only to, you know, help assist the VA, but also to protect our
local hospitals.
Any comments you might have for someone like me that serves
in a rural area?
Mr. Guthrie. Oh, absolutely. I think of it, sir, not just
with my bill, but any time a service person wants or serviceman
or woman wants service and they can get it locally and they can
get what they need locally, you know, if they live next door to
the VA hospital. If they live in Nashville, instead of going to
Vanderbilt, you go to the VA hospital. I might get that because
I live just as close to Nashville.
But if they are, you know, out where you are, they should
go get the service where they can get it. And I have people in
my district like that, that are not as close to Nashville as I
am. I know I am in Kentucky, but we are on the border.
And so I agree with you. I think we ought to find a way to
deliver services the best that we can to people in the way that
they can receive it.
Mr. Huelskamp. Yeah. I appreciate that.
And the VA had an initiative a few years ago. They are
proceeding with that, Project Arch, and one of the pilot spots
was formerly in my district, but in the first year they had not
found a single person that had received mental health services
through that pilot project.
And so we have a long ways to go. I appreciate your
gentlemen's proposals and I look forward to working with those
in the Committee.
And, Mr. Chairman, I yield back.
Mr. Benishek. Thank you.
I will now yield to my colleague, Dr. Ruiz.
Mr. Ruiz. Thank you very much, Mr. Chairman.
Thank you both, Dennis and Brett, for your work in
introducing these bills.
I applaud and encourage highly the gathering of accurate
data. I believe very much in evidence-based medicine, and I
believe very much in evidence-based policy. And it is the best
way that we can find the bottlenecks that is justified through
the information that we get on performance measurements in
order to make the best decisions and the best policy that we
can for our veterans.
Brett, I am a strong supporter of our urotrauma surgeons
and making sure that we provide the best treatment. This is
something that we need to follow through all the way to the
outcomes and measuring what those outcomes are.
I know that Dr. Anine has been the champion and going
around meeting a lot of us on the Committee. And I applaud his
work and I encourage more urologists to do the same.
In terms of the task force, oftentimes, there is concerns
that the task force or advisory committee recommendations are
ignored and are not very effective. And this is something that
we cannot let happen.
So what can we do to ensure that any recommendation is
actionable and we can carry through to have some actual
outcomes?
Mr. Guthrie. Yeah, that is frustrating. Now I say sometimes
task forces or good ideas go to die sometimes. And we just have
to do the oversight. They have to report two years after the
task force is implemented. They have two years, one year for a
report, the second year the final report.
And I think it is our job as Members of Congress as people
have brought this issue to us, is that to make sure these are
implemented and have oversight of the implementation of the
task force because it will go as far as we reflect. And
hopefully it will go without us, oversight, but certainly our
oversight will help it move forward. And I think that is what
we have to do is be dedicated to this issue.
Mr. Ruiz. Well, I look forward to working with you on this
and after the recommendations are given.
Mr. Guthrie. I appreciate that very much.
Mr. Ruiz. I yield back my time.
Mr. Guthrie. Really look forward to it.
Mr. Benishek. Well, does anyone else have any questions of
the panel?
[No response.]
Mr. Benishek. Well, I certainly appreciate your time this
morning, gentlemen. I am looking forward to working with you on
this legislation moving forward. Thanks.
I would like to welcome the second panel to the witness
table, please.
Joining us on the second panel will be Dr. Mark Edney, a
Member of the Legislative Affairs Committee and the Urotrauma
Task Force for the American Urological Association; Mr. Michael
O'Rourke who is the Assistant Director of Government Relations
for the Blinded Veterans Association; Mr. Adrian Atizado, the
Assistant National Legislative Director for the Disabled
American Veterans; and Mr. Alex Nicholson, Legislative Director
for the Iraq and Afghan Veterans of America; and Ms. Alethea
Predeoux, Associate Director for Health Analysis for the
Paralyzed Veterans of America.
I hope I got your name right.
Thank you for all your service to our Nation in uniform and
through your advocacy work. I appreciate you all being here
today and look forward to hearing your views.
And let's begin the panel with Dr. Edney. Please go ahead.
You have five minutes.
STATEMENTS OF MARK EDNEY, MEMBER, LEGISLATIVE AFFAIRS COMMITTEE
AND UROTRAUMA TASK FORCE, AMERICAN UROLOGICAL ASSOCIATION;
MICHAEL O'ROURKE, ASSISTANT DIRECTOR OF GOVERNMENT RELATIONS,
BLINDED VETERANS ASSOCIATION; ADRIAN ATIZADO, ASSISTANT
NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; ALEX
NICHOLSON, LEGISLATIVE DIRECTOR, IRAQ AND AFGHANISTAN VETERANS
OF AMERICA; ALETHEA PREDEOUX, ASSOCIATE DIRECTOR, HEALTH
ANALYSIS, PARALYZED VETERANS OF AMERICA
STATEMENT OF MARK EDNEY
Dr. Edney. Chairman Benishek, Ranking Member Brownley,
Members of the Committee, honored guests, fellow
servicemembers, I thank the Committee on Veterans Affairs'
Subcommittee on Health for inviting me to testify regarding
H.R. 984, a bipartisan bill introduced by Representative
Guthrie, to direct the secretary of Defense to establish a task
force on urotrauma.
I am a urologist, a surgical specialist who treats
genitourinary disease and injury. I am also an army reservist
of 11 years. My active duty tours include service with the
399th combat support hospital in Mosul, Iraq in 2006.
I have treated genitourinary trauma in the theater of
operations and I have also participated in its chronic
management at our largest military medical center stateside.
It is an honor to represent the American Urological
Association, the world's premier professional association of
urologists and our Urotrauma Coalition in support of H.R. 984
on behalf of this unique class of injured servicemembers.
Our Urotrauma Coalition includes distinguished medical
societies including the American College of Surgeons, the
American Congress of Obstetrics and Gynecology, the Society of
Women's Health Research, and a diverse group of veteran service
organizations and industry partners who all support urotrauma
policy initiatives contained in H.R. 984.
Fifty thousand American servicemen and women have been
injured in Iraq and Afghanistan. A recent study indicates that
about a thousand soldiers have sustained injury to the
urogenital organs.
Approximately 60 percent of these injuries involve the
external organs including penoscrotal, testicular and urethral
injury with another 40 percent involving kidney, ureter and
bladder, and in women, the uterus, vagina, fallopian tubes, and
ovaries.
Dismounted complex blast injury is the constellation of
lower extremity loss, often bilateral, occasionally with upper
extremity loss, and often with genitourinary injury.
Urotrauma is up 350 percent in Afghanistan compared to Iraq
because of the increased necessity of soldiers to patrol on
foot rather than in fortified vehicles.
Although veterans suffering genitourinary injury may
exhibit no outward evidence, they suffer the life-changing loss
of proper urinary, bowel, and sexual function and fertility.
These deficits have significant effects on marriages, other
social relationships, and enormous effects on overall quality
of life.
The cumulative physical and psychological impact of
urotrauma on these soldiers is no less profound than those
recovering from extremity loss and neurocognitive injury.
As a complex injury pattern, urotrauma has not received the
same policy attention and care coordination that has been
afforded the more common injury patterns such as extremity
loss, traumatic brain injury, and eye injury, each with its own
center of excellence.
Genitourinary injury is increasingly a critical military
women's health issue. With women now able to serve in direct
combat roles, we must do better with the care and coordination
of urotrauma.
An AUA urotrauma work group was convened in 2009 to define
areas of opportunity for improvement in urotrauma care. To
broaden the discussion and establish the framework for
accomplishing these policy objectives, the AUA with Congressman
Guthrie has crafted H.R. 984.
This establishes an interagency task force to study a broad
range of opportunities for enhancing the prevention,
management, and study of urotrauma. The task force will
evaluate and define improvement opportunities in a variety of
areas including an assessment of the true scope and impact of
the injury pattern, the status of prevention, and assessment of
current facilities and programs within the DoD and VA engaged
in the prevention, management, and study of urotrauma with a
special focus on the status of research, expertise, and health
care infrastructure for female victims of urotrauma and then
analysis of the reproductive services available to
servicemembers who have been rendered infertile as a result of
urotrauma.
The care of these complicated injuries requires a
tremendous amount of expertise in care coordination. It is
clear that the transition of soldiers with urotrauma from the
DoD to the VA represents an area of opportunity not only with
respect to DoD physician to VA physician communication, but
also with the geographic placement of soldiers with these
unique needs in proximity to the available expertise,
technology, and programs in the VA to provide for their needs.
Finally, although each of the functional challenges that
result from damage to the genitourinary organs is life
altering, perhaps one of the most profound is the loss of
fertility. The brave young Americans who are voluntarily
putting themselves in harm's way in defense of our country are
often doing so prior to their reproductive years. Some are
suffering injuries that severely impair or eliminate their
natural reproductive capability, shattering the dream of many
to begin a family of their own.
H.R. 984 seeks an analysis of the technical,
administrative, and budgetary mechanisms to allow for enhanced
reproductive services for members who have been affected by
urotrauma or who are at high risk of urotrauma.
The AUA recognizes that there is much to be done in this
area from pre-deployment sperm banking to prior preservation of
sperm at the initial point of care when testicular loss is
inevitable, to providing advanced reproductive services to all
military victims of urotrauma who are infertile and receiving
care in the DoD and the VA.
We are currently short of that goal and the AUA working
group also supports legislation to enhance these policies.
In summary, the rate of genitourinary injury suffered by
American soldiers is up 350 percent in Afghanistan compared to
Iraq as a result of the increased necessity of dismounted
patrol.
Genitourinary injuries are increasingly common, complex
constellation of wounds with devastating long-term implications
for urinary, bowel, and sexual function and fertility. These
sequelae in turn have profound impacts on soldiers' mental
health, marriages, and other social relationships and overall
quality of life.
H.R. 984 prescribes the comprehensive study required to
address the variety of opportunities for improving the
prevention, initial management, care coordination, and research
of this devastating and increasingly prevalent pattern of
injury. We owe these finest Americans no less for the
sacrifices they have made for our great Nation.
On behalf of the American Urological Association and the
Urotrauma Coalition partners, I urge you to support H.R. 984
and favorably report it out of the Committee.
Again, I want to thank the Veterans' Affairs Committee for
their invitation to testify before you, and I am available to
answer any questions.
[The prepared statement of Mark Edney appears in the
Appendix]
Mr. Benishek. Thank you, Dr. Edney. Appreciate your
testimony.
Mr. O'Rourke, please proceed.
STATEMENT OF MICHAEL O'ROURKE
Mr. O'Rourke. Thank you, Mr. Chairman.
On behalf of the Blinded Veterans of America, we thank you
for this opportunity to provide testimony on current
legislation before the Subcommittee on Health.
Chairman Benishek, Ranking Member Brownley, and Members of
the House Committee, we are very interested and look at
beneficial travel for blinded veterans, H.R. 1284. We
appreciate the Ranking Member Brownley for introducing the
bill.
We would like to point out that last week in the Senate,
the VA Committee held a hearing on a companion bill, S.633,
introduced by Senator Tester that was broadly supported by the
witnesses.
The legislation, H.R. 1284, would assist disabled spinal
cord injury and blinded or visually impaired veterans who are
currently ineligible for beneficial travel benefits. This bill
would assist mostly low-income and catastrophically-disabled
veterans by removing the travel financial burden to access
vital care that will improve independence and quality of life.
We look at the blind rehabilitation centers that the VA
provides and the spinal cord injury centers which are probably
two of the most renowned facilities the VA has that they
utilize. It makes no sense to have developed over the past
decades outstanding blind rehabilitation programs known for
their very high quality and patient care, only to tell low-
income veterans that they are unable and, therefore, cannot
attend these centers.
To put this dilemma in perspective, a large number of our
constituents are living at or below the poverty line while the
VA means test threshold for travel is $14,340. This bill here
would assist individuals to partake at a blind rehabilitation
center.
To elaborate on the challenges of the travel for a blinded
person, we look at current facts. In a study of new
applications for recent vision loss rehabilitative services,
seven percent had current major depression and 26.9 percent met
the criteria for sub-threshold depression.
Vision loss is a leading cause of falls in the elderly. One
study found that visual field loss was associated with a six-
fold risk. While only 4.3 percent of those 65 and older in that
population live in nursing homes, the number rises to about six
percent for those who are visually impaired and 40 percent for
those who are blind. Medicare direct cost of this is $11
billion per year.
If blinded or spinal cord injury veterans are not able to
obtain the rehabilitative center training to learn to function
at home independently because of travel cost barriers, the
alternate charges for nursing home care or assisted home care
are far larger than they can afford. Thus, the Federal
Government usually subsidizes in the form of Medicare.
We caution that private agencies for the blind are located
in large urban cities; New York City, Chicago, Seattle,
Orlando, or Boston. So travel barriers would preclude
utilization of many of these sites for some of our veterans.
VA centers often use specialized nursing, physical therapy,
audiology, pharmacy, radiology, and laboratory support services
that are necessary for clinical care and blinded veterans.
Again, we stress one of the big challenges is that in the
civilian medical world, there is not a high incident of these
kinds of facilities that are available to veterans.
That concludes my testimony. I will be able to stand by and
answer any questions you might so have.
[The prepared statement of Michael O'Rourke appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. O'Rourke. I really
appreciate your time.
Mr. Atizado, you can go ahead for five minutes. Thank you.
STATEMENT OF ADRIAN ATIZADO
Mr. Atizado. Thank you, Chairman Benishek, Ranking Member
Brownley, Members of the Subcommittee.
On behalf of DAV's 1.2 million wartime wounded and injured
veterans, I am pleased to present our views on the legislative
measures subject to today's hearing.
Requesting my written testimony be made part of the record,
I will only address those bills on today's agenda for which DAV
has a mandate from our membership.
The Veterans Integrated Mental Health Care Act of 2013
would establish a new authority for VA to use in contracting
for mental health services for eligible veterans.
DAV national resolutions were passed at our most recent
national convention which calls for program improvement and
enhanced resources for VA mental health programs as well as
care coordination when VA purchases care in the community.
However, in light of this Subcommittee's hearing on
September 14, 2012, and as Chairman Miller had mentioned in his
opening statement, where we had discussed the VA's patient
centered community care and non-VA care coordination
initiatives. These initiatives are to promote coordinated
contract health care services including mental health care.
DAV believes this bill overlaid on these initiatives which
are ongoing would hamper VA's efforts and thereby cause
disruption and delay to reform all contract and fee-based
health care.
Mr. Chairman, I would like to note at this point that it
has been years since we have been asking for care coordination
in contract care, which is why I believe enactment of this bill
should be done prudently.
For these reasons, DAV recommends that this bill be held in
abeyance at this time until we realize or at least find out in
concrete manner how this bill if enacted would impact the
current initiatives.
H.R. 241, The Veterans Timely Access to Health Care Act,
would establish a statutory access to care standard of 30 days
within the VA health care system. The bill would also require
VA to submit to Congress continuing semi-annual performance
reports on waiting times.
Timely access to needed medical care is a critical domain
of high-quality care. Our membership approved national
resolutions addressing timely access to VA health care services
for service-disabled veterans.
However, we urge the Committee against prescribing a single
standard of waiting times across the universe of appointment
types as was mentioned earlier with the first panel. A 30-day
standard may lengthen waiting times considering VA's current
access standards.
DAV believes the transparency potential conveyed in this
bill to document more accurate waiting times is a worthwhile
concept. We ask for consideration and adding to the reports
greater granularity such as including waiting times for
purchased care, care purchased in the community whether it is
mental health or inpatient or rehab services.
We also ask for greater specificity in reporting such as
performance reporting by each VA facility.
H.R. 288, The CHAMPVA Children's Protection Act of 2013,
would extend the maximum age eligibility of a qualifying
veteran's child to CHAMPVA coverage from age 23 to 26 only if
the child is pursuing a full-time course of instruction at an
approved educational institution or is unable to continue to do
so because of a disability not resulting from a child's willful
misconduct.
Now, DAV supports this measure based on resolution number
222. However, we strongly urge amending it to conform to Public
Laws 111-148 and 111-152. These two public laws require private
health insurance to cover adult dependent children in covered
families until these individuals attain the age of 26
irrespective of marital status, financial dependency, or other
factors, and including in this instance educational status.
DAV urges the measure to be amended to ensure children of
severely-disabled veterans and survivors of veterans who have
paid the ultimate sacrifice enjoy the same rights and
privileges as other young adults of our country.
This concludes my testimony, Mr. Chairman. Thank you for
allowing DAV to testify, and I would be pleased to answer any
questions you or the Members of the Subcommittee may have.
[The prepared statement of Adrian Atizado appears in the
Appendix]
Mr. Benishek. Thank you very much for your input, sir. I
really appreciate it.
Mr. Nicholson, please proceed with your testimony for five
minutes.
STATEMENT OF ALEX NICHOLSON
Mr. Nicholson. Thank you, Mr. Chairman, Ranking Member
Brownley, and distinguished Members of the Subcommittee.
On behalf of Iraq and Afghanistan Veterans of America or
IAVA, we thoroughly appreciate the opportunity to share our
views regarding these important pieces of legislation pending
before you today.
As many of you know, IAVA is the Nation's first and largest
nonprofit, nonpartisan organization for the veterans of the
wars in Iraq and Afghanistan and their supporters. Founded in
2004, our mission is important but simple, to improve the lives
of Iraq and Afghanistan veterans and their families.
With a steadily growing base of over 200,000 members and
supporters, we strive to create a society that honors and
supports veterans of all generations. IAVA believes that all
veterans must have access to quality health care and related
services. IAVA is therefore supportive of each of the bills
that are the subject of this hearing here today.
With regard to H.R. 241, IAVA supports The Veterans Timely
Access to Health Care Act because it will help hold the VA
accountable for meeting maximum allowable wait times. A
veteran's ability to access timely care plays a vital role in
sustaining his or her quality of life post service. But from a
mental health point of view in particular, the importance of
providing timely care becomes even more critical.
Timely mental health care can sometimes mean the difference
between life and death for veterans in crisis. And IAVA
believes that every VA medical center and health care provider
should be able to provide reasonable standards of timeliness
when providing care for veterans.
IAVA also supports H.R. 288, The CHAMPVA Children's
Protection Act of 2013. With the enactment of The Affordable
Care Act, children up to age 26 can now be covered by their
parents' health insurance plans.
While legislation was subsequently enacted to extend this
coverage to eligible children of TRICARE recipients, this
legislation is still needed so that benefits can also continue
to be similarly provided to children of our Nation's wounded
warriors under CHAMPVA.
IAVA also supports H.R. 984 which would establish a task
force on urotrauma in order to expand research on and develop
new care recommendations for these injuries. Urotrauma, which
is often seen in servicemembers and veterans who have sustained
blast injuries, has unfortunately become more prevalent among
those who have served in Iraq and Afghanistan.
Because of advances in modern treatment practices within
the military medical community, servicemembers and veterans are
surviving these types of injuries with greater frequency than
in past conflicts which means that VA now finds itself treating
more injuries such as genitourinary injuries for which there
may not be a wide range of experience or vast body of knowledge
extant within the system.
IAVA sees H.R. 984 as an important step in providing the
necessary research and treatment options to address these
serious wounds of war.
IAVA supports H.R. 1284, which would authorize the VA to
reimburse the travel costs associated with seeking approved
inpatient care at a VA special disabilities rehabilitation
program for additional categories of catastrophically-disabled
veterans.
We believe this legislation will provide critical
assistance for more disabled veterans to allow them to receive
the specialized inpatient treatment that they need.
IAVA also supports Chairman Miller's draft bill, The
Veterans Integrated Mental Health Care Act. IAVA's 2013 member
survey revealed that 80 percent of respondents do not think
servicemembers and veterans are getting the mental health care
they need.
IAVA believes that one way to help address the mental
health care needs of veterans is through building the type of
community partnerships that are advocated for and facilitated
by this bill, and we believe this bill was a step in the right
direction toward building such positive and beneficial
community partnerships.
And finally, IAVA supports The Demanding Accountability for
Veterans Act, which would formalize the system of
accountability within VA, give the VA inspector generals'
report recommendations more authority, and institute
consequences for failing to fix problems clearly identified by
the VA's IG.
IAVA believes this bill will strengthen current systems of
accountability by narrowing the focus of scrutiny as to who is
responsible for producing and correcting IG identified public
safety issues.
Mr. Chairman, we at IAVA again appreciate the opportunity
to provide our views on these important pieces of legislation
and we look forward to continuing to work with each of you,
your staff, and the Subcommittee to improve the lives of
veterans and their families.
Thank you for your time and attention.
[The prepared statement of Alex Nicholson appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Nicholson. I
appreciate your comments.
Ms. Predeoux, five minutes.
STATEMENT OF ALETHEA PREDEOUX
Ms. Predeoux. Chairman Benishek, Ranking Member Brownley,
and Members of the Subcommittee, Paralyzed Veterans of America
would like to thank you for the opportunity to present our
views on health care legislation being considered by this
Subcommittee.
These important bills will help ensure that veterans
receive the best health care services available. We are
particularly pleased that two bills, H.R. 288 and H.R. 1284,
that are very high priorities for PVA are being considered
today.
My remarks will focus only on a few bills as PVA's full
statement has been submitted to the Subcommittee.
At this time, PVA does not support The Veterans Integrated
Mental Health Care Act of 2013, a bill that would require the
VA to provide veterans with an integrated delivery model for
mental health care through care coordination contracts.
The VA is currently working on multiple initiatives to
improve care coordination with private providers and increase
timely access to mental health services. More specifically, the
VA is in the process of transforming its national non-VA care
program in an effort to improve coordination services with non-
VA providers which includes mental health services.
PVA believes that the current VA initiative should be
further developed before additional resources are put into
another program for non-VA care coordination.
PVA generally supports the intend of The Veterans Timely
Access to Health Care Act which proposes to direct the VA
secretary to establish standards of access to care for veterans
seeking services from VA medical facilities.
If enacted, this bill would establish a standard for access
to care that requires the date on which a veteran contacts the
VA seeking an appointment and the date on which a visit with an
appropriate health care provider is completed to be 30 days.
While this legislation may potentially improve the delivery
of VA services, the language does not take into account the
fact that the standard for access to care may vary depending on
the type of care needed.
As such, PVA has concerns regarding the use of a 30-day
standard for access to care without specifying the type of care
that is being provided.
While PVA believes that timely access to quality care is
vital to VA's core mission of providing primary care and
specialized services to veterans, it is also important that
factors such as the nature of the services provided and
efficient use of VA staff and resources be considered when
developing standards for access to care.
PVA supports H.R. 288, legislation to increase the maximum
age for children eligible for medical care under the Civilian
Health and Medical Program of the Department of Veterans,
CHAMPVA.
CHAMPVA is a comprehensive health care program in which the
VA shares the cost of covered health care services for eligible
beneficiaries including children up to age 23.
As part of health reform, all commercial health insurance
coverage increased the age for covered dependents to receive
health insurance on their parents' plan from 23 years of age to
26 years of age in accordance with the provisions of Public Law
111-148, The Patient Protection and Affordable Care Act.
This change also included health care coverage provided to
servicemembers and their families through TRICARE.
Today, the only qualified dependents that are not covered
under a parent's health insurance policy up to age 26 are those
of 100-percent service-connected disabled veterans covered
under CHAMPVA.
This unfortunate oversight has placed a financial burden on
these disabled veterans whose children are still dependent upon
their parents for medical coverage, particularly if the child
has a preexisting medical condition.
PVA believes that this legislation will make the necessary
adjustment to help veterans and their families in this
position.
Lastly, PVA strongly supports H.R. 1284, a bill that if
enacted would provide coverage under the Beneficiary Travel
Program to non-service-connected veterans with a spinal cord
injury or disorder, double or multiple amputations, or vision
impairment.
Too often, catastrophically-disabled veterans, particularly
non-service-connected veterans who do not have the benefit of
travel reimbursement, choose not to go to VA medical centers
for care due to significant costs associated with their travel.
When these veterans do not receive the necessary care, the
result is often the development of far worse health conditions
and higher medical costs for the VA. For veterans who have
sustained a catastrophic injury like a spinal cord injury or
disorder, timely and appropriate medical care is vital to their
overall health and well-being.
PVA believes that expanding VA's beneficiary travel benefit
to this population of severely-disabled veterans will lead to
an increasing number of catastrophically-disabled veterans
receiving quality, timely comprehensive care and result in
long-term cost savings for the VA.
Again, thank you for the opportunity to submit PVA's views
on the legislation being considered today, and I am happy to
answer any questions that you may have.
[The prepared statement of Alethea Predeoux appears in the
Appendix]
Mr. Benishek. Thank you, Ms. Predeoux.
I am going to yield myself a few minutes to ask a few
questions about some of the legislation.
I want to thank you all for your candid comments because I
think your input is very valuable. I had some of the same
thoughts and questions about some of the legislation myself.
I am so happy to hear your opinion. And I hope that you all
will be willing to work with the Committee to try to improve
some of this legislation.
I know that many of you had concerns about the Chairman's
Veterans Integrated Mental Health Care Act. I am concerned
about addressing the concerns that you brought up, so hopefully
you will be able to work with the Committee and the Chairman to
address that.
I have a question concerning my legislation, The Demanding
Accountability for Veterans Act. I sponsored this after the
Subcommittee had a hearing where they had this IG report where
VA has not had a plan for physician staffing the last 30 years.
The IG had reported like eight times that we should do
something and then the VA reported back, oh, we are going to
have something in three years.
I cannot imagine how we could get people to do what they
are supposed to do at the VA. With the amount of open IG
recommendations, do any of you have any ideas as to how we can
make these particular managers more responsible?
I understand that Congress has oversight responsibility,
but, we come upon an incident somewhere in the VA and we
highlight it here it in Committee and it is talked about
everywhere, but there are things going on. There are a thousand
open IG recommendations. We cannot get to every one of them in
these committees for oversight. The IG is their own oversight.
So shouldn't we have those IG reports have some teeth to
them? And I would like to ask any of you if you have any
opinion as to what my legislation does or if you have a better
idea as to how to hold the VA accountable for getting things
done.
Mr. O'Rourke, do you have anything?
Mr. O'Rourke. No, sir, not at the present time.
Mr. Benishek. Mr. Atizado?
Mr. Atizado. Thank you for the question, Chairman Benishek.
I can tell you that it is an appropriate question to ask
about IGs' recommendations. I actually had the opportunity,
probably about a year and a half ago, to try and follow-up on
these recommended actions and I could not follow it.
I called between the IG and the program office at VA to see
what the status was on the recommendations and for the most
part, the actions that were recommended were actually
negotiated, which means the recommended actions that were
written on the report were not actually the recommended actions
that VA was working on as agreed upon by OIG.
Meaning to say, Mr. Benishek, that while this bill intends
to put some greater enforcement and accountability on the part
of the IG, we have to be a little bit more thoughtful on how
this is done.
For example, better definition of what covered reports are.
Anything that VA does which is a public health institution
deals with public health and safety. Does it include all the
reports that the IG provides? What does significant progress
mean?
Just some thoughts, Mr. Benishek. That is all I have.
Mr. Benishek. I understand what you are thinking, but I am
trying to find the best way to do this too. How do we hold the
VA accountable? How do we get people to actually produce?
Mr. Nicholson, do you have any other ideas there?
Mr. Nicholson. I would just add, Mr. Chairman, that I think
we are on the same page in terms of solutions that would
actually have teeth to them. You know, I think whether it is
public safety issues, IG recommendations, following through on
reducing the backlog, it does not sort of matter, you know,
what issue you look at, you know, the VA, I think, keeps
promising us progress year after year and, you know, we see
backlogs and not only disability claims, you know, issues, but,
you know, like you mentioned earlier in following through on
all these outstanding IG recommendations.
You know, so something, I think, that would add some teeth
to, you know, the accountability factor, I think, would be
certainly welcomed by us.
You know, we hear from our members consistently year after
year. You know, we do an annual survey of our membership which
is one of the largest that is done independently of Iraq and
Afghanistan era veterans. And we consistently hear that while
veterans are satisfied with the care they receive, they
continue to be dissatisfied overall with the VA itself. You
know, there is sort of a disconnect between, you know, sort of
the tactical level and the strategic level here.
And so, you know, I would say from our perspective
solutions like you mentioned with teeth, would certainly be
welcome and I think it is, you know, high time that we start
adding teeth into these types of bills.
Thank you.
Mr. Benishek. I want to talk a bit more about this, but I
want to give Ms. Brownley an opportunity to ask some questions.
Ms. Brownley. Thank you, Mr. Chair.
Again, I also want to thank everybody here who has
testified and appreciate your comments and recommendations. And
I want to particularly thank Mr. O'Rourke for a detailed
perspective on H.R. 1284 and the benefits for veterans.
I would like to hear from the Blinded Veterans Association
and the DAV and the PVA if they have any comments relative to
some of the VA testimony that this particular bill as written
might provide some disparate travel eligibility to a limited
group of veterans and they would favor opening up the travel
benefits to a wider group of veterans, of course contingent
upon funding, but would like to hear your response to that
suggestion.
Ms. Predeoux. I can begin. PVA certainly would not be
opposed to expanding that benefit. However, we believe that the
three populations that are targeted is a good start simply
because these groups have systems or centers of care within the
VA that are not always geographically accessible for this
population of veterans, these populations of veterans.
When you consider that they may have clinics or other
access to VA facilities, comprehensive care that is needed at
least at a minimum, oftentimes more, once a year getting to
those facilities oftentimes could be three to four hours. And
so to ensure that they are receiving the care at least once a
year, we wanted to make sure that cost did not prevent them
from doing that.
So it is those centers of care oftentimes, we cannot have
one everywhere, and particularly in the rural areas, so I think
this is a good first step and we would definitely support the
expansion of the benefit to other veteran populations.
Ms. Brownley. Thank you.
Mr. Atizado.
Mr. Atizado. Ranking Member Brownley, thank you for that
question.
So in our testimony, we talk about possibly expanding
beyond the current statutory requirement as well as what this
bill proposes to do. Simply because there is a provision,
actually it is paragraph two below the one that this bill wants
to amend, that gives the secretary discretionary authority to
provide these benefits to any other veteran that the secretary
deems fit or appropriate to which we do not believe it has
actually been exercised but for very anecdotal, very specific
instances.
For example, facility transfers from SCI to SCI, air
travel, things of that nature. So the need is there and there
is a wide gap between those anecdotal incidences as well as
these three populations. We think it should be a little bit
more broader with a sense that there should be more parity.
Yes, the three populations that this bill considers is
certainly deserving, but there are others as well, whether it
be those who are frail elderly who just cannot drive and need
somebody to help them drive to a facility, things of that
nature. That is where we would like to see this provision go.
We agree with PVA that it is a good first step and would not
oppose its enactment.
Ms. Brownley. Thank you for that.
Mr. O'Rourke, do you have any additional comments?
Mr. O'Rourke. Yes, ma'am. I think the VA has some
outstanding facilities and I think that at times they go under-
utilized. So my point being here is, we would like to expand
into the inpatient treatment facilities more patient care from
eligible veterans. And this would be the first step for those
that are non-service that come down with age-related disease
entities.
As we progress in age, some things just happen to us. We do
not want them to happen, but they do. Glaucoma becomes more
constant, diabetic neuropathy with the diabetic population.
In our veterans, we look at macular degeneration. We look
at the many different types of wounded that are coming back
from OIF/OEF that that IED, that blast does not just stop at
the TBI or the traumatic brain injury. It affects the eyes. It
affects audiology. It affects the lower abdomen.
I wish we had Kevlar to take care of that, but we do have
fine upstanding VA facilities that I think are going under-
utilized, if that is appropriate terminology. And I think we
have the veterans that need and deserve the care at these
facilities.
And this travel bill will assist them. And they do such
good work there that I would think that it would be
advantageous for the VA to do it in many other arenas, but I
understand finances. And today's society, I think it is the
next right move.
Ms. Brownley. Thank you very much.
And I will yield back to the Chairman.
Mr. Benishek. Thank you, Ms. Brownley.
We have a few more questions, but I think maybe I will
submit some of the questions that I have to you in writing and
hopefully get a response from you there because I know as far
as my legislation is concerned, I do not want to have any, you
know, let me put it that way, that I want to have some strict
definitions of what is going on there so that we can actually
hold people accountable and not slip out, if you understand
what I mean.
So I truly appreciate all your comments here today and look
forward to speaking to you further about these issues and these
pieces of legislation. I truly appreciate your time and you
being here today.
So unless you have any other questions, you can expect a
few written questions from us, and the panel is now excused.
Thank you very much for being here.
And at that point then, we are going to welcome our third
and final panel to the witness table. And that will be from the
Department of Veterans Affairs Dr. Robert Jesse, the Principal
Deputy Under Secretary for Health. Dr. Jesse is accompanied by
Susan Blauert, Deputy Assistant General Counsel.
So, Dr. Jesse, thanks for joining us today. I appreciate
your presence and I look forward to your comments about the
proposed legislation before us. And you can proceed when you
are ready.
STATEMENT OF ROBERT L. JESSE, PRINCIPAL DEPUTY UNDER SECRETARY
FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS, ACCOMPANIED BY SUSAN BLAUERT, DEPUTY
ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Jesse. Well, thank you, sir.
And good morning, Chairman Benishek and Ranking Member
Brownley and Members of the Subcommittee. And thanks for the
opportunity to address the bills on today's agenda and the
impact that these are going to have on the VA.
And as you mentioned, I am accompanied by Susan Blauert,
VA's Deputy Assistant General Counsel.
Sir, we very much appreciate your continued efforts and
those of the Subcommittee to support and improve veterans'
health care.
Because of the short time for preparation views, we do not
have formal testimony on two of the draft bills, H.R. 241, The
Veterans Integrated Mental Health Care Act of 2013, and H.R.
984, Demanding Accountability for Veterans Act of 2013.
Despite not having formal prepared views on these bills, we
do recognize the importance of addressing these underlying
issues and that are related in each of these bills. In fact,
all these bills are issues that are very important to the VA.
For example, we have worked steadily to implement the
letter intent of the Executive Order improving access to mental
health care services for veterans, servicemembers, and military
families.
We believe that we have made significant progress towards
hiring mental health professionals and many of the other
ongoing mental health initiatives demonstrate our strong
commitment to ensuring the availability of mental health
services to all of our veterans wherever and whenever it is
needed.
Likewise, VA understands the needs for a system and
organizational processes that support a culture of excellence
and one of accountability. And H.R. 241 and your draft
Demanding Accountability for Veterans Act both seek to hold VA
to high standards. And please know that we share those common
values.
And I will take a moment and explain now the position we
have on the two bills for which we were able to complete views.
There is a more detailed treatment of these in my written
statement.
VA generally support bills that expand services to veterans
when resources permit us to do so and this would include
increasing the maximum age to 26 for eligibility of young
adults covered by our CHAMPVA program.
We are concerned with the bill as it is written because we
fear it may not accomplish the objective because it fails to
address a technical definition of the term child contained in
the current statute. And our written statement provides a more
detailed explanation.
I use the term young adults because I have kids that age
and they do not like it when I call them children.
Be assured that we are anxious to work with the Committee
toward providing the best language to support the intent of the
bill. We fully support ensuring that CHAMPVA coverage is
consistent with private sector coverage provided under The
Affordable Care Act.
The second bill, H.R. 1284, would extend VA's beneficiary
travel benefits to certain veterans with vision impairment,
spinal cord injury or disorder, and double or multiple
amputations.
The eligibility provided in this bill is offered
specifically for when this class of veterans is traveling to
receive care from the VA's special disabilities rehabilitation
program on an inpatient basis or when the trip qualifies for
temporary lodging.
And I have been well schooled by Tom Zampieri and Mr.
O'Rourke about the complexities of getting particularly blinded
veterans back and forth even for their primary care
appointments.
We believe the legislation could be improved then by
broadening the scope. VA supports extending the beneficiary
travel eligibility to all veterans who could most benefit from
the program.
VA provides rehabilitation for many injuries and diseases
including for veterans who are catastrophically disabled. VA
also provides care at numerous specialized centers other than
those noted in H.R. 1284.
For example, we have other programs for closed and
traumatic brain injury, for post-traumatic stress disorder,
military sexual trauma, and other various addiction programs.
Many of these programs provide outpatient care to veterans
who might not require lodging, but still travel significant
distance or are challenged in traveling to those appointments
on a daily basis. And under this proposed legislation, the
group of veterans would not be eligible.
For these reasons, VA does not support the legislation as
written because it would provide disparate travel eligibility
to a limited group of veterans.
However, we do support the idea of travel for a larger
group of catastrophically-disabled veterans including veterans
who are blind or have SCI and amputees and those with special
needs who may not otherwise be eligible for travel benefits.
Once again, VA welcomes the opportunity to work with the
Committee to craft appropriate language that is mindful of both
resources and especially the needs of these veterans.
So thank you for the opportunity to testify before the
Committee and we will be pleased to answer your questions.
[The prepared statement of Robert L. Jesse appears in the
Appendix]
Mr. Benishek. Thank you very much, Doctor.
Let me ask you a question. How much time did you have then
to prepare for the hearing today? When was the notice given,
because you said you did not respond because there was not
enough time?
Dr. Jesse. Well, I would defer that to our congressional
affairs people because I am not aware exactly when it came in.
But I think it was within less than two weeks. So it was a
relatively short notice.
Mr. Benishek. All right.
Dr. Jesse. We can get the exact timing for you.
Mr. Benishek. Well, I am just curious. I think three weeks
is probably the standard, I guess, for the hearing notice, and
I just feel disappointed when I hear that answer in view of e-
mail and that.
Nowadays, it usually happens pretty quickly. So it seems
like two weeks would be a pretty good amount of time to figure
out a response to some of these legislative ideas.
You understand the purpose of my piece of legislation, Dr.
Jesse?
Dr. Jesse. Yes.
Mr. Benishek. I am trying to figure out how to get the VA
to get some things done that do not seem to be getting done.
Some of the comments by the previous panel identified some
shortcomings that I do not specifically target what exactly I
am looking for.
I just do not like the fact that people, managers of a
project, that do not respond to an IG report for over a year
and, this incident of, no physician plan for staffing has been
going on for 30 years with eight separate IG reports over the
past 30 years.
And then when I had them in front of my Committee, a month
ago, it was, well, they are going to have a plan in three
years. They have agreed that they need a plan for the last 30
years and, yet, nothing is getting done.
So how do I fix that, Dr. Jesse?
Dr. Jesse. So I can, I guess, reflect on that in my
experience within the VA. And my job prior to this one was as
the director of, well, initially as cardiology and then of
medical surgical services.
And I know that there has been work on this, in fact, so I
am not sure about the exact date, but it was about the time
that I became head of medical surgical services, an office was
stood up, the Office of Productivity Evaluation, really looking
exactly at this. And it is up in Boston.
And we found that primary care is pretty easy. You can
build a panel and we work on a goal of about 1,200 patients per
primary care provider. And for specialty care, it is quite a
bit harder and----
Mr. Benishek. Oh, no, I understand all that for that
particular issue. And it is not so much the physicians. The
secretary does this kind of stuff all the time. That is just
one of the issues that I am getting at. Okay?
Dr. Jesse. Okay. Yeah.
Mr. Benishek. I understand that as a physician, you kind of
figure this out. You know what I mean? But what I am learning
about there is some manager somewhere whose responsibility it
was to get this done and it seems like something could have
been done in the last 30 years with eight reports and VA
agreeing with the reports, but nothing happening.
And I think that identifying the person in charge of that
program is important because when we have these people before
us, it is never the actual person that was in charge that
actually appears here. And then we have a hard time figuring
out who that person actually was.
You understand what I am saying?
Dr. Jesse. Yes. I guess my comment to that would be often
it is not a person that gets responsible. So it may not fall
under one particular program office at times. And that is part
of the problem is--I mean, you are exactly correct--in how one
assigns the lines of accountability to get things done. These
are often--well, everything is complex in health care.
Mr. Benishek. I know. But, I hate when you come up here and
you say to me there is no one who is responsible. You said that
there. There is not one person responsible, so then how do we
hold them accountable because everybody else, they shift that
responsibility here and there. It was not my fault. That is not
my department.
You know what I mean? We need to have that better defined
and I am trying to fix that. And my legislation is an attempt
to do that. You know, it may not be perfect. That is why I want
input.
Dr. Jesse. No. And I think you are exactly correct in
looking at these issues that are open for a long period of time
and do not meet their deadlines because clearly there is
something wrong if we have committed to do something in a
certain amount of time and we are not getting there. Then we
owe an explanation as to why.
And sometimes there are very good explanations, but often
there are not. And I think when we do not, then we do need to
be held accountable for that and to you and with the
transparency that we believe we operate under to make that
clear.
Mr. Benishek. Yeah. Well, I appreciate your comment and the
fact that sometimes there is not anyone responsible. That is a
really good point that you make there. I think maybe we can try
to fix that as we look at, adjusting this bill and actually
have it have some teeth. So I appreciate that.
I will allow Ms. Brownley an opportunity to ask questions.
Ms. Brownley. Thank you, Mr. Chair.
And I wanted to follow-up as well on the bill that I am
carrying, H.R. 1284. And I certainly appreciate your testimony
with regards to expanding these kinds of services to a larger
population.
I am just wondering if you have any kind of cost estimate
if it were expanded.
Dr. Jesse. I do not have it in my head, but we could
certainly get that to you.
Ms. Brownley. So you have looked at it then?
Dr. Jesse. Yeah. I think we have looked into it. I can
probably look it up in here, but we can get a rough estimate to
you.
I would like to answer that from a different side because
it is an important issue and it is not quite as quantitative.
But we know that one of the most costly things in medicine
is when people miss appointments and that, in general, making
sure that patients get to appointments is in a very broad scope
cost effective. And that is not just related to the cost of the
travel. It is the cost of the complications of untreated
diseases. It is the cost of compliance and all these other
things that add in.
And this has been a pretty consistent theme that we have
seen, but also in a lot of the other large health systems. And
so it is one of the reasons why we are, you know, regardless of
the cost, we are very supportive of the ability to get patients
to their appointments.
It is also one of the reasons why we are so strongly
committed to really moving health care from being about just
the appointment to being about the sustained relationships
because so many of these issues can be mitigated if patients
can just reach into the system and through telehealth, securing
messaging, and any other number.
You have all heard a lot about where we are going in those
directions. These are important contributors to ensuring good
health care, but they are all part of a large package. But that
is one of the reasons why we are so strongly committed to that,
so that everybody does not have to come in for an appointment,
but when they do, we want them there.
And that is why we are very supportive of the
transportation and particularly rural transportation. And I
know that Mr. Michaud is very committed to this.
Ms. Brownley. Well, just following up with that, and I
appreciate your comments relative to that, because I think
everybody here really does believe that a bill like this,
providing the transportation, making sure that veterans show up
for their appointments and so forth in the long term is a cost
savings, will be a cost savings to the VA and really a bill
like this, I wish it was always presented as a cost savings as
opposed to a cost.
And just wondering again whether the VA has done any kind
of analysis to demonstrate and quantify, if you will, what the
real savings are.
Dr. Jesse. I can get back to you on the record for that. I
just cannot tell you right now.
Ms. Brownley. So you actually have all of that information?
Dr. Jesse. Well, I will see what we do have. I know this is
an area that we have been very interested in. We have got a lot
of interest in looking at this. I just cannot tell you
precisely the numbers and data that we have at this time. We
will get back to you with where we are on that.
Ms. Brownley. Okay. Great. And I just wanted to follow-up
on my colleague's bill, Mr. Michaud's bill and the CHAMPVA, and
appreciate your comments vis-a-vis the technical area in the
bill and certainly will appreciate your technical assistance so
that we can get the bill----
Dr. Jesse. Yeah. We believe this is important. We just want
to make sure it is correct.
Ms. Brownley. Okay. Great. Very, very good. And the other
thing is that I understand that in terms of identifying the
population, the young adults, as you refer to, there were some
statistics from the March 31st, 2010 data run.
I am just wondering if there is any updated data on that. I
think that the 2010 data run said that the VA estimated a
figure of about 59,000 additional young adults would become
CHAMPVA eligible and just wondering if you have any updates on
that.
Dr. Jesse. I think it is going to be in about that same
range.
Ms. Brownley. Okay.
Dr. Jesse. We do know those numbers.
Ms. Brownley. Thank you, sir.
I yield back my time.
Mr. Benishek. Well, I have a couple of little follow-up
questions.
Dr. Jesse. Sure.
Mr. Benishek. I think we are going to end up submitting
some written questions to you as well, Dr. Jesse, and I would
appreciate your written response to them later.
But one of the comments that Dr. Edney made the urologist
that testified talked about the difficulties sometimes
coordinating urotrauma care in the VA--when the veteran ends up
going to a VA close to his home.
Do you agree that a coordinated centralized effort to treat
the long-term urotrauma would be a good idea and how do you see
that working within the VA system?
Dr. Jesse. So I was very interested in his testimony. A
couple things sort of came to my mind. And one is, as he
mentioned, the complexity of moving patients from their active
duty into the VA system and it argues very strongly for the
work that we are trying to get through at the VLER, the Virtual
Lifetime Electronic Record, to make sure that moves across.
VA already has, I think it is about 16 of our VISNs have
centers that can deal with complex urinary trauma including the
five polytrauma centers. And these are the kind of specialty
care that need to go to specialty places.
You know, this is the type of thing that I would normally
be thinking about and my thinking on this was changed pretty
dramatically about a year ago. I was sitting on a plane and the
woman in the middle seat next to me was quite upset. And it
turned out why she was upset because her husband was at the
front of the plane and she was at the back of the plane. And
the guy sitting up front was not willing to change seats with
her.
But I got to talking to her. Her husband had complex GU
trauma. And I learned an awful lot about--you know, he was
getting excellent care for this, but the issue was far beyond
the technical surgical care. Really there were just so many
complex family issues involved in this.
And that is not the stuff that moves to the specialty
centers. Yes, we have expertise in there, but that kind of care
needs to go on everywhere when they get back into their
communities and it needs to be very much a part of all the rest
of the health care that they get.
And that is the coordination piece that I think you talk
about. We need to make sure that, you know, our providers are
attuned to these issues and can deal with them in more than the
technical medical and surgical parts, but also be very attuned
to the, you know, the complexities that go on with these.
So, you know, we have done a lot in educating particularly
about military sexual trauma. The women's health program in VA
is just astounding in the work they have done in the past four
or five years and particularly now with work in reproductive
health which was part of his testimony.
So all these pieces are, in fact, coming together, but, you
know, if it is just about the technical GU surgery piece, I
think the specialized centers are really important. But I think
we also need to have the windows wide open to see the entire
complexity of the situation.
Mr. Benishek. Well, I agree with you on that, but I think
that the urology specialists provide more than just simply the
technical expertise. They provide also a value in understanding
some of these social issues sometimes----
Dr. Jesse. Oh, absolutely.
Mr. Benishek. --psychosocial issues associated with this
trauma sometimes more than the person at the local VA who is
taking care of the patient. I agree that the person at the
local VA should be in communication with the specialist so they
have a familiarity with those things.
But as a general surgeon, I feel a little bit distraught
when you say it is simply a technical----
Dr. Jesse. No, I did not mean to imply that.
Mr. Benishek. We have more than simply a technical ability.
We deal with these issues.
Let me ask you another question if you do not mind. In your
written testimony, you stated the VA believes that eligibility
for coverage of children under the CHAMPVA would be consistent
with certain private sector coverage under The Affordable Care
Act. Yet, during the consideration of and the passage of The
Affordable Care Act, the Administration did not include in its
budget or submit a legislative request to amend the CHAMPVA to
extend the coverage for children up to age 26.
Do you know why that happened?
Dr. Jesse. I do not, but we can get that back to you. We
are in favor of it. I do not know why it did not come through
from us.
Mr. Benishek. All right. Ms. Brownley, do you have any
other questions?
Ms. Brownley. No.
Mr. Benishek. Well, I think that will conclude the hearing
today. Please be ready to get the remainder of the questions
that we want to have answered to help us formulate this
legislation a little better.
But I truly appreciate everyone being here and your
comments today and feel free to follow-up with the Subcommittee
for any other input you want to provide. And thank you so much
for your time this morning.
Dr. Jesse. Thank you, sir.
[Whereupon, at 11:46 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Dan Benishek, Chairman
Good morning. The Subcommittee will come to order.
Thank you all for joining us today as we meet to discuss six
legislative proposals aimed at strengthening the health care and
services we provide to our honored veterans through the Department of
Veterans Affairs (VA).
The six bills on our agenda this morning are:
- draft legislation, the Veterans Integrated Mental Health Care Act
of 2013;
- draft legislation, the Demanding Accountability for Veterans Act
of 2013;
- H.R. 241, the Veterans Timely Access to Health Care Act;
- H.R. 288, the CHAMPVA Children's Protection Act of 2013;
- H.R. 984, to direct the Secretary of Defense to establish a task
force on urotrauma; and,
- H.R. 1284, to provide for coverage under VA's beneficiary travel
program for certain disabled veterans for travel for certain special
disabilities rehabilitation.
These bills seek to address a number of important issues facing our
veterans.
I expect today's hearing to encompass a highly detailed and
thorough discussion of the potential merits, challenges, and
implications of each proposal before us.
I look forward to working with the Ranking Member, the bill
sponsors, and our Subcommittee colleagues to fully evaluate these
proposals and ensure that we advance meaningful and appropriate
legislation to fulfill the promise we made to our veterans.
My bill - the Demanding Accountability for Veterans Act - is
intended to address the pervasive lack of action taken by VA based on
their own agreed upon timelines for remediation of issues and
recommendations included in VA Inspector General (IG) reports.
Currently, the IG tracks open recommendations on their Web site and
in their Semiannual Report to Congress, the latest of which showed that
there were 177 total open reports and 1,140 total open recommendations.
Of those, 33 reports and 93 recommendations had remained open for more
than one year.
My bill would require the IG to make a determination whether VA is
making ``significant progress'' on implementing VA's own agreed upon
action plan and timeline to implement the recommendations made by the
IG in a report concerning public health or patient safety.
Under the bill, if the IG determines that ``significant progress''
has not been made, the IG would be required to notify the Committees
and the Secretary of the Department's failure to respond appropriately.
Following notification, the Secretary, would be given fifteen days to
submit the names of each VA manager responsible for taking action to
the IG.
In turn, the Secretary would be required to promptly notify each
responsible manager of the issue requiring action, direct that manager
to resolve the issue, and provide him or her with appropriate
counseling and a mitigation plan.
The Secretary would also be required to include in the responsible
manager's performance review an evaluation of actions in response to a
relevant IG report and prohibit the individual from receiving a bonus
or other performance award for failure to take action.
The goal of this legislation is simple - to create a culture within
VA where problems that go unresolved are unacceptable.
Far too often, I have seen serious issues that the IG has
identified go unaddressed by the Department.
Such inaction is intolerable where the care and services provided
to our veterans is concerned and it is well past time for those at VA
who are responsible for implementing needed changes to be held
accountable for their work.
I am hopeful that the Demanding Accountability for Veterans Act is
the first step in ensuring that they are.
I am happy to answer any questions my colleagues may have on this
bill and to listen to the views of all of our witnesses.
To that end, I would like to thank all the sponsors for taking the
time to speak with us about their proposals today. I am grateful to
each for their leadership and advocacy efforts on behalf of our
veterans and their families.
I would also like to thank our veteran service organization
partners and other stakeholders - both those who will testify here this
morning and those who submitted statements for the record - for their
valuable input.
I am also grateful to VA for being here to provide the Department's
views on these important proposals.
With that, I now yield to Ranking Member Brownley for any opening
statement she may have.
Thank you.
Prepared Statement of Hon. Julia Brownley
Thank you Mr. Chairman.
Today, we have a full schedule that includes six bills before us
that address some of the unique needs of our Nation's veterans'
population. The bills pertain to a variety of areas that affect the
lives of veterans every day and this Subcommittee has conducted many
oversight hearings to understand the problems and then fix them.
The first two bills on today's agenda, including one of your
proposals, Mr. Chairman, are pieces of draft legislation to address
mental health concerns and increasing accountability at the VA.
The next bill, H.R. 241, the Veterans Timely Access to Health Care
Act, was introduced by Mr. Ross of Florida and pertains to timely
organized and scheduled visits to VA Medical facilities.
H.R. 288, the CHAMPVA Children's Protection Act of 2013 sponsored
by Mr. Michaud, Ranking Member of the Full Committee, would amend the
maximum age for children to obtain medical care under CHAMPVA from 23
to 26 and effectively reflect the Patient Protection and Affordable
Care Act enacted in 2010. I will speak further on this bill during the
first panel.
Next, H.R. 984, introduced by Mr. Guthrie of Kentucky, would direct
the Secretary of Defense to establish a National Taskforce on
Urotrauma.
And finally, my bill, H.R. 1284, the Veterans Medical Access Act,
would provide better access for blind and severely disabled veterans
who need to travel long distances to obtain care at a special
rehabilitation center. Oftentimes blind and catastrophically disabled
veterans choose not to travel to VA medical centers for care because
they cannot afford the costs associated with the travel. Currently, the
VA is required to cover the cost of transportation for veterans
requiring medical care for service-connected injuries. H.R. 1284 would
extend these travel benefits to a veteran with vision impairment, a
veteran with a spinal cord injury or disorder, or a veteran with double
or multiple amputations whose travel is in connection with care
provided through a special disabilities rehabilitation program of the
VA. Our disabled veterans have already made the greatest of sacrifices
and I firmly believe, as I am sure many people in the room here today
do, that no veteran should be denied needed medical care.
I thank all of the Members for their thoughtful legislation and I
want to thank you, Mr. Chairman, for including my bill here today.
Thank you and I yield back.
Prepared Statement of Hon. Jeff Miller
Thank you, Dan.
It is a pleasure to be here today with you, the Members of the
Subcommittee on Health, representatives from our veterans service
organizations, and other interested stakeholders and audience members
to discuss my draft bill, the Veterans Integrated Mental Health Care
Act of 2013.
Two weeks ago yesterday, I spent the day in Atlanta, Georgia, with
several Members of the Georgia delegation to discuss inpatient and
contract mental health program mismanagement issues at the Atlanta
Department of Veterans Affairs Medical Center (VAMC)
This visit occurred after the VA Inspector General (IG) issued two
reports, which found that failures in management, leadership,
oversight, and care coordination at the Atlanta VAMC contributed to the
suicide deaths of two veteran patients and the overdose deaths of two
others.
Alarmingly, the IG found that approximately four-to-five-thousand
veteran patients fell through the cracks and were lost in the system,
after the Atlanta VAMC failed to adequately coordinate or monitor the
care they received under VA's contracts with community mental health
providers.
I wish that I could say that the issues in Atlanta are an isolated
aberration. Unfortunately, that would be far from the truth.
Rather, the Atlanta story is just the latest in a tragic series of
incidents highlighting serious and systemic deficiencies plaguing the
provision of mental health care to at-risk veterans through the VA
health care system.
Since 2007, VA's mental health care programs, budget, and staff
have increased significantly.
Yet, the numbers of veterans taking their own lives has remained
stagnant for the past twelve years - with eighteen to twenty-two
veteran suicide deaths per day since 1999, according to VA's own
numbers.
I could go on but the bottom line is this - the one-size-fits-all
path to mental health care that the Department is on is failing the
veterans most in need of its services. And, the time to act is now.
I have been and will certainly continue to be a strong and
supportive advocate of the VA taking action to hire staff, and address
the continued failures of mental health care provided within its own
walls.
However, it has become abundantly clear - through the data I have
discussed this morning, through Committee oversight, through numerous
IG and Government Accountability Office reports, and through the
personal accounts of the veteran constituents that call my office and
the offices of my colleagues on a daily basis to ask for help - that VA
cannot cope with the magnitude of mental health needs our veterans
experience in a bureaucratic vacuum with the normal VA business-as-
usual approach.
In order to truly maximize mental health care access for today's
veterans, VA must embrace an approach to care delivery that treats
veterans where and how they want, not just where and how VA wants. Some
have said this could undermine VA health care as we know it. Nothing
could be further from the truth. This isn't about supplanting the VA
health care system, it's about supporting it.
To the contrary, to truly address and resolve the breakdown in the
provision of mental health care services to veteran patients, VA must
adopt a proactive, integrated, coordinated care delivery model for
mental health care.
Most importantly, VA must adopt a mental health care delivery model
that is truly veteran-centric - one that meets and cares for veteran
patients where they are, treats the entirety of their concerns with
supportive and timely wraparound services, and recognizes and respects
their unique circumstances, goals, and health care needs throughout
their lives as veterans.
That is why I have proposed this draft Veterans Integrated Mental
Health Care bill before us. It would take the first important step to
help veterans in need, whether those services are provided in or out of
VA facilities.
Specifically, the draft bill would:
- require VA to provide mental health care to an eligible veteran
who elects to receive such care at a non-VA facility through a care
coordination contract with a qualified entity; and,
- require such entity to meet specific performance metrics
regarding quality and timeliness of care and exchange relevant clinical
information with VA.
It would ensure that existing mental health care resources - both
those found within VA facilities and those provided to veterans through
fee basis care - are managed effectively.
It would also ensure that the care provided to veteran patients in
need of mental health services is timely, convenient, and coordinated
from the initial point of contact throughout the recovery process.
I understand that some veterans service organizations (VSOs) have
expressed concern about waiting until VA rolls out its own new contract
care initiatives.
And - while I appreciate, understand, and respect these views, I
look forward to working closely with them to address their concerns -
but the time for waiting is over.
Last year, the IG found that more than half of the veterans who go
to VA seeking mental health care services wait fifty days on average to
receive even an initial evaluation.
This year, the IG found that thousands of Georgia veterans had
fallen through giant cracks in VA's mental health care system and may
or may not have received the care they so desperately needed.
We cannot wait to see what next year brings.
When a veteran is need of mental health care services, the
difference of a day or a week or a month can be the difference between
life and death, between contentment and struggle.
The time to act is now.
I look forward to working hand-in-hand with Committee Members, our
VSO partners, and other stakeholders to strengthen the language in this
draft bill and address any issues that may be raised during the
Subcommittee's discussion this morning.
Thank you once again, Dan, for holding this hearing today and for
your hard work and steadfast leadership of the Subcommittee on Health.
I appreciate the opportunity to be with you all today.
With that, I yield back.
Prepared Statement of Hon. Dennis Ross
Thank you, Chairman Benishek, for holding this hearing today, and
for allowing me to testify on behalf of legislation I introduced
entitled the Veterans Timely Access to Health Care Act.
America's Veterans are the backbone of the freedom and prosperity
this country has enjoyed for over two hundred years. We owe them a debt
that we can never truly repay.
Unfortunately, across the country, and across Florida's 15th
Congressional District, Veterans continue to encounter unacceptable
problems and delays receiving appointments from the Veterans
Administration (VA) for essential medical and specialty health care
needs.
For instance, the VA has set a goal to provide an initial mental
health examination within 14 days from the time a Veteran contacts a VA
medical provider to schedule a consultation. They have claimed to meet
this goal with a 95% success rate.
However, an Inspector General (IG) 2012 report published greatly
contradicts these claims. In fact, this IG report determined the VA
only met its goal 49% of the time - with the remaining patients being
forced to wait approximately 50 days for the VA to provide this
critical mental health evaluation.
To be clear - more than 184,000 Veterans waited approximately 50
days to receive a critical mental health evaluation. Not treatment -
just the formal evaluation. This is a disgrace to our Veterans, and
something that should not be tolerated.
Additionally, Chairman Mike Coffman of the Subcommittee on
Oversight and Investigations held a hearing on March 14, 2013 to
examine patient wait times at VA medical facilities. Sadly, the
Chairman revealed that according to VA documents, at least two Veterans
died last year from diseases while awaiting a medical consultation at
the VA.
That is why I am proud to have introduced H.R. 241, the Veterans
Timely Access to Health Care Act.
This legislation, supported by the Military Officers Association of
America (MOAA) and The Retired Enlisted Association (TREA), will ensure
Veterans seeking primary and specialty care from a VA medical facility
receive an appointment within 30 days - period.
This legislation also contains a number of detailed reporting
requirements, so that Congress may better track the VA's progress. And
if the VA discovers they are not meeting their goals and mandated 30-
day access to care, it is my hope that they will reach out to Congress
before their reports are filed so we can work together to meet the
needs of our nation's brave and courageous Veterans.
We are all on the same team, with the same goal of providing
timely, high quality care to our Veterans.
However, this legislation will go a long way in ensuring Veteran's
critical medical needs, like those needs of more than 184,000 Veterans
who waited 50 days for an initial mental health screening, no longer
slip through the cracks of the system. It will also prevent the
unnecessary loss of life of those Veterans in need of medical care and
consultation.
Moving forward, I would like to work with this Subcommittee to
strengthen this legislation - potentially including additional access-
to-care standards. Today, this legislation is a first step to hold the
VA accountable.
Thank you Mr. Chairman, and I yield back the balance of my time.
Prepared Statement of Hon. Brett Guthrie
Good morning and thank you, Chairman Benishek, Ranking Member
Brownley, and distinguished colleagues of the House Committee on
Veterans' Affairs.
I come before you today as both a Member of Congress and a former
Army Officer, to thank you for your past support of a priority issue
for wounded warriors, and to ask that you continue to pursue needed
work on the subject
As you may know, genitourinary trauma, or simply urotrauma, is a
class of wounds that literally hit below the belt. Urotrauma accounts
for wounds to the kidneys, reproductive organs, and urinary tract
organs. These injuries are some of the most common and debilitating
suffered by our veterans from IED detonations and have long-lasting
physical and psychological impacts. Urotrauma is one of the signature
wounds of the IED and now accounts for one-eighth of all injuries
suffered by our troops in Afghanistan. Unfortunately, the most recent
available data suggests that this figure is still rising, even after
nearly doubling in incidence between 2009 and 2010.
I know that we're in the Veterans' Committee today, but by way of
background, let me paraphrase the Department of Defense's report to
Congress titled ``Genitourinary Trauma in the Military,'' and the Army
Surgeon General's report titled ``Dismounted Complex Blast Injury''.
According to these papers, urotrauma on today's battlefield exceeds
incidence rates of all prior conflicts by at least 350 percent. And
yet, the DoD Under Secretary for Personnel and Readiness concedes that
``urotrauma injury is not part of the standards of pre-deployment
training for U.S. military surgeons and nurses,'' and that the existing
infrastructure for tracking these casualties ``is not sufficient to
assess the long-term prognosis of GU trauma injuries.'' This lack of
adequate infrastructure is exacerbated by the inherent complications of
transitional care from DoD to VA, where most victims will receive
treatment for the remainder of their lives.
Now let me say that it is not my view that the VA and DoD are
ignoring urotrauma. To the contrary, I believe that many skilled
professionals are hard at work on the issue; but as is often the case
in government, their efforts are divided, un-integrated, and because of
this, less effective.
By my tally, there are six government agencies currently working on
urotrauma. And while I'm heartened that this research is occurring, I'm
discouraged that there seems to be little dialogue or centralization of
information. Put simply, we aren't learning from experience and if we
are, we're learning too slowly.
And that's why I introduced H.R. 984, a bill that I have authored
with the help of practicing urologists who have cared for wounded
warriors in Iraq and Afghanistan. This bill would unite public and
private resources to address the growing problem that is urotrauma.
I'd like to highlight two specific opportunities for improved care
that are within this committee's jurisdiction.
First, the existing infrastructure to track urotrauma patients is
not sufficient. We need the research infrastructure to facilitate
urotrauma outcomes research and corresponding follow-up within DoD and,
most critically, after transition to the VA. Unfortunately, one thing I
have heard time and time again is that the Joint Theater Trauma
Registry (JTTR), which tracks approximately 16,000 trauma victims,
lacks the specificity of detail needed to accomplish this end. VA, DoD,
and health care providers need a better platform to coordinate care
across a lifetime for our wounded warriors.
Related to this is the second issue I'd like to focus on -
transition of care. Rather than mincing words, I will quote the
American Urologists Association's Urotrauma Task Force directly:
``It is clear to those urologists in DoD who care for soldiers with
complex urotrauma that the transition to the VA is currently fraught
with barriers. These barriers include deficits of communication of the
detailed medical and surgical history of injured service members from
DoD physicians to VA physicians. Another problem continues to be GU-
injured soldiers within the VA system being cared for in locations
where access to expertise in GU trauma is lacking.''
One solution to this problem would be to designate care
coordinators to urotrauma victims. These coordinators would need access
to DoD and VA health information and guide our wounded warriors towards
existing centers of excellence in polytrauma care.
However, as a Member of Congress, I am not wedded to a single
solution to this or any other improvement to urotrauma care. That is
why H.R. 984 allows for a ``big tent'' solution. As DoD has said in
writing, we need ``inter-Service and inter-agency relationships to
facilitate aggressive, innovative, and relevant translational and
outcomes-based clinical research,'' and that's what H.R. 984 does:
bring together VA, DoD, HHS, the Surgeon Generals of each of our Armed
Services, and civilian expertise to create a plan to care for these
wounded warriors from the point of injury to their final resting place,
decades from now.
This is a bipartisan bill with many cosponsors who represent
communities like Ft. Knox, in my district, where their constituents are
frequently deployed to the front lines. These communities understand
the frequency and severity of these wounds at a human level and a
professional one. We have all met families who show true courage as
they care for their gravely wounded loved ones; and we have met the men
who march into harm's way knowing that the next IED could have their
name on it.
Let me say in closing that the miracles of modern medicine,
combined with the devotion of our military medical corps, have allowed
many of these wounded warriors to live long lives rather than dying in
the line of duty. However, giving these service men and women the
ability to survive is not enough. We have a responsibility to do what
we can to ensure that they are allowed to live as full a life as
possible. That's the debt we owe to those who defend freedom.
I urge this committee to continue the work it has already done to
further our care for these wounded warriors suffering the effects of
urotrauma and yield back my time.
Prepared Statement of Mark T. Edney
Chairman Benishek, Ranking Member Brownley, Members of the
Committee, honored guests, fellow service members; I thank the
Committee on Veterans Affairs, Subcommittee on Heath for inviting me to
testify regarding HR 984, a bipartisan bill introduced by
Representative Guthrie to direct the Secretary of Defense to establish
a task force on urotrauma.
I am a urologist, a surgical specialist who treats genitourinary
disease and injury, in private practice in Salisbury, MD. I am also an
Army Reservist of 11 years. I have been called to active duty 3 times:
first to Walter Reed Army Medical Center in 2004, one tour with the
399th Combat Support Hospital in Mosul, Iraq in the winter of 2006, and
finally a tour at Tripler Army Medical Center in 2009. I have treated
genitourinary trauma, or urotrauma, in the theater of operations and
have participated in its chronic management at our largest military
medical centers stateside.
It's an honor to represent the American Urological Association
(AUA), the world's premier professional association of urologists, and
our urotrauma coalition in support of HR 984 on behalf of this unique
class of injured service members. Our urotrauma coalition includes a
diverse group of medical societies, veterans' services organizations
and industry partners who all support the policy initiatives with
respect to genitourinary injury or urotrauma contained in HR 984. Our
coalition partners who have pledged their organizational support to our
urotrauma initiative include the: American College of Surgeons,
American Congress of Obstetrics and Gynecology, American Association of
Clinical Urologists, Large Urology Group Practice Association, American
Fertility Association, American Society of Andrology, Society for the
Study of Male Reproduction, Society of Male Reproduction and Urology,
Society for Women's Health Research, Veterans of Foreign Wars (VFW),
Disabled American Veterans (DAV), AMVETS, Paralyzed Veterans of
America, Blinded Veterans Association, Men's Health Network, Zero- The
Project to End Prostate Cancer, RESOLVE: The National Infertility
Association, Blue Ribbon Advocacy Alliance, Johnson and Johnson,
Astellas, and Endo Pharmaceuticals.
There have been approximately 50,000 soldiers wounded in action
since 2003 in Operation Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF). Of those, approximately 16,000 injuries are catalogued
in the Joint Theater Trauma Registry (JTTR), the inter-service in-
theater trauma database that has been in operation since 2003. Recent
studies have indicated that 5-10% of battlefield injuries involve
injury of the genitourinary (GU) organs for a total of around 1000 GU
injuries. Of those, approximately 60% involve the external organs
(scrotum, testicles, penis and urethra), and 40% involve other organs
including kidneys, bladder, ureters, uterus, fallopian tubes, and
ovaries. The DoD's Dismounted Complex Blast Injury Task Force studied
and reported on this pattern of injury at the direction of the Army
Surgeon General in June, 2011. Because improvised explosive devices
(IED) are the enemy's weapon of choice and because soldiers are
increasingly required to patrol on foot or ``dismounted'' in
Afghanistan (as compared to Iraq), the incidence of complex blast
injury is up 350% in OEF. Dismounted complex blast injury describes the
constellation of catastrophic extremity injury with often bilateral
lower limb loss, sometimes together with upper limb loss, traumatic
brain injury, and in many cases injury to the genitourinary organs.
Although GU-injured veterans may exhibit no outward signs of their
injury, they suffer life-changing loss of proper sexual, bowel, and
urinary function and fertility. These deficits have significant social
effects on marriages and other relationships and enormous effects on
quality of life. The cumulative physical and psychological impact of
urotrauma on these soldiers is no less profound than for those
recovering from extremity loss and neurocognitive injury. As a complex
injury, urotruama has not received the same policy attention and care
coordination that has been afforded the more common injury patterns
such as extremity loss, traumatic brain injury and eye injury--each
with its own DoD center of excellence. Genitourinary injury is
increasingly a critical military women's health issue with women now
able to serve in direct combat roles. We must do better with the study
and care coordination of urotrauma.
In 2009, the AUA convened a working group comprised of AUA members
within the Department of Defense (DoD) together with civilian trauma
and GU reconstruction experts to formulate policy, craft legislation,
and develop a comprehensive legislative strategy. The broad goals of
the working group were to: improve the prevention of, improve and
educate regarding the initial management of, and better coordinate the
chronic care of urotrauma and to enhance urotrauma's research
infrastructure to facilitate outcomes research and longitudinal follow-
up of urotrauma cases.
As a result of those discussions in 2009, key knowledge gaps were
identified, necessitating a broader discussion with respect to the
treatment of urotrauma. HR 984 ensures that broader discussions occur
by directing the Secretary of Defense to establish a task force on
urotrauma. The task force is required to conduct a study of urotrauma
among members of the Armed Forces and veterans including: an analysis
of the incidence, duration, morbidity rate, and mortality rate of
urotrauma; an analysis of the social and economic costs and effects of
urotrauma; with respect to the Department of Defense and Department of
Veterans Affairs (VA), an evaluation of the facilities, access to
private facilities, resources, personnel, and research activities that
are related to the diagnosis, prevention, and treatment of urotrauma;
an evaluation of the programs (including such biological, behavioral,
environmental, and social programs) that improve the prevention or
treatment of urotrauma; a long-term plan for the use and organization
of the resources of the Federal Government to improve the prevention
and treatment of urotrauma; an analysis of the shortfalls in research,
expertise, and health care infrastructure for female victims of
urotrauma; an analysis of the technical, administrative, and budgetary
mechanisms to allow for enhanced reproductive services for members who
have been affected by urotruama or who are at high risk of urotrauma;
an assessment of opportunities to enhance the coordination of Federal
resources used to research, prevent, and continuously improve the
management of urotrauma; and inter-agency efforts regarding the chronic
physical, behavioral, and emotional care of victims of urotrauma.
With respect to research, I am aware of at least two DoD databases
that prospectively collect data on urotrauma injuries for the purpose
of longitudinal follow-up and outcomes research: the Walter Reed Army
Medical Center (WRAMC)/National Naval Medical Center (NNMC)/ Walter
Reed National Military Medical Center (WRNMMC) surgical database that
has been in use for 6 years and the Expeditionary Medical Encounter
Database (EMED), in operation at the Naval Health Research Center,
Medical Modeling, Simulation and Mission Support Division in San Diego,
CA. The JTTR, as I mentioned earlier, has catalogued more than 16,000
battlefield traumas since 2003, but lacks specificity for details of
urotrauma that would enable longitudinal follow-up and outcomes
research. The VA also has a robust repository of patient-level data in
its electronic medical record, Vista. The appropriate department should
be tasked with coordinating these databases as well as any other
similar databases, to ensure that they are collecting appropriate
urotrauma measures so that they may facilitate the longitudinal follow-
up and outcomes research of urotrauma.
The seamless transition from the DoD to the VA, of the soldier
suffering urotrauma with his or her complex care needs, represents an
opportunity for improvement. DoD Instruction 1300.24 directs the
Assistant Secretary of Defense for Health Affairs under the authority,
direction, and control of the Under Secretary of Defense for Personnel
and Readiness to ``coordinate with the VA to develop and implement
administrative processes, procedures, and standards for transitioning
RSMs [recovering service members] from DoD care and treatment to VA
care, treatment, and rehabilitation that are consistent with [language
stipulated in the instruction].'' A critical element of the transition
is that of the transfer of a complete medical and surgical record to
accepting providers in the VA. The AUA's working group has heard from a
variety of urologists in both the DoD and VA that the record transfer
is not happening in many cases.
DoD currently provides a high level of expertise and care
coordination for soldiers with urotrauma. However, the difficulty
arises when RSMs are transferred to the VA. While the VA has polytrauma
centers of excellence with many highly trained surgeons, there are
regions of reduced access to the technology and surgical expertise
required to care for these complex cases. Therefore, there are
opportunities to improve and standardize communication between DoD and
VA physicians. There are also opportunities to optimize the placement
of GU-injured soldiers in proximity to the expertise and technology
that they need and to employ telemedicine and other new information
technologies to deliver needed services reducing the impact of
geography on access.
Finally, although each of the functional challenges that result
from damage to the genitourinary organs is life-altering, perhaps one
of the most profound is the loss of fertility. The brave young
Americans who are voluntarily putting themselves in harm's way in
defense of our country are often doing so prior to their reproductive
years. Some are suffering injuries that severely impair or eliminate
their natural reproductive capability shattering a dream of many--to
begin a family of their own. HR 984 seeks ``an analysis of technical,
administrative, and budgetary mechanisms to allow for enhanced
reproductive services for members who have been affected by urotrauma
or who are at high risk of urotrauma''. The AUA recognizes that there's
much to be done in this area from pre-deployment sperm banking, to
cryopreservation of sperm at the initial point of care when testicular
loss is inevitable, to providing advanced reproductive services to all
military urotrauma victims who are infertile and receiving care in the
DoD and VA. We are currently short of that goal and the AUA working
group also supports legislation to enhance these policies.
In summary, the rate of genitourinary injury suffered by American
soldiers is up 350% in the Afghanistan theater compared to the Iraqi
theater as a result of the increased necessity of dismounted patrol.
Genitourinary injures are an increasingly common, complex constellation
of wounds with devastating long term implications for urinary, bowel,
and sexual function and fertility. These sequelae in turn have profound
impact on soldiers' mental health, marriages, other social
relationships and overall quality of life. HR 984 prescribes the
comprehensive study required to address the variety of opportunities
for improving the prevention, initial management, care coordination and
research of this devastating and increasingly prevalent pattern of
injury. We owe these finest of Americans no less for the sacrifices
they have made for our great nation. On behalf of the American
Urological Association and the urotrauma coalition partners, I urge you
to support HR 984 and favorably report it out of the committee.
Again, I want to thank the Veteran's Affairs Committee for their
invitation to testify before you and I am available to answer any
questions.
Prepared Statement of Mike O'Rourke
INTRODUCTION
On behalf of BVA, thank you for this opportunity to provide
testimony today on the current legislation before the Subcommittee on
Health. Chairman Benishek, Ranking Member Brownley, and members of the
House Committee, thank you for the bringing these bills before the
committee. The Blinded Veterans Association (BVA) is the only
congressionally chartered Veterans Service Organization exclusively
dedicated to serving the needs of our Nation's blinded veterans and
their families; BVA has served blinded veterans for over 68 years.
BENEFICIARY TRAVEL FOR BLINDED VETERANS: HR 1284
We appreciate the ranking member Congresswoman Brownley for
introducing H.R. 1284 and we would point out that last week the Senate
VA Committee held hearing on the companion bill S 633 introduced by
Senator Tester that was broadly supported by the witnesses. This
legislation would assist disabled spinal cord injured (SCI) and blinded
or visually impaired veterans who are currently ineligible for
Beneficiary travel benefits. This bill would assist mostly low- income
and catastrophically disabled veterans by removing the travel financial
burdens to access vital care that improve independence and quality of
life. Veterans who must currently shoulder this hardship, which often
involves airfare, can be discouraged by these costs to travel to a
Blind Rehabilitation Center (BRC) or Spinal Cord Injury (SCI) VA
medical center for either inpatient or residential bed stay while
receiving training. The average age of blinded veterans attending a BRC
is 67 because of the high prevalence of degenerative eye diseases in
this age group.
It makes little sense to have developed, over the past decades,
outstanding blind rehabilitation programs at 13 Blind Centers known for
very high quality inpatient specialized services, only to tell low
income, non-service connected disabled blinded veterans that they must
pay their own travel expenses to access the training they need. To put
this dilemma in perspective, a large number of our constituents are
living at or below the poverty line while the VA Means threshold for
travel assistance sets $14,340 as the income mark for eligibility to
receive Means tested travel benefits. VA utilization data revealed that
one in three veterans enrolled in VA health care was defined as either
a rural resident or a highly rural resident. The data also indicate
that blinded veterans in rural regions have significant financial
barriers to traveling without utilization of public transportation.
To elaborate on the challenges of travel without this financial
assistance analysis confirmed that rural veterans are a slightly older
and a more economically disadvantaged population than their urban
counterparts. Twenty-seven percent of rural and highly rural veterans
were between 55 and 64. Similarly, approximately 25 percent of all
enrolled veterans fell into this age group. \1\ In FY 2007, rural
veterans had a median household income of $19,632, 4 percent lower than
the household income of urban veterans ($20,400) \2\. The median income
of highly rural veterans showed a larger gap at $18,528, adding
significant barriers to paying for air travel or other public
transportation to enter a BRC or SCI rehabilitation program. More than
70 percent of highly rural veterans must drive more than four hours to
receive tertiary care from VA. Private blind outpatient agency services
such as Lighthouse for Blind are all located in large urban cities and
usually established as outpatient training sites, again barrier for
rural veterans traveling long distances every day to get training
verses VA rehabilitation centers.
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\1\ Department of Veterans Affairs, Office of Rural Health,
Demographic Characteristics Of Rural Veterans Issue Brief (Summer
2009).
\2\ VSO IB 2013 Beneficiary Travel pg 119-120, 124-125
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Consider the following facts:
In a study of new applications for recent vision loss
rehabilitation services, 7 percent had current major depression and
26.9 percent met the criteria for subthreshold depression. \3\
---------------------------------------------------------------------------
\3\ Horowitz et,.al. 2005, Major and Subthreshold Depression Among
Older Adults Seeking Vision Rehabilitation Services The Silver Book
2012, Volume II pg9 [email protected]
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Vision loss is a leading cause of falls in the elderly.
One study found that visual field loss was associated with a six-fold
risk of falls. \4\
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\4\ Ramratten, et.al. 2001 Arch Ophthalmology 119(12) 1788-94.
Prevalence and Causes of Visual Field Loss in the Elderly,
www.Silverbook.org/visionloss Silver Book, Volume II 2012 pg 9
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While only 4.3 percent of the 65 and older population
lives in nursing homes, that number rises to 6 percent of those who are
visually impaired, and 40 percent of those who are blind and Medicaid
direct costs of $11 Billion per year. \5\
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\5\ Rein, David B. et.,al. 2006 The Economic Burden of Major Adult
Visual Disorders in the U.S. www.Silverbook.org/visionloss Silver Book,
Volume II 2012pg 9
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Individuals who are visually impaired are less likely to
be employed-44 percent are employed compared to 85 percent of adults
with normal vision in working population age 19-64. \6\
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\6\ Rein, et. al. The Economic Burden of Major Adult Vision
Disorders in the U.S. 2006 www.Silverbook.org/visionloss Volume II pg.
10
If blinded or spinal cord injured veterans are not able to obtain
the rehabilitation center training to learn to function at home
independently because of travel cost barriers, the alternative--
institutional care in nursing homes--may be far more expensive. The
average private room charge for nursing home care was $212 daily
($77,380 annually), and for a semi-private room it was $191 ($69,715
annually), according to a MetLife 2008 Survey. Even assisted living
center charges of $3,031 per month ($36,372) rose another 2 percent in
2008. BVA would point to these more costly alternatives in describing
the advantages of VA Beneficiary Care so that veterans can remain in
their homes, functioning safely and independently, and with the
rehabilitation training needed to re-enter the workforce. For FY 2014
VA has proposed spending $7,637 Billion in Nursing Home Care program.
We caution that private agencies for the blind are located in large
urban cities in New York City, Chicago, Seattle, Orlando, or Boston, so
the travel barriers would preclude utilization of those sites. VA
Centers offer the full specialized nursing, physical therapy,
audiology, pharmacy, radiology or laboratory support services that are
necessary for the clinical care. BVA requests that private agencies
demonstrate peer reviewed quality outcome measurements that VHA Blind
Rehabilitative Service have and they must be accredited by either the
National Accreditation Council for Agencies Serving the Blind and
Visually Handicapped (NAC) or the Commission on Accreditation of
Rehabilitation Facilities (CARF). Blind Instructors should be certified
by the Academy for Certification of Vision Rehabilitation and Education
Professionals (ACVREP).
13 Inpatient Blind Rehabilitation Centers (BRCs)
For those members here today we would encourage you to visit one of
the 13 VA BRC's and to visit VA SCI locations to better understand the
coordinated care being provided at these hub and spoke locations. The
BRCs provide the most intense and in-depth rehabilitation to severely
disabled blind veterans and servicemembers returning from OIF and OEF.
Comprehensive, individualized blind rehabilitation services are
provided in an inpatient VA Medical Center environment by a
multidisciplinary team of rehabilitation specialists. The management of
chronic medical conditions is addressed as part of the training regimen
as well. Blind Rehabilitation Specialists guide the individual through
a rehabilitation process that leads to adjustment to blindness, new
skill development in living skills, orientation and mobility, manual
skills, and use of prescribed adaptive technology devices and Computer
Access Training (CAT) learning the use of this specialized technology
and reorganization of the person's life to enhance their independence.
All BRC's use same training approach to maximize the team approach to
the needs of each blind veteran. These new skills and attitudes foster
new abilities to contribute to family and community life and allow
individuals to often regain employment.
BVA supports the change in Beneficiary Travel being proposed in HR
1284 and in our discussions with VA Veterans Travel Program office
found support for this legislation that would improve access to
rehabilitation care and services for this severely disabled population.
Recently VHA however testified before SVAC on S 633 and stated the
language currently in this bill was restrictive, and it should include
other disabilities like PTSD or TBI veterans. HR 1284 addresses
catastrophically disabled veterans going to very specialized
rehabilitation centers, and VA operates more than 300 community-based
PTSD Vet Center sites, has more than 50 mobile VA centers, and dozens
of TBI centers and we would hesitate having the committee broadening
this language trying to include many other conditions that are often
treated at the 153 VA medical centers.
H.R. 288 CHAMPVA Children's Eligibility Act: BVA fully supports
this bill to amend Title 38 USC, to increase the maximum age for
children eligible for medical care under the CHAMPVA program that would
allow same coverage mandated in other current federal programs.
Dependent children who currently turn age 23 have loss of insurance
coverage under CHAMPVA and have difficulty finding and being able to
afford health insurance. We believe to change this to age 26 is
consistent with other mandated coverage for other insurance plans.
Often college students or those new graduates who face difficult
employment challenges are unable to afford their own health insurance
and being covered by CHAMPVA would provide them protection from being
uninsured.
Urotrauma Task Force HR 984:
Soldiers who now survive on front line at highest percentages ever
however now suffer much more grievous injuries. Bulletproof Kevlar
vests protect soldiers' central chest and abdomen, but not their limbs,
groin and genitals, and this bill highlight the need for more resources
for better care for genito-urinary (GU) wounds. Because there's little
research for urologists in the military to draw upon in diagnosing and
the surgical initial management and reconstruction of treating these
complex cases, plus the social stigma about discussing genitor-urinary
problems, this serious life altering injury has received far less
attention over past eight years than other combat blast injuries. Most
urologists in training and private practices rarely treat civilian
patients with these kinds of severe genito-urinary trauma now seen in
the military field hospitals or large military trauma centers caused by
IED's blasts during dismounted combat patrols.
The Veterans Affairs Office of Public Health tracks veterans who
have left active duty in Iraq and Afghanistan and have sought medical
treatment in the VA system. From July 2002 through June 2009, 12.5
percent of the 508,000 veterans who sought treatment were diagnosed
with diseases or disorders of the genitourinary system, but the report
doesn't specify how many of those diagnoses are related to combat
injuries and still doesn't report specific GU trauma which we point out
highlights growing need for joint DOD-VA urological trauma clinical
registry for these specific injuries similar to those existing for TBI,
amputees, and for vision and hearing.
Again we stress one big challenge is that in the civilian medical
world, there is not a high incidence of these kinds of blast urotrauma
injuries so development of best practices to treat these kinds of
battlefield genitourinary system injuries from this Task Force are
urgently needed and DOD and VA must find improved reconstructive
approaches for them. Genitor-urinary system mutilation can cause
incontinence, infertility, impotence, recurrent infections in these
young service members, plus they have emotional and psychological
consequences of depression, and psycho-social isolation, and are at
higher rates suicide risk in this young mostly male population. It is
imperative, therefore, management of this complex pattern of GU injury
requires attention paid towards surgical reconstruction and
psychological health of these urological injuries with adequate
deployment peer reviewed genitor-urinary trauma research funding.
GENITOURINARY (GU) RECONSTRUCTION
GU interventions must be performed in multiple stages starting at
front line field surgical sites. If extensive soft tissue is lost,
finding adequate tissue to cover these wounds, debridement, immediate
wound management, then later in evacuation chain when is best time to
perform reconstruction is more challenging. Individuals with Dismounted
Combat Battle Injury (DCBI) and genital injury will often require a
protracted inpatient/outpatient stay. It is best if these injuries are
managed by the same surgical team over time rather than transferring
care elsewhere. Because of this, provisions must be made to have
adequate staffing, housing, administrative, and medical support at Role
V facilities to provide protracted care for these individuals.
Currently, there are a limited number of providers (civilian and
military) who perform phallic reconstruction surgery--thus indicating
the need to train more military urologists and plastic surgeons in
these techniques. \7\
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\7\ Surgeon General Army Report Dismounted Combat Battle Injury
(DCBI) pg. 45
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GENITAL LOSS AND HORMONAL CONCERNS
While GU injuries present complex surgical and behavioral health
challenges, other medical issues must be addressed. Low testosterone
levels have been reported after trauma, serum testosterone levels are
significantly reduced. Therefore testicular loss will only complicate
further hormone deprivation. The role of hormone replacement to promote
soft tissue and nervous tissue healing has not yet been determined. It
is also unknown when the optimal timing for replacement should begin.
Given the long-term needs of hormonal replacement and monitoring,
systems should be established to provide life-long care by medical
specialists in this area. BVA strongly supports passage of this bill by
the HVAC and HASC.
H.R. 241 ``Timely Access to Health Care Act''
BVA supports the recommendations made in the Veteran Service
Organizations Independent Budget (VSOIB) FY 2014 section on the
problems of access to care and waiting times. VHA managers plan budget
priorities, measure organizational and individual medical center
directors' performance, and determine whether strategic goals are met,
in part by reviewing data on waiting times and lists. However, they
cannot manage and improve what they cannot measure. Unreliable data
compromise meaningful analyses for decision making on the timeliness of
access and trends in demand for health care services, treatments, and
providers.
The OIG reports of 2005, 2007, and 2012 reiterate the continuing
weaknesses causing VA's failure to meet its own access standards. Based
on the reports by the OIG and Booz Allen Hamilton137 on the weaknesses
in the Department's outpatient scheduling process, the VHA needs to
improve data systems that record and manage waiting lists for primary
care, and improve the availability of some clinical programs to
minimize unnecessary delays in scheduling specialty health care. \8\
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\8\ VSOIB FY 2014 Medical Care Access pg. 89-90.
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BVA appreciates that the committee has investigated the long
standing problems over waiting times for clinic appointments and has
heard previously in other recent hearings on March 13 about the finding
of GAO ``Waiting For Care; Examining Patient Wait Times at VA'' the
testimony by the Director, Health Care Government Accountability
Office, Debra Draper provided recommendations. \9\ GAO outlined
problems found in examining wait times at various VA clinics that
despite attempts to solve the problem ``VHA report times are unreliable
and there was inconsistent implementation of certain elements of VHA's
scheduling policy.'' \10\ BVA supports the intent of HR 241 to address
this problem.
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\9\ GAO ``Waiting For Care; Examining Patient Wait Times at VA''
Testimony Director, Health Care Government Accountability Office, Debra
Draper March 13, 2013 pg. 3.
\10\ Ibid VSOIB FY 2014 pg. 90
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DRAFT ``Veterans Integrated Mental Health Care Act of 2013'':
The problems of mental health care access and wait times in this
area are ongoing concern to BVA and the other veteran service
organizations as suicides have increased despite numerous programs by
both DOD and VA that have been established in the past few years and
growing numbers of veterans are being diagnosed with variety of mental
health disorders we feel more must be done. The number of Veterans
receiving specialized mental health treatment from VA has risen each
year, from 927,052 in fiscal year (FY) 2006 to more than 1.3 million in
FY 2012 \11\. One major reason for this increase is VA's proactive
screening of all Veterans to identify those who may have symptoms of
depression, Post Traumatic Stress Disorder (PTSD), problem use of
alcohol or who have experienced military sexual trauma (MST).
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\11\ VHA Mental Health Care Services March 2013 report.
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BVA applauds efforts made by VA and the DOD to improve the safety,
consistency, and effectiveness of mental health care programs for
servicemembers and veterans. We also appreciate that Congress is
continuing to provide increased funding in pursuit of a comprehensive
package of services to meet the mental health needs of veterans, in
particular veterans with wartime service and post-deployment
readjustment needs. \12\
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\12\ 12 VSOIB FY 2014 pg. 75-76
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While the VSOs are pleased with VA's progress in implementing its
Mental Health Strategic Plan, and veterans who are able to get care
from the 300 Vet Centers are very satisfied, we still have concerns
that these goals may be frustrated unless proper oversight is provided
and VA enforces its own mechanisms to ensure its policies at the top
are reflected as results on the ground in VA facilities. As members
here know VA announcement from the Secretary of Veterans Affairs Eric
K. Shinseki the department would add approximately 1,600 mental health
clinicians - to include nurses, psychiatrists, psychologists, and
social workers as well as nearly 300 support staff to its existing
workforce of 20,590 mental health staff as part of an ongoing review of
mental health operations. \13\
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\13\ VA Press Release April 12, 2012 Mental Health Care Services
Expansion
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While VA has increased the total numbers of full time psychiatrists
in 2006 from 1,836 to FY 2012 up to 2,586, and the number of
psychologists 1,788 from FY 2006 up to 4,200 in FY 2012, and VA also
has 3,498 clinical social workers, and 645 nurse practitioners full
time assigned to mental health clinics with additional 244 advanced
practice nurses. \14\ Still as everyone knows here the wait times grow
and so does the OIF OEF enrollment numbers. DOD and VA both continue
struggling to hire the same pool of mental health providers and each
agency will probably continue to fail to meet the growing demands. We
must find alternatives to provide care.
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\14\ VHA Report Mental Health Providers Full Time 2006-2012 BVA
request March 2012
---------------------------------------------------------------------------
Chairman Miller draft ``Veterans Integrated Mental Health Care Act
of 2013'' would provide mechanisms for medical centers to coordinate
necessary clinical services through care-coordination contracts. BVA
supports the draft version of this and stresses that ensuring that any
veteran that obtains care has their medical records sent to the VA is
vital. The VA should exchange clinical best practice guidelines with
outside providers on management.
CONCLUSION
Chairman Benishek and Ranking member Brownley, BVA again expresses
its support for these proposed changes to VHA programs listed above
being considered here today. BVA appreciates the opportunity to provide
this testimony today and be glad to answer any questions now.
DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS
The Blinded Veterans Association (BVA) does not currently receive
any money from a federal contract or grant. During the past two years,
BVA has not entered into any federal contracts or grants for any
federal services or governmental programs.
BVA is a 501c (3) congressionally chartered, nonprofit membership
organization.
Prepared Statement of Adrian M. Atizado
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee:
On behalf of the DAV (Disabled American Veterans) and our 1.2
million members, all of whom are wartime wounded and injured veterans,
I am pleased to present our views on legislative measures that are the
focus of the Subcommittee today, and to DAV and our members.
Draft Bill, the Demanding Accountability for Veterans Act of 2013
This bill would establish a requirement in law for the Department
of Veterans Affairs (VA) Inspector General (IG) to report to the
Secretary and to Congress any matters of public health or safety
emanating from reports of the IG that remain unresolved by VA within a
specified time period after the Secretary or a subordinate VA official
agrees with the IG to address such matters. In that connection, the
bill would require the Secretary to reveal to the IG the personal
identities of the responsible VA official(s) and manager(s) who did not
resolve the issue(s) (but such identities would not be released to the
public). The bill would require the Secretary to promptly notify any
such individual(s) to resolve the cited issue(s); to counsel the
manager(s) concerned about the failure to resolve the issue(s) brought
to light; and to develop mitigation plans, presumably to the
satisfaction of the IG in resolving the matters concerned.
The bill would prohibit the award of any performance award or bonus
to a VA official or manager (whether in the Senior Executive Service or
the competitive civil service) who had not resolved such IG
recommendations under the terms of this bill, and even if they were
resolved later, that the existence of previously unaddressed matters of
public health and safety would be considered in future performance
evaluations of any such official.
DAV has received no resolution from our membership dealing with
this specific issue and takes no position on this bill. However, we
urge the Subcommittee to work with VA in advancing it and to ensure
those issues raised by this bill are properly addressed.
Draft Bill, the Veterans Integrated Mental Health Care Act of 2013
This draft bill proposed by the Chairman of the full Committee
would establish a new authority for VA to use in contracting for VA
mental health care services for eligible veterans. It would place in
the hands of a veteran certain mandatory information provided by VA to
guide the veteran in making a voluntary decision on whether to receive
care in a VA facility, or to receive it in a non-VA facility. The bill
would further require VA to contract with qualified entities that
administer networks of health care providers, including those
experienced in administering the TRICARE networks, to provide
coordinated mental health care. The bill would require a series of
performance qualifications standards that must be met by such
contractors, and would require VA to dispense or pay for prescriptions
written for veterans under this program by contractor providers on the
same basis as it does for other veterans receiving VA-authorized
contract care under section 1703 of title 38, United States Code.
Mr. Chairman, your Subcommittee held a hearing on September 14,
2012, to discuss and consider VA's multiple approaches to providing
contract health care services, including specific focus on the upcoming
award of VA contracts to regionalized entities that will administer
coordination of care through provider networks, including mental health
care. I had the privilege of testifying on behalf of DAV at that
hearing, and I would call your attention to my complete statement \1\
as well as to Dr. Robert Petzel's statement, made on behalf of VA. I
quote a small but crucial element of VA's statement for the benefit of
the Subcommittee with respect to this bill, as follows:
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\1\ http://dav.org/voters/documents/statements/Atizado20120914.pdf
PCCC [Patient Centered Community Care] will consist of a network of
centrally supported standardized health care contracts, available
throughout VHA's Veterans Integrated Service Networks (VISN). This
initiative will focus on ensuring proper coordination between VA and
non-VA providers. PCCC is not intended to increase the purchasing of
non-VA care, but rather to improve management and oversight of the care
that is currently purchased. This includes improvements in numerous
areas such as consistent clinical quality standards across all
contracts, standardized referral processes, and timeliness of receipt
of clinical information from non-VA providers. The goal of this program
is to ensure Veterans receive care from community providers that is
timely, accessible, and courteous, that honors Veterans' preferences,
enhances medical documentation sharing, and that is coordinated with VA
providers when VA services are not available.
While VA intends to administer these contracts directly, it has not
yet determined how they will be managed. Additionally, VA is currently
researching the appropriateness of incentives tied to performance
standards to help ensure the selected contractors provide excellent
customer service and timely care. VA conducted a business case analysis
which compared the cost of purchasing care through individual
authorizations and through regional contracts. The analysis showed that
regional contracts are more cost-effective, with the cost/benefit ratio
improving as participation increases. The PCCC contracts will cover
inpatient and outpatient specialty care and mental health care.
[Emphasis added.]
In a precedent-setting effort to reform VA contract care, the
Department is again receiving bids under PCCC from entities that are
qualified and prepared to deliver not only mental health services but a
wide range of other specialty health care services, one must question
whether Congress, in enacting a new contracting mandate exclusively
limited to mental health services would hamper VA's efforts and inject
additional uncertainty to those firms that bid for PCCC contracts, and
thereby cause disruption and delay in VA's plans to reform all contract
and fee-basis health care. For these reasons, DAV recommends this bill
be held in abeyance at this time. Our National Resolution No. 210 calls
for program improvement and enhanced resources for VA mental health
care programs, but we believe this bill, overlayed on the PCCC effort,
could have the opposite effect. Therefore, we cannot support this bill
in its current form.
H.R. 241, the Veterans Timely Access to Health Care Act
If enacted, this bill would establish a statutory access-to-care
standard of 30 days within the VA health care system, and would define
that period as the difference between the date on which a veteran
contacts VA seeking a health care appointment, through the date on
which a patient care visit by that veteran actually occurs with an
appropriate VA health care provider. The bill would require VA to
submit continuing semi-annual reports to Congress on waiting times,
with specified criteria to define waiting periods, and to prescribe the
content of these reports.
Our membership has approved National Resolution Nos. 211 and 225,
addressing timely access to VA health care services for America's
service-disabled veterans. Timely access to needed medical care is a
critical domain of high quality care. Currently, VA claims to be
largely meeting its stated timeliness standards, but DAV receives much
anecdotal information from our members and also from VA employees that
these standards are not being met in reality and suggest that ``gaming
the numbers'' to meet standards may be in play.
DAV believes the transparency potential conveyed in this bill to
document more accurate waiting times could be a worthwhile idea.
However, the bill would also set a statutory limit of 30 days as a
single nationwide standard within which all types of VA medical
appointments for veterans must be completed. The bill would prescribe a
single maximum waiting time across the universe of primary, specialty,
and subspecialty care, and for routine, urgent, or emergent care
appointments. DAV questions whether one performance standard of this
nature would be appropriate or workable, given VA's current waiting-
time standards, under which VA's performance is already reported. In
some cases, a 30-day standard might in fact lengthen waiting times
versus current standards; in others, it would potentially clash with
the medical judgment of clinicians about when patients should make
return visits for care or monitoring. Therefore, we recommend the 30-
day provision be dropped from the bill.
Notably, VA spent about $4.6 billion in fiscal year 2011 to
purchase health care services from non-VA entities such as other
government agencies, affiliated universities, community hospitals,
nursing homes, and individual providers. Yet, performance reporting
under the timeliness standard for purchased care services remains
largely invisible to Congress and the public.
DAV therefore recommends this measure be amended to reflect by
reference those timeliness standards adopted and reported by VA to the
public, and to include such reporting the timeliness in access to care
purchased by VA in the community. In addition, we recommend the
required report include the performance by VA facility.
On the strength of Resolution Nos. 211 and 225, and amending this
worthwhile measure to include the above mentioned recommendations to
reinforce the idea of timely access as a key element in health care
delivery, health care quality and health care satisfaction, we would
support the bill and urge its enactment.
H.R. 288, the CHAMPVA Children's Protection Act of 2013
This bill would amend title 38, United States Code, section 1781(c)
to increase the maximum age of children eligible for medical care under
the Civilian Health and Medical Program of the Department of Veterans
Affairs (CHAMPVA).
Established by law in 1973, CHAMPVA provides cost reimbursement for
private health care services provided to dependents, survivors, and
(via Public Law 111-163) some personal family caregivers, of certain
disabled veterans. CHAMPVA enrollment has grown steadily over the years
and, and as of the end of fiscal year 2011, CHAMPVA covers
approximately 355,000 individual beneficiaries.
A child of a veteran is eligible for CHAMPVA benefits if the
veteran is rated permanently and totally disabled due to a service-
connected disability; was rated permanently and totally disabled due to
a service-connected condition at the time of death; died of a service-
connected disability; or, died on active duty, and the dependent is
ineligible for Department of Defense (DoD) TRICARE benefits. Under
current law, a dependent child's eligibility, which otherwise
terminates at age 18, continues to age 23 if such child is pursuing a
VA-approved full-time course of education or instruction.
On the strength of DAV National Resolution No. 222, DAV supports
this measure; however, we strongly urge amending it to conform to
Public Laws 111-148 and 111-152. In its current form, the eligibility
of a qualifying veteran's child for CHAMPVA coverage from age 18 to 26
is extended only if the child is pursuing a full-time course of
instruction at an approved educational institution or is unable to
continue such pursuit due to incurring a disabling illness or injury
that is not the result of such child's own willful misconduct.
DAV urges the measure be amended to ensure the eligibility of a
qualifying veteran's child for CHAMPVA coverage is under the same
conditions of covered adult children in private health plans under the
landmark Patient Protection and Affordable Care Act, Public Law 111-
148, as amended by the Health Care and Education Reconciliation Act of
2010, Public Law 111-152.
Under Public Laws 111-148 and 111-152, private health insurers are
required to cover young adult, but still-dependent, children in covered
families until these individuals attain age 26, irrespective of
educational status, and regardless of financial dependency, marital
status, residency or other factors. Because CHAMPVA is being governed
by a different standard in law, however, children of severely disabled
veterans and survivors of veterans who paid the ultimate sacrifice are
being penalized by denial of these same rights and privileges as other
young adults.
H.R. 984, to direct the Secretary of Defense to establish a task force
on urotrauma
Mr. Chairman, DAV has not received a resolution calling for a
special DoD task force on this particular combat injury. DAV
understands that the small number of deserving injured veterans
suffering from genitourinary trauma, life-defining injuries, currently
are not afforded the same level of visibility, scrutiny or
investigation as veterans with other injuries, such as traumatic brain
injury or PTSD, within the DoD or VA health care systems.
However, while the proposed DoD established urotrauma task force
may very well meet its charge and yield fruitful results, we believe
the report of the Dismounted Complex Blast Injury Task Force, \2\ whose
membership consists of closer to the front line personnel involved with
the care of severely injured service members and veterans, should also
be considered by the Subcommittee.
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\2\ http://www.health.mil/Libraries/110808--TCCC--Course--
Materials/0766-DCBI-Task-Force-Report-Final-Redacted-110921.pdf
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The task force this bill would establish follows on a report issued
December 27, 2011, by a private urology group, entitled ``Genitourinary
Trauma in the Military.'' \3\ This report was stimulated by a previous
report of the Dismounted Complex Blast Injury Task Force, issued June
18, 2011, by the U.S. Army. The Army study identified and recommended
the need for new approaches for earlier treatment of combat
genitourinary injuries, to intervene more aggressively to treat the
acute needs of service members with severe genitourinary injuries.
Also, it described the need for new injury prevention measures and
recommended urologists be deployed into combat theaters, with a focus
on salvage, repair, and reconstruction to promote positive long-term
outcomes. Presumably, the new task force authorized by this bill would
address these earlier recommendations.
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\3\ http://tricare.mil/tma/congressionalinformation/downloads/
H.Rpt.%20111-
491%20Page%20316%20Genitourinary%20Trauma%20in%20the%20Military.pdf
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H.R. 1284
This bill would amend the VA beneficiary travel statute to ensure
beneficiary travel eligibility for travel expenses in connection with
medical examination, treatment, or care on an inpatient basis, and
while a veteran is being provided temporary lodging at VA medical
centers. Veterans eligible for this benefit would be restricted to
those with vision impairments, spinal cord injury or disorder, and
those with double or multiple amputations whose travel is in connection
with care provided through a VA special disabilities rehabilitation
program.
Currently, VA is authorized to pay the actual necessary expenses of
travel (including lodging and subsistence), or in lieu thereof to pay
an allowance based upon mileage, to eligible veterans traveling to and
from a VA medical facility for examination, treatment, or care.
According to title 38, United States Code, Section 111(b)(1), eligible
veterans include those with service-connected ratings of 30 percent or
more; those receiving treatment for service-connected conditions;
veterans in receipt of VA pensions; those whose incomes do not exceed
the maximum annual VA pension rate; or veterans traveling for scheduled
compensation or pension examinations.
DAV has no resolution on this specific issue and thus takes no
position on this bill. However, we would note that while the intended
recipients of this expanded eligibility criteria would certainly
benefit from it, we would urge the Committee to consider a more
equitable approach rather than one based on the specific impairments of
disabled veterans. Further, we ask that if the Committee does favorably
consider this measure, it also take appropriate action to ensure that
sufficient additional funding be provided to VA to cover the cost of
the expanded program.
DAV appreciates the opportunity to submit our views on the several
legislative measures under consideration at this hearing. Much of the
proposed legislation would significantly improve VA services for our
nation's disabled veterans and their families, and would make VA more
accountable to ensure veterans and their families receive the benefits
and services they have earned and deserve.
This concludes my testimony, Mr. Chairman. I would be pleased to
answer any questions related to my statement and the views I have
expressed on behalf of DAV.
Prepared Statement of Alexander Nicholson
--------------------------------------------------------------------------------------------------------------------------------------------------------
Bill # Bill Name Sponsor Position
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 241 Veterans Timely Access to Health Care Act Ross Support
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 288 CHAMPVA Children's Protection Act of 2013 Michaud Support
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 984 A bill to direct the Secretary of Defense to Guthrie Support
establish a task force on urotruama
--------------------------------------------------------------------------------------------------------------------------------------------------------
H.R. 1284 A bill to provide for coverage for certain Brownley Support
eligible veterans under the beneficiary travel
program
--------------------------------------------------------------------------------------------------------------------------------------------------------
DRAFT Veterans Integrated Mental Health Care Act of Miller Support
2013
--------------------------------------------------------------------------------------------------------------------------------------------------------
DRAFT Demanding Accountability for Veterans Act Benishek Support
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chairman Benishek, Ranking Member Brownley, and Distinguished
Members of the Subcommittee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA), I
would like to extend our gratitude for being given the opportunity to
share with you our views and recommendations regarding these important
pieces of legislation.
IAVA is the nation's first and largest nonprofit, nonpartisan
organization for veterans of the wars in Iraq and Afghanistan and their
supporters. Founded in 2004, our mission is important but simple - to
improve the lives of Iraq and Afghanistan veterans and their families.
With a steadily growing base of over 200,000 members and supporters, we
strive to help create a society that honors and supports veterans of
all generations.
IAVA believes that all veterans must have access to quality health
care and related services. The men and women who volunteer to serve in
our nation's military do so with the understanding that they and their
families will be cared for during their period of service, and also
after their period of service should they sustain injuries or
disabilities while serving.
H.R. 241
IAVA supports H.R. 241, the Veterans Timely Access to Health Care
Act, which would mandate that an acceptable VA health care appointment
wait time is no more than 30 days from the date requested by the
veteran. This bill will also help hold VA accountable for meeting this
maximum allowable wait time through mandatory quarterly reviews and
reporting on timeliness to this Committee. IAVA believes that all
veterans should have equal and timely access to VA health care,
regardless of where they reside. Furthermore, IAVA believes that a
veteran's ability to access timely care plays a vital role in
sustaining his or her quality of life. Moreover, from a mental health
point of view, the importance of providing timely care becomes even
more critical. Timely mental health care can sometimes mean the
difference between life and death for veterans in crisis. IAVA believes
that every VA medical center and VA health care provider should be held
to the same reasonable standards of timeliness when providing care for
veterans.
H.R. 288
IAVA supports H.R. 288, the CHAMPVA Children's Protection Act of
2013. With the enactment of the Affordable Care Act, children up to age
26 can now be covered by their parents' health insurance plans.
However, these provisions did not extend to recipients of TRICARE and
the Civilian Health and Medical Program of the Department of Veterans
Affairs (CHAMPVA). While legislation was subsequently enacted to extend
this coverage option to eligible children of TRICARE recipients, no
action has been taken on behalf of the same population under CHAMPVA.
IAVA believes that we must enact this bill so that CHAMPVA benefits
continue to be provided to the children of our nation's wounded
warriors and those who paid the ultimate price in service to our
country.
H.R.984
IAVA supports H.R. 984, which would direct the Secretary of Defense
to establish a task force on urotrauma in order to expand research on
and develop new care recommendations for these injuries. Urotrauma,
which involves an injury to the genitourinary system and is often seen
in service members and veterans who have sustained blast injuries, is
becoming more prevalent among today's veteran population, especially
among those who served in Iraq and Afghanistan. Additionally, the
increased weight of modern body armor and gear worn by today's service
members can strain the abdominal muscles over time, which can also
damage urinary function and other parts of the genitourinary system.
While the number of urotrauma injuries has continued to rise, the body
of knowledge on and available treatment options for these injuries have
remained relatively stagnant. IAVA believes H.R. 984 is an important
step in providing the necessary research and treatment options to
address these serious wounds of war.
H.R.1284
IAVA supports H.R. 1284, which would authorize the VA to reimburse
the travel costs associated with seeking approved in-patient care at a
VA Special Disabilities Rehabilitation Program for additional
categories of catastrophically disabled veterans. Under current law,
the VA reimburses certain veterans for costs associated with travel to
and from approved VA medical facilities. However, there are certain
categories of catastrophically disabled veterans who are not entitled
to this reimbursement. We believe this legislation would provide
critical assistance for more disabled veterans to allow them to receive
the specialized in-patient treatment they need.
DRAFT BILL (Rep. Miller)
IAVA supports the Veterans Integrated Mental Health Care Act of
2013, which would assist veterans with accessing quality mental health
care through VA-approved providers and TRICARE program networks. The
overall shortage of mental health care providers is seriously impacting
both VA and DoD. IAVA's 2013 membership survey revealed that 80 percent
of our respondents don't think service members and veterans are getting
the mental health care they need. IAVA believes that one way to help
address the mental health care needs of veterans is through building
the type of community partnerships that are advocated in and
facilitated by this bill. These partnerships, which VA can use to help
fill in gaps in its ability to deliver care and services, will allow
veterans who would have otherwise had very lengthy wait times the
opportunity to receive timely mental health care in their local
communities. We believe this bill is a step in the right direction
toward building such positive and beneficial community partnerships.
DRAFT BILL (Rep. Benishek)
IAVA supports the Demanding Accountability for Veterans Act, which
would formalize a system of accountability within VA, give the VA's
Office of the Inspector General (OIG) report recommendations more
authority, and institute consequences for failing to fix problems
clearly identified by the OIG. IAVA believes this bill will strengthen
current systems of accountability by narrowing the focus of scrutiny as
to who is responsible for producing and correcting OIG-identified
public safety issues.
Mr. Chairman, we at IAVA again appreciate the opportunity to offer
our views on these important pieces of legislation, and we look forward
to continuing to work with each of you, your staff, and the
Subcommittee to improve the lives of veterans and their families. Thank
you for your time and attention.
Prepared Statement of Alethea Predeoux
Chairman Benishek, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to present our views on health care legislation
being considered by the Subcommittee. These important bills will help
ensure that veterans receive the best health care services available.
We are particularly pleased that two bills--H.R. 288 and H.R. 1284 that
are very high priorities for PVA--are being considered.
The ``Veterans Integrated Mental Health Care Act of 2013''
PVA does not support the, ``Veterans Integrated Mental health Care
Act of 2013,'' a bill to amend title 38, U.S.C. to direct the Secretary
of Veterans Affairs to provide certain veterans with an integrated
delivery model for mental health care through care-coordination
contracts. The VA is currently working on multiple initiatives to
improve care-coordination with private providers and increase timely
access to mental health services. Specifically, the VA is developing
mental health contracts with community based providers as required by
the President's Executive Order #13625--``Improving Access to Mental
Health Services for Veterans, Service Members, and Military Families,''
and is also in the process of transforming its national non-VA care
program in an effort to improve coordination services with non-VA
providers, which includes mental health services. PVA believes that the
current VA initiatives should be further developed before additional
resources are put into another program for non-VA care-coordination.
The ``Veterans Timely Access to Health Care Act''
PVA generally supports the intent of the, ``Veterans Timely Access
to Health Care Act,'' which proposes to direct the Secretary of the VA
to establish standards of access to care for veterans seeking health
care from VA medical facilities. If enacted, this bill would establish
a standard for access to care that requires the date on which a veteran
contacts the VA seeking an appointment and the date on which a visit
with an appropriate health care provider is completed to be 30 days.
While this legislation may potentially improve the delivery of VA
services, the language does not take into account the fact that the
standard for access to care may vary depending on the type of care
needed. As such, PVA has concerns regarding the use of a 30 day
standard for access to care without specifying the type of care that is
being provided. While PVA believes that timely access to quality care
is vital to VA's core mission of providing primary care and specialized
services to veterans, it is also important that factors such as the
nature of the services provided and efficient use of VA staff and
resources be considered when developing standards for access to care.
H.R. 288, the ``CHAMPVA Children's Protection Act of 2013''
PVA supports H.R. 288, legislation to amend title 38, United States
Code, to increase the maximum age for children eligible for medical
care under the Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA). CHAMPVA is a comprehensive health care
program in which the VA shares the cost of covered health care services
for eligible beneficiaries, including children up to age 23. As a part
of health reform, all commercial health insurance coverage increased
the age for covered dependents to receive health insurance on their
parents plan from 23 years of age to 26 years, in accordance with the
provisions of P.L. 111-148, the ``Patient Protection and Affordable
Care Act.'' This change also included health care coverage provided to
service members and their families through TRICARE.
Today, the only qualified dependents that are not covered under a
parent's health insurance policy up to age 26 are those of 100 percent
service-connected disabled veterans covered under CHAMPVA. This
unfortunate oversight has placed a financial burden on these disabled
veterans whose children are still dependent upon the parents for
medical coverage, particularly if the child has a preexisting medical
condition. PVA strongly supports this legislation because it will make
the necessary adjustment in this VA benefit.
H.R. 984, Urotrauma Task Force
PVA supports H.R. 984, legislation that would establish a national
Task Force on Urotrauma. Since 2005, the rate of injury to the
urogenital organs of service men and women has increased to
approximately 10 percent of all war injuries in both Iraq and
Afghanistan. The majority of these devastating injuries are the result
of exposure to improvised explosive devices (IEDs), with many others
from gunshot wounds to the pelvis or abdomen. Similarly, non-urologic
injuries such as spinal cord injury affect urologic function. Although
less common than extremity injury, trauma to the urogenital organs is
no less debilitating both physically and psychologically.
This proposed bill requires the Department of Defense, in
conjunction with the VA and the Department of Health & Human Services,
to establish a national commission on urotrauma. The commission's
objectives are:
1) to conduct a comprehensive study of the present state of
knowledge of the incidence and duration of, and morbidity and mortality
rates resulting from urotrauma;
2) to study the social and economic impact of such conditions;
3) evaluate the public and private facilities and resources
(including trained personnel and research activities) for the
prevention, diagnosis, treatment of, and research in such conditions;
and
4) to identify programs (including biological, behavioral,
environmental, and social) through which improvement in the management
of urotrauma can be accomplished.
The nature of the sacrifice that the service men and women who have
experienced urogenital injuries have made is beyond measure. It is
incumbent upon Congress and the Administration to take every step
necessary to help make these men and women as whole as possible. This
task force is a necessary first step.
H.R. 1284
PVA strongly supports H.R. 1284, a bill to amend title 38, U.S.C.,
to provide for coverage under the beneficiary travel program of the VA
of certain non-service connected catastrophically disabled veterans for
travel in connection with certain special disabilities rehabilitation.
This legislation is one of our priorities for the current Congress. If
enacted, this legislation would provide reimbursement for travel that
is in connection with care provided through a VA special disabilities
rehabilitation program to veterans with a spinal cord injury or
disorder, double or multiple amputations, or vision impairment. Such
care must also be provided on an inpatient basis or during temporary
lodging at a VA facility.
For this particular population of veterans, their routine annual
examinations often require inpatient stays, and as a result,
significant travel costs are incurred by these veterans. Too often,
catastrophically disabled veterans, particularly non-service connected
veterans who do not have the benefit of travel reimbursement, choose
not to travel to VA medical centers for care due to significant costs
associated with their travel. When these veterans do not receive the
necessary care, the result is often the development of far worse health
conditions and higher medical costs for the VA. For veterans who have
sustained a catastrophic injury like a spinal cord injury or disorder,
timely and appropriate medical care is vital to their overall health
and well-being.
PVA believes that expanding VA's beneficiary travel benefit to this
population of severely disabled veterans will lead to an increasing
number of catastrophically disabled veterans receiving quality, timely
comprehensive care, and result in long-term cost savings for the VA.
Eliminating the burden of transportation costs as a barrier to
receiving health care, will improve veterans' overall health and well
being, as well as decrease, if not prevent, future costs associated
with exacerbated health conditions due to postponed care.
The ``Demanding Accountability for Veterans Act of 2013''
PVA does not have an official position on the, ``Demanding
Accountability for Veterans Act of 2013.'' If enacted, this bill would
amend title 38 U.S.C. to improve the accountability of the VA secretary
to the Inspector General of the VA. PVA supports the overall intent of
this legislation to guarantee that systems of checks and balances are
in place to help make certain that federal services are effective and
provided in a timely manner. PVA believes that it is the responsibility
of the VA to provide an action plan in response to VA Inspector General
Reports, and carry out such plans as determined appropriate for the
successful delivery of veterans' benefits and health care services.
Yet, we must question the need for such legislation when Congress
already has the authority to conduct oversight.
We would once again like to thank the Subcommittee for the
opportunity to submit our views on the legislation considered today.
Enactment of much of the proposed legislation will significantly
enhance the health care services available to veterans, service
members, and their families. We would be happy to answer any questions
that you may have for the record.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2013
No federal grants or contracts received.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$262,787.
Prepared Statement of Robert L. Jesse
Good Morning Chairman Benishek, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for inviting me here today to
present our views on several bills that would affect Department of
Veterans Affairs (VA) health programs and services. Joining me today is
Susan Blauert, Deputy Assistant General Counsel.
Because of the time afforded for preparation of views, we do not
yet have cleared views on H.R. 241, H.R. 984, the draft bill ``the
Veterans Integrated Mental Health Care Act of 2013'' and the draft bill
``the Demanding Accountability for Veterans Act of 2013''.
H.R. 288 Increase of Maximum Age for Children Eligible for Medical Care
Under CHAMPVA Program.
The intent of H.R. 288 as expressed in its subtitle is to increase
the maximum age for children eligible for medical care under the
Civilian Health and Medical Program of the Department of Veterans
Affairs (CHAMPVA). However, VA believes the language in H.R. 288, as
written, may not accomplish this intent because it does not address the
definition of ``child'' in 38 U.S.C. Sec. 101 which limits eligibility
for children under CHAMPVA in 38 U.S.C. Sec. 1781. VA would be glad to
provide technical assistance to the Subcommittee if it does intend to
extend eligibility for coverage of children under CHAMPVA until they
reach age 26. VA believes that eligibility for coverage of children
under CHAMPVA should be consistent with certain private sector coverage
under the Affordable Care Act.
Assuming the intent of H.R. 288 is to accord the eligibility for
medical care under CHAMPVA to children until they reach the age of 26,
VA supports it, contingent upon Congress providing additional funding
to support the change in eligibility. Should the bill carry out that
intent, VA estimates costs of $51 million in FY 2014; $301 million over
5 years; and $750 million over 10 years.
H.R. 1284 Coverage Under Department of Veterans Affairs Beneficiary
Travel Program of Travel in Connection with Certain Special
Disabilities Rehabilitation.
H.R. 1284 would amend VA's beneficiary travel statute to ensure
beneficiary travel eligibility for Veterans with vision impairment,
Veterans with spinal cord injury (SCI) or disorder, and Veterans with
double or multiple amputations whose travel is in connection with care
provided through a VA special disabilities rehabilitation program
(including programs provided by spinal cord injury centers, blind
rehabilitation centers, and prosthetics rehabilitation centers), but
only when such care is provided on an in-patient basis or during a
period in which VA provides the Veteran with temporary lodging at a VA
facility to make the care more accessible. VA would be required to
report to the Committees on Veterans' Affairs of the Senate and House
of Representatives no later than 180 days after enactment on the
beneficiary travel program as amended by this legislation, including
the cost of the program, the number of Veterans served by the program,
and any other matters the Secretary considers appropriate. The
amendments made by this legislation would take effect on the first day
of the first fiscal year that begins after enactment.
VA supports the intent of broadening beneficiary travel eligibility
for those Veterans who could most benefit from the program, contingent
on provision of funding, but believes this legislation could be
improved by changing its scope. As written, the bill could be construed
to apply for travel only in connection with care provided through VA's
special rehabilitation program centers and would apply only when such
care is being provided to Veterans with specified medical conditions on
an inpatient basis or when the Veteran must be lodged. VA provides
rehabilitation for many injuries and diseases, including for Veterans
who are ``Catastrophically Disabled,'' at numerous specialized centers
other than those noted in H.R. 1284, including programs for Closed and
Traumatic Brain Injury (CBI+TBI), Post-traumatic Stress Disorder and
other mental health issues, Parkinson's Disease, Multiple Sclerosis,
Epilepsy, War Related Injury, Military Sexual Trauma, Woman's Programs,
Pain Management, and various addiction programs. In addition, many of
these programs provide outpatient care to Veterans who might not
require lodging but must travel significant distances on a daily basis
who would not be eligible under this legislation.
Therefore, VA feels that the legislation as written would provide
disparate travel eligibility to a limited group of Veterans. However,
VA does support the idea of travel for a larger group of
``Catastrophically Disabled'' Veterans (including Veterans who are
blind or have SCI and amputees) and those with special needs who may
not be otherwise eligible for VA travel benefits. VA welcomes the
opportunity to work with the Committee to craft appropriate language as
well as ensure that resources are available to support any travel
eligibility increase that might impact upon provision of VA health
care.
VHA estimates costs for this provision as $2.4 million for FY 2014;
$13.1 million over 5 years; and $29.8 million over 10 years.
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to appear before you today. I would be pleased to respond
to questions you or the other Members may have.
Statements For The Record
THE AMERICAN LEGION
Draft Legislation, the Veterans Integrated Mental Health Care Act of
2013
To amend title 38, United States Code, to direct the Secretary of
Veterans Affairs to provide certain veterans with an integrated
delivery model for mental health care through care-coordination
contracts.
The American Legion believes that veterans should not be denied
earned care based on where they choose to live. While we understand
that it is not feasible for every community to have a full slate of VA-
administered services, every community has access to medical care in
some form. For example, The American Legion conducted a site visit to
Martha's Vineyard last year for our report on Rural Health Care. In
2000, a contract was signed between the Providence VA Medical Center
and Martha's Vineyard Hospital. Through the contract, veterans living
on Martha's Vineyard were able to receive care at Martha's Vineyard
Hospital through fee-basis instead of having to travel off of the
island. The contract lapsed around 2004, but the VA failed to realize
this until 2008, when the hospital acquired new management. Veterans
who were being treated under the original contract found out that the
contract had lapsed when Martha's Vineyard Hospital sent collection
bill notices to those veterans for medical expenses previously covered
under the contract. Though a new contract was finally signed in the
fall of 2012, it took four years for this to be arranged, with the
veteran residents of Martha's Vineyard being forced to commute from
their homes to Providence VA Medical Center - a trek involving a ferry
ride and a two hour drive - each time they needed care.
Though there are only a few veterans living on the island, these
veterans deserve fair treatment, and access to the benefits they have
earned through their service. This delay illustrates the frustrations
that veterans living in rural and isolated locations or other areas
across the country experience in waiting for contracts and receiving
assurances from VA that the contract will be resolved. VA should
develop and implement a process to ensure all VA and non-VA purchased
care contracts are inputted into a tracking system to ensure they
remain current and do not lapse. If there are instances with a contract
lapsing, such as in Martha's Vineyard, VA should make every effort to
hold stakeholder meetings with veterans from those communities to
solicit input and keep veterans enrolled in these contracts/services
informed.
Exacerbating this problem are mental health issues which many
veterans suffer - PTSD and TBI - which at times may require immediate
care in order to prevent veterans from harming themselves or others.
This legislation would make strides toward addressing this issue by
facilitating contracts between VA and non-VA facilities to provide
mental health care to veterans who live in areas which do not have VA
medical facilities.
The American Legion supports this bill.
Draft Legislation, the Demanding Accountability for Veterans Act of
2013
To amend title 38, United States Code, to improve the
accountability of the Secretary of Veterans Affairs to the Inspector
General of the Department of Veterans Affairs.
The American Legion's Resolution No. 99, passed at National
Convention 2012 states that ``bonuses for VA senior executive staff
[should] be tied to qualitative and quantitative performance measures
developed by VA.'' While The American Legion refrains from commenting
on the specific nature of these qualitative and quantitative
performance measures - these decisions are left to the discretion of
Congress and the administration - The American Legion believes that the
implementation of such measures are a necessary step toward creating a
culture of accountability within the VA. This bill, by establishing
particular performance standards tied to bonuses received by VA senior
executive staff, moves toward addressing this issue.
The American Legion supports this bill.
H.R. 241, the Veterans Timely Access to Health Care Act
Veterans Timely Access to Health Care Act - Directs the Secretary
of Veterans Affairs to ensure that the standard for access to care for
a veteran seeking hospital care and medical services from the
Department of Veterans Affairs (VA) is 30 days from the date the
veteran contacts the VA.
Directs the Secretary to periodically review the performance of VA
medical facilities in meeting such standard.
Requires quarterly reports from the Secretary to the congressional
veterans' committees on the VA's experience with respect to appointment
waiting times.
The American Legion has long been concerned with the inordinate
wait times experienced by many veterans when attempting to access VA
medical care. In 2002, the inaugural year for The American Legion's
System Worth Saving initiative, the resulting report found that over
300,000 veterans were waiting for health care appointments. Of those,
over half were waiting more than eight months for primary care
appointments. In the intervening decade since then, little has changed,
as is demonstrated by the ongoing System Worth Saving reports. While VA
medical care is among the best in the world, access has proven to be a
problem for far too many of those who have earned it through their
service.
On March 6th of this year, this committee's Subcommittee on
Oversight and Investigations held a hearing entitled ``Waiting for
Care: Examining Patient Wait Times at VA'' aimed at examining this
issue. The American Legion, in addition to submitting testimony,
provided an attachment for the record containing numerous stories from
Veteran Integrated Service Networks (VISNs) across the nation,
detailing first-hand accounts of the barrier to care that these wait
times present - up to eight months, in some cases. This bill would
address this issue, and while The American Legion would prefer a
standard of less than 30 days - a goal of 14 days would be preferable -
this legislation is a step in the right direction.
The American Legion supports this bill.
H.R. 288, the CHAMPA Children's Protection Act
CHAMPVA Children's Protection Act of 2013 - Increases from 23 to 26
the maximum age of eligibility for certain dependent children of
veterans for medical care under CHAMPVA (the Civilian Health and
Medical Program of the Department of Veterans Affairs [VA]).
The American Legion has no position on this bill.
H.R. 984, To Direct DOD to Establish a Task Force on Urotrauma
Directs the Secretary of Defense (DOD), in order to continue and
expand the DOD report submitted in 2011, to establish the Task Force on
Urotrauma to: (1) conduct a study on urotrauma (injury to the urinary
tract from a penetrating, blunt, blast, thermal, chemical, or
biological cause) among members of the Armed Forces and veterans; and
(2) provide an interim and final report to the congressional defense
and veterans committees on such study.
The American Legion has no position on this bill.
H.R. 1284, To Provide Coverage Under VA's Beneficiary Travel Program of
Certain Disabled Veterans for Travel for Certain Special Disabilities
Rehabilitation
Authorizes payment under the Department of Veterans Affairs (VA)
beneficiary travel program of travel expenses in connection with
medical examination, treatment, or care of a veteran with vision
impairment, a spinal cord injury or disorder, or double or multiple
amputations whose travel is in connection with care provided through a
VA special disabilities rehabilitation program, if such care is
provided: (1) on an inpatient basis, or (2) while a veteran is provided
temporary lodging at a VA facility in order to make such care more
accessible.
Requires a report from the Secretary to the congressional veterans
committees on the travel program.
The American Legion has no position on this bill.
For additional information regarding this testimony, please contact
Mr. Shaun Rieley at The American Legion's Legislative Division, (202)
861-2700 or [email protected].
OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS
Mr. Chairman, Ranking Member Brownley, and Members of the
Subcommittee, thank you for the opportunity to discuss how the
Chairman's draft bill, Demanding Accountability for Veterans Act of
2013, will affect the operations of the Office of Inspector General
(OIG).
Timely implementation of OIG recommendations is critical to
improvement of VA programs and delivery of services to our Nation's
veterans, and we share the Subcommittee's interest in seeing that
responsible VA program officials are held accountable for correcting
program deficiencies. In considering the proposed legislation, we
believe it will be helpful for the Subcommittee to understand the OIG's
Follow-Up Program, which is the principal means by which we track VA's
progress implementing our recommendations.
OIG FOLLOW-UP PROGRAM
Follow-up is an important component of OIG oversight work. The
Office of Management and Budget requires a process to follow up and
report on the status of OIG report recommendations. The OIG is also
required to report in its Semiannual Report to Congress on the status
of report recommendations. Moreover, after the Inspector General
testified before this Committee in February 2007, we began providing
quarterly updates \1\ to Congress and the VA Secretary on the status of
open report recommendations, with an emphasis on those recommendations
pending over 1 year. In June 2010, the Deputy Inspector General
testified before the full Committee about the Department's progress
toward implementing recommendations.
---------------------------------------------------------------------------
\1\ The update for the 2nd and 4th quarter of the fiscal year is
the Semiannual Report to Congress.
---------------------------------------------------------------------------
Included in each OIG final report is VA's response to the report, a
statement whether they concur with each recommendation, and an
implementation plan for the recommendations, that includes target
dates. Those dates are determined by VA.
OIG staff take great care in developing recommendations to correct
identified deficiencies to ensure that they are clear and specific;
provide a yardstick to measure improvement; and gauge full
implementation. Since 2007, we have worked closely with VA officials to
develop recommendations for corrective action that can be realistically
implemented within a year. As such, the OIG no longer accepts VA
implementation plans that take more than a year to complete, except
under the rarest of circumstances and only when measurable timelines
are provided. In some instances, based on OIG staff evaluation, VA
program offices take corrective action while we are onsite or during
the period between the issuance of the draft report and when the final
report is published. When this happens, we close out the recommendation
as fully implemented and reflect the action in our final report.
However, a majority of the reports we issue contain open
recommendations. Once a final report is issued, OIG follow-up staff
begin a process of tracking each recommendation until fully
implemented. The first OIG follow-up request is sent to the responsible
VA program office 90 days after the report is published.
(Recommendations in the annual audits related to the Federal
Information Security Management Act of 2002 and VA's Consolidated
Financial Statements are tracked separately by our independent public
accounting firm and the results published annually in separate
reports.)
In each follow-up status request we seek a description of what
actions have occurred toward implementing the recommendations during
the preceding 90 days. We set a 30-day deadline for VA officials to
respond in writing. The response must contain documentary evidence such
as issued policies, certifications, or other material supporting any
request to close recommendations. Our intermediate goal is to obtain
evidence that VA is making progress in implementing recommendations. If
we do not receive a timely reply, or if we determine VA's efforts
appear to be falling behind schedule, we schedule a face-to-face
meeting to discuss how to get implementation back on track.
OIG follow-up staff coordinate with OIG line officials who worked
on the report. To ensure VA's implementation plans remain on track,
they discuss the documentary evidence VA submits with the status
reports. If a report recommendation remains unimplemented, OIG staff
repeat this follow-up cycle every 90 days. Once a report passes the 6-
month mark and we determine implementation is unlikely within the 1-
year goal, we increase the frequency of discussions with OIG line staff
and VA program officials, and ensure the appropriate senior management
officials in the OIG and VA recognize the probability of missing the 1-
year target for implementation.
In Appendix B of our Semiannual Report to Congress, we present
tables on open reports and recommendations. In the first table, we
provide a matrix with totals for both open reports and the associated
unimplemented recommendations. The table further breaks the data into
those open less than or more than 1 year, and provides the same data by
VA Administration or Staff Office. The second table shows only those
reports and recommendations that are unimplemented for more than 1
year. In this table, we show the report title, date of issue,
responsible VA organization, monetary impact, full text of each
recommendation, and an indication of how many recommendations on each
report are still open.
NAME CHECK PROCESS
To promote accountability, VA has a process in place to consult
with the OIG and certain VA staff offices to assist the Secretary in
making his decisions on performance awards and nominations for
Presidential Rank Awards for members of the Senior Executive Service
and Title 38 equivalents. The OIG performs name checks where the list
of potential award recipients are checked against OIG records to
determine whether there are any open criminal or administrative
investigations involving the individuals or whether there are any
adverse findings in closed cases involving the individuals. These
results are provided to VA for consideration by the Secretary when
making final decisions on executive awards. We have made it clear to VA
that nominating officials are responsible for considering the results
of OIG audits and inspections because these results may not be
associated with individual executives in our reports or record system.
DRAFT LEGISLATION
We offer the following comments on the draft legislation:
Page 2, Line 19, Notifying the OIG of responsible
managers by the Secretary - It would be helpful when identifying the
manager, if there was a requirement to identify which recommendation(s)
that manager was responsible for implementing.
Page 3, Line 3, Notifying the manager - ``Promptly
notify'' should be defined in terms of number of days.
Page 4, Line 16, Defining responsible managers - Because
VA has many positions covered under Title 38 of the United State Code,
the section defining managers should include employees covered under
Title 38 in addition to employees covered under Title 5 in the
competitive service and Senior Executive Service.
CONCLUSION
The OIG appreciates the Subcommittee's interest in our work and
ensuring that VA takes the necessary steps to address recommendations
that the OIG and VA have agreed will remediate identified problems. We
also appreciate the willingness of Subcommittee staff and Chairman
Benishek's staff to discuss the draft bill and make clarifying edits.
We will continue to work actively with VA to ensure that OIG
recommendations are implemented and to keep Congress advised on the
status of those recommendations.
MILITARY OFFICERS ASSOCIATION OF AMERICA (MOAA)
CHAIRMAN BENISHEK, RANKING MEMBER BROWNLEY AND DISTINGUISHED
MEMBERS OF THE COMMITTEE, on behalf of the over 380,000 members of The
Military Officers Association of America (MOAA), we are pleased to
present the Association's views on selected bills that are under
consideration at today's hearing.
MOAA does not receive any grants or contracts from the federal
government.
Thank you for the opportunity to submit comments and
recommendations on the following pending legislative provisions:
Draft, Veterans Integrated Mental Health Care Act of 2013
Draft, Demanding Accountability for Veterans Act of 2013
H.R. 241, Veterans Timely Access to Health Care Act
H.R. 288, CHAMPVA Children's Protection Act of 2013
H.R. 984, Direct the Secretary of Defense to Establish a
Task Force on Urotrauma
H.R. 1284, Amend Title 38 U.S.C. to Provide Coverage
Under the Beneficiary Travel Program of the Department of Veterans
Affairs (VA) of Certain Disabled Veterans for Travel for Certain
Special Disabilities Rehabilitation
MOAA supports all the above provisions with only minor additions as
noted below. We believe strongly that such legislation will strengthen
existing programs and services under VA's purview, addressing some
existing gaps in care, while providing additional tools for oversight
and accountability across the medical system.
PENDING PROVISIONS
Draft, Veterans Integrated Mental Health Care Act of 2013. This
provision would require the Secretary of VA to furnish mental health
care to eligible veterans that is provided by a non-Department
facility.
MOAA recognizes that more needs to be done to address the rapidly
growing demand for veterans' mental health services. This provision
allows more opportunities for care and provides an integrated model for
addressing access issues by using network providers outside the VA.
Further, greater coordination and oversight of contracts and data
sharing between government and non-government entities is supported by
this legislation.
We have long supported leveraging existing civilian network
providers, such as the TRICARE purchased care network to address the
demand. This provision will do just that, as well as help provide
necessary data to effectively measure patient outcomes.
MOAA fully supports this provision.
Draft, Demanding Accountability for Veterans Act of 2013. The
purpose of this bill is to improve the accountability of the Secretary
to the Inspector General (IG) of the VA.
Specifically, the provision requires the IG to notify Congress
should the Secretary not appropriately respond with significant
progress to a report issued by the IG by the required deadline of the
covered report.
MOAA is encouraged by this provision, allowing additional authority
to address reporting shortfalls with the Secretary. We see this as a
positive way for both the Secretary and Congress to exercise additional
oversight capability to improve accountability across the Department.
MOAA fully supports the draft provision.
H.R. 241, Veterans Timely Access to Health Care Act. The bill
mandates the Secretary to establish standards of access to care for
veterans seeking health care from VA medical facilities.
Our Association believes this legislation provides the forcing
mechanism needed for VA to standardize access--an important step in
eliminating the significant wait times facing veterans trying to
schedule initial and follow-on appointments.
MOAA is also concerned about veterans needing immediate follow-up
care after presenting in a VA emergency room (ER). Recently a caregiver
took her veteran to a VA ER and was told after discharge to make an
appointment for immediate follow-up but was told the earliest appoint
available was in 3 months--a common scenario we hear.
MOAA supports the draft provision and would ask the Subcommittee to
consider adding language requiring:
Completing appointments within 5-15 days (or some
medically-appropriate timeframe) following an urgent care visit to an
ER if prescribe by a VA provider.
Breaking out and tracking of veteran access by Enrollment
Priority Groups 1-8.
Adding a patient satisfaction rate measurement as a
metric of effectiveness.
H.R. 288, CHAMPVA Children's Protection Act of 2013. The provision
would amend Title 38, U.S.C. to increase the maximum age for children
eligible for medical care under CHAMPVA program from age 23 to 26.
The expansion of eligibility for CHAMPVA for eligible children up
to age 26 is in line with provisions in the Patient Protection and
Affordable Care Act (ACA) and the TRICARE Young Adult benefit.
According to a new GAO Report on the relationship of TRICARE and VA
care to the ACA, ``[the] ACA requires that if a health insurance plan
provides for dependent coverage of children, the plan must continue to
make such coverage available for an adult child until age 26. This
requirement relating to coverage of adult children took effect for the
plan years beginning on or after September 23, 2010. Under ACA, both
married and unmarried children qualify for this coverage. The
authorizing statute for CHAMPVA currently does not conform to this ACA
requirement.''
MOAA fully supports H.R. 288.
H.R. 984, Direct the Secretary of Defense to Establish a Task Force
on Urotrauma. Subject to availability of appropriations, H.R. 984 would
require the Secretary of Defense, in consultation with VA and the
Department of Health and Human Services to establish a Task Force to
conduct a study on urotrauma for a four-year period.
Given the severity of wounds and the changing combat environment,
MOAA supports the need for more research and analysis, particularly in
assessing incidents of urotrauma among our military members.
An important part of national security and readiness of our
military force is to have a good understanding of the effects of war.
This bill allows an opportunity to study significant injuries as a
result of the wars in Iraq and Afghanistan. Timing is crucial for this
provision as the need to capture useful data is essential in order to
apply what we learn in these wars and to be able to deploy in future
conflicts.
MOAA supports the provision and suggests adding to the Ex Officio
members list, military and veteran patient(s)/beneficiaries to
ensure the warrior's perspective is considered in task force
deliberations.
H.R. 1284, Amend Title 38 U.S.C. to Provide Coverage Under the
Beneficiary Travel Program of the Department of Veterans Affairs (VA)
of Certain Disabled Veterans for Travel for Certain Special
Disabilities Rehabilitation. Under this provision travel would be
authorized for a veteran with a vision impairment, a veteran with
spinal cord injury or disorder, or a veteran with double or multiple
amputations whose travel is in connection with care provided through a
special disabilities rehabilitation program of the VA (including spinal
cord injury center programs, blind rehabilitation center programs, and
prosthetics rehabilitation center programs).
Veterans with catastrophic non-service connected (NSC) disabilities
are currently ineligible for travel benefits associated with their
visits to one of the 13 Blind Rehabilitation Centers or 29 Spinal Cord
Injury locations around the country. These veterans must bear
significant financial costs, including air travel which often deters
them from getting the necessary training they need to live an
independent lifestyle.
Additionally, 32 percent of the NSC blind veterans live at the
poverty level and the average age of this population is 67 years old.
This issue is also outline in the Independent Budget, highlighting
that, ``When veterans do not meet the eligibility requirement for
travel reimbursement, and they do not have the financial means to
travel, the chances of their receiving the proper medical attention are
significantly decreased . . . For veterans who have sustained a
catastrophic injury like spinal cord injury, blindness, or limb
amputation, time and appropriate medical care is vital to their overall
health and well-being.''
We agree with our VSO colleagues that this provision is a
`preventive medicine' bill.
MOAA fully supports H.R. 1284.
CONCLUSION
The Military Officers Association of America is grateful to the
members of the Subcommittee on Health. Thank you for your leadership in
keeping these important issues before the Congress and for your
commitment to our Nation's heroes and their families.
VETERANS OF FOREIGN WARS OF THE UNITED STATES
MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:
On behalf of the men and women of the Veterans of Foreign Wars of
the United States (VFW) and our Auxiliaries, I would like to thank you
for the opportunity to offer testimony on today's pending legislation.
H.R. 241, Veterans Timely Access to Health Care Act
This legislation would direct the Secretary of Veterans Affairs to
ensure that all medical visits to Department of Veterans Affairs (VA)
facilities are completed no more than 30 days after the veteran
contacts VA to schedule an appointment. Additionally, it would require
that VA submit a detailed report to Congress on scheduled wait times no
later than 60 days after the end of each quarter.
The VFW understands that unacceptably long appointment wait times
present a serious and ongoing problem, especially for new enrollees and
those seeking specialty care, and agrees with the intent of this
legislation to address that issue. We are concerned, however, that its
enactment would remove too much flexibility from the scheduling
process. Appointment wait times can be measured either from the date
the veteran schedules the appointment or the date that the veteran
desires the appointment to take place. The date of contact, or create
date, could be several months in advance of the desired date,
specifically when the veteran takes the opportunity to schedule a
follow-up at the conclusion of his or her current appointment. Many
medical conditions require periodic visits with the veteran's health
care provider on a less than monthly basis. Legally mandating that all
appointments must take place within 30 days of the create date could
prevent VA from being able to offer long-term scheduling even when the
veteran and the provider agree that it is appropriate. A veteran
desiring an appointment 60 days in the future would have until 30 days
prior to the desired date to schedule. This would greatly complicate
the VA appointment reminder policy by necessitating reminders for when
veterans should be making their appointments in addition to when those
appointments occur. For these reasons, we feel that eliminating the
ability of VA to schedule appointments based on a distant desired date
would inevitably lead to missed appointments, creating unnecessary cost
to VA and diminished care for veterans.
The failure of VA scheduling staff to accurately establish
veterans' desired dates, however, has led to exceedingly long and
inaccurately reported wait times in the past, as highlighted by the
December, 2012 Government Accountability Office (GAO) report,
Reliability of Reported Outpatient Medical Appointment Wait Times and
Scheduling Oversight Need Improvement. To correct this problem, GAO
recommended that VA adopt a scheduling policy which more clearly
defines the desired date or adopt new wait time measures that are not
subject to interpretation. In response, VA has adopted the use of the
create date to determine the appointment wait times for all new
enrollees. VA has further stated that it will move to a policy which no
longer uses the desired date as determined by the scheduler, and
instead begin using an ``agreed upon date'' which is determined jointly
by the provider and the veteran to track appointment wait times for
established enrollees. The VFW will be closely monitoring these reforms
and encourages Congressional oversight of their progress and
effectiveness.
The VFW believes that, if executed properly, this new scheduling
policy creates an accurate and reliable method of determining wait
times and will increase veteran satisfaction while maintaining the
current level of scheduling flexibility. Consequently, we cannot
support H.R. 241 in its current form. The VFW would, however, consider
supporting similar legislation requiring VA to schedule all appointment
requests no more than 30 days after the agreed upon date for
established enrollees, and the create date for new enrollees and all
those seeking referrals from their current providers to new providers
or specialty care.
H.R. 288, CHAMPVA Children's Protection Act of 2013
The VFW supports this legislation to extend the age limit for
coverage of certain veterans' dependents through the Civilian Health
and Medical Program of the Department of Veterans Affairs (CHAMPVA) to
the level set by the Patient Protection and Affordable Care Act (ACA).
The ACA, passed in early 2010, allowed families with private health
insurance coverage to keep their children on their plans until age 26.
TRICARE and CHAMPVA recipients were not included in that change. Thanks
to responsible leaders in Congress, TRICARE coverage has been
guaranteed to this age group. Unfortunately, CHAMPVA beneficiaries have
not been afforded the same privileges. This remains an outstanding
issue that must be rectified.
The VFW urges, however, that this legislation be strengthened to
explicitly provide coverage to all children of CHAMPVA beneficiaries
under the age of 26, not just those who are enrolled full-time at an
approved educational institution or are unable to do so because of
disability. Such a change would provide the standard of coverage
offered under the ACA, as amended by the Health Care and Education
Reconciliation Act of 2010, which offers coverage to all dependent
children until age 26, regardless of educational status. The VFW
strongly believes that CHAMPVA, which was established in 1973 and has
more than 378,000 unique beneficiaries comprised of dependents and
survivors of certain veterans, should in no instance ever receive less
than the national standard.
H.R. 984, To direct the Secretary of Defense to establish a task force
on urotrauma.
The VFW is pleased to offer our support for this legislation which
would establish an interagency task force on genitourinary organ
injuries (urotrauma) to advise on research and action needed to advance
the care and treatment of urotrauma.
The American Urological Association has reported that urotrauma
injuries account for 10 percent of battlefield injuries with a 350
percent increase in incidence for those serving in Afghanistan compared
to those who served in Iraq. Although less common than other physical
injuries, the long-term emotional yet publicly invisible wounds from a
genitourinary injury can mean loss of function and fertility for many
service members. The psychological outcome of these battlefield
injuries for both men and women can be devastating.
The VFW believes that this legislation will begin to address some
of those needs by bringing together the Departments of Defense,
Veterans Affairs, and Health and Human Services to study current
incidence, morbidity and mortality rates, as well as the social and
economic impact. It would also task the agencies to evaluate public and
private resources for the diagnosis, prevention, treatment and most
importantly, research of these injuries. Finally, it would focus on
identifying programs and best practices among stakeholders to improve
the coordination and management of urotrauma injuries.
Better coordination and efficient use of resources both public and
private will provide the key to improved care, treatment and management
of those suffering from the residuals of these injuries. We urge
Congress to pass this bill quickly.
H.R. 1284, To amend title 38, United States Code, to provide for
coverage under the beneficiary travel program of the Department
of Veterans Affairs of certain disabled veterans for travel for
certain special disabilities rehabilitation, and for other
purposes.
The VFW supports this legislation which would extend beneficiary
travel benefits to veterans with certain severe non-service connected
disabilities who travel to receive care provided through a VA special
disabilities rehabilitation program. Veterans who are catastrophically
disabled due to spinal cord injuries, visual impairments, and multiple
amputations often require in-patient care in order to achieve full
rehabilitation. Not all VA facilities, however, offer the specialized
programs of care needed to properly treat these severe disabilities,
and many veterans are forced to travel great distances to receive the
care they need. Those not eligible for travel reimbursement must do so
at great personal cost and, as a result, may be forced to forego
essential primary or preventative care for financial reasons. This
legislation would alleviate that hardship for this small but vulnerable
population of veterans.
Draft Bill, Veterans Integrated Mental Health Care Act of 2013
The VFW does not support this legislation which would require VA to
furnish non-VA mental health care to any eligible veteran who elects to
receive such care at a non-VA facility that is able to meet certain
care-coordination standards. The VFW strongly believes that veterans
deserve access to timely and high quality mental health care that is
fully integrated and responsive to their needs. However, VA must remain
firmly in control of health care delivery. VA is currently moving
forward with a major national initiative to revolutionize fee basis
care, the Patient Centered Community Care (PCCC) program, which would
establish contracts to provide a number of managed care services at
non-VA facilities based upon individual need, including mental health
services. The VFW believes that mandating new contracting requirements
when VA is on the cusp of awarding PCCC contracts could create
confusion within VA, halting or disrupting the progress of PCCC reform.
Draft Bill, Demanding Accountability for Veterans Act of 2013
The VFW cannot support this legislation in its current form, which
dictates specific disciplinary actions on any responsible manager
following a failure by VA to properly respond to the recommendations of
a covered report of the Inspector General (IG), as determined by IG. We
understand and agree with its intent, but are concerned with the
precedent set by placing IG in a personnel management role. Managers
must be held responsible for failing to properly perform their duties,
but VA must maintain direct control over the accountability of its
employees.
Mr. Chairman, this concludes my testimony.
Information Required by Rule XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, VFW has
not received any federal grants in Fiscal Year 2013, nor has it
received any federal grants in the two previous Fiscal Years.
VETSFIRST/UNITED SPINAL ASSOCIATION
Chairman Benishek, Ranking Member Brownley, and other distinguished
Members of the Subcommittee, thank you for the opportunity to submit
written testimony regarding VetsFirst's views on the CHAMPVA Children's
Protection Act of 2013 (H.R. 288) and H.R. 1284.
VetsFirst, a program of United Spinal Association, represents the
culmination of over 60 years of service to veterans and their families.
We provide representation for veterans, their dependents and survivors
in their pursuit of Department of Veterans Affairs (VA) benefits and
health care before VA and in the federal courts. Today, we are not only
a VA-recognized national veterans service organization, but also a
leader in advocacy for all people with disabilities.
CHAMPVA Children's Protection Act of 2013 (H.R. 288)
The Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA) is a comprehensive health care program for
the spouses and dependent children of veterans who are permanently and
totally disabled, died while on active duty, or died due to a service-
connected disability. For the families of these veterans, CHAMPVA
provides critical physical and mental health care benefits. Children
who are CHAMPVA beneficiaries typically lose coverage at age 18 unless
they are full-time students, in which case they maintain benefits until
age 23.
The Affordable Care Act (ACA) allows a child to remain on a
parent's health insurance until age 26. However, TRICARE and CHAMPVA
child beneficiaries were not covered by this provision. The National
Defense Authorization Act (NDAA) for FY 2011 brought TRICARE into
alignment with the ACA provision by extending coverage to age 26 for
TRICARE beneficiaries. CHAMPVA child beneficiaries, however, were not
included in the NDAA provision.
Thus, CHAMPVA child beneficiaries are prohibited from receiving a
benefit similar to that provided to other adult children in our nation.
H.R. 288 will correct this injustice by allowing child beneficiaries to
continue to receive health care benefits under the CHAMPVA program
until age 26. This legislation will ensure parity for the children of
permanently and totally disabled veterans and those who died in service
to our nation.
VetsFirst supports the CHAMPVA Children's Protection Act of 2013
because it will ensure that the children of men and women who have
greatly sacrificed for our nation will be able to finish educational
opportunities and begin careers without having to forgo access to
critical health care benefits. We urge swift passage of this important
legislation.
To provide coverage under VA's beneficiary travel program for the
travel of certain disabled veterans for certain special disabilities
rehabilitation (H.R. 1284)
Veterans who have spinal cord injuries or disorders, vision
impairments, or double or multiple amputations require access to
rehabilitation services that allow them to live as independently as
possible with their disabilities. For those veterans who need these
services but who are not eligible
for travel benefits, the ability to pay for travel to these
rehabilitation programs can be very burdensome. In addition, few of
these services are available locally, particularly to veterans who live
in rural areas.
All disabled veterans who need to travel to receive in-patient care
at special disabilities rehabilitation programs should be eligible to
receive travel benefits from VA. Every effort must be made to reduce
barriers that limit access to these services. The long-term savings of
ensuring that these veterans are able to maintain their health and
function significantly outweighs the short-term costs associated with
this legislation.
VetsFirst supports H.R. 1284 because it will improve access to
rehabilitation services for all veterans who have spinal cord injuries
or disorders, vision impairments, or double or multiple amputations.
Thank you for the opportunity to submit written testimony
concerning VetsFirst's views on H.R. 288 and H.R. 1284. We appreciate
your leadership on behalf of our nation's disabled veterans and their
families.
Information Required by Clause 2(g) of Rule XI of the House of
Representatives
Written testimony submitted by Heather L. Ansley, Vice President of
Veterans Policy; VetsFirst, a program of United Spinal Association;
1660 L Street, NW, Suite 504; Washington, D.C. 20036. (202) 556-2076,
ext. 7702.
This testimony is being submitted on behalf of VetsFirst, a program
of United Spinal Association.
In fiscal year 2012, United Spinal Association served as a
subcontractor to Easter Seals for an amount not to exceed $5000 through
funding Easter Seals received from the U.S. Department of
Transportation. This is the only federal contract or grant, other than
the routine use of office space and associated resources in VA Regional
Offices for Veterans Service Officers that United Spinal Association
has received in the current or previous two fiscal years.
WOUNDED WARRIOR PROJECT
Chairman Benishek, Ranking Member Brownley, and Members of the
Subcommittee:
Thank you for inviting Wounded Warrior Project (WWP) to provide
views on pending health-related legislation. Several of the measures
under consideration address issues of keen importance to wounded
warriors and their family members.
Mental Health Care
Provision of timely, effective mental health care for warriors is a
matter of the greatest concern to Wounded Warrior Project. As such, we
appreciate the effort in the draft Veterans Integrated Mental Health
Care of 2013 to improve access to such care for those with service-
incurred mental health conditions.
The draft bill proposes to give veterans who seek treatment for a
service-incurred mental health condition (or who have a total and
permanent disability resulting from service-connected disability) a
choice between VA care and care provided under contract with an entity
that administers a provider-network. Under the draft bill, VA would be
required to inform those veterans when, where and who would provide
such needed VA treatment, and the veteran could choose to receive that
care from VA or instead from a contract provider. The measure would
permit VA to award a contract only if an entity demonstrates that it
can meet certain capabilities, including the ability to provide
nonurgent mental health care with access to a care-coordinator; the
ability to ensure an acceptable no-show rate and to exchange relevant
clinical information with VA within 30 days after an appointment; and
the ability to meet performance metrics regarding the quality of care
provided, patient satisfaction, timely access, and cost-effectiveness.
We welcome consideration of the principle of offering a warrior
choice regarding treatment for a service-connected condition. At the
same time, the draft bill raises a number of questions. It is not
clear, for example, how informed a veteran's choice would be under the
proposed framework and whether the treatment modalities available to
the veteran through a contract provider would be as extensive as they
might from VA. More specifically, the bill does not make clear whether
the veteran would have the same information regarding the contract-care
option as regarding the VA option (who would provide treatment and
when). And would the veteran have access to the same treatment
modalities under the contractor option as through VA? We infer not. For
example, the contractor would be responsible for providing ``nonurgent
mental health care or medical services.'' That suggests that a veteran
whose care needs become urgent or critical would be referred back to
the care-option he or she had earlier rejected, the VA. The reference
to ``or medical services'' (in the phrase ``the term'covered mental
health care' means nonurgent mental health care or medical services . .
. '') raises the question, what kind of providers could furnish the
required services and whether those services could simply be provided
by primary care physicians rather than behavioral health specialists.
The measure also raises the question, what would be the scope of care
provided under contract arrangements? Would psychotherapy be routinely
available, or would the first-choice (or only) treatment modality be
limited to prescribing and managing medications? Real choice surely
calls for a patient to have full information regarding the options,
particularly if they do not involve an ``apples to apples'' choice.
There are certain reasons why a veteran might elect to receive
treatment from a contract provider, but a veteran would likely also
want to understand the implications of first electing the contractor
option and subsequently seeking to opt-out. Could that veteran return
to the VA under those circumstances? And, if so, would VA still be
responsible for payment for a full course of treatment?
The principle of choice is an important one, but the goal, in our
view, should not be simply to afford a choice, but to provide timely,
effective mental health care. The draft bill reflects concern for
issues of quality, but its language sets no specific expectation as to
patient outcomes or effectiveness of treatment. Yet a relatively recent
study by the Institute of Medicine on the quality of behavioral health
care in this country stated that ``despite what is known about
effective care for M/SU [mental health and substance use] conditions,
numerous studies have documented a discrepancy between M/SU care that
is known to be effective and care that is actually delivered. \1\
---------------------------------------------------------------------------
\1\ Institute of Medicine Committee on Crossing the Quality Chasm:
Adaptation to Mental Health and Addictive Disorders, ``Improving the
Quality and Health Care for Mental and Substance-Use Conditions,'' (The
National Academies Press 2006), 5.
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At its most basic, for care to be effective, there must be a
relationship of trust between provider and patient. \2\ We know from
many of our warriors, however, that one critical element of that trust,
particularly as it relates to a highly sensitive subject like mental
health, is the provider's understanding of the warrior experience and
ability to relate, accordingly. Comments we have received from our
field staff regarding warriors' experience with mental health care are
illuminating in that regard. The following are typical:
---------------------------------------------------------------------------
\2\ Lambert, Michael J.; Barley, Dean E. ``Research summary on the
therapeutic relationship and psychotherapy outcome,'' Psychotherapy:
Theory, Research, Practice, Training, Vol 38(4), 2001, 357-361.
``The biggest [warrior] complaint seems to be . . . [that providers
have] no military background and they don't `get it' or understand what
I am going through and struggling with . . . .[It's] hard to connect
---------------------------------------------------------------------------
with someone when they haven't been in your shoes.''
``I ask warriors how they are coming along in their recovery; in
more cases than not, warriors do not want to talk about their war time
experiences with non-vets.''1A\3\
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\3\ Conference call with WWP alumni managers; May 1, 2013.
``Cultural competence'' is an important component of building a
therapeutic alliance, but the draft bill does not specify that the
contract entity meet any cultural training requirements. So there is
little reason to believe that contract providers under the proposed
framework would have the training and experience to address military
and veteran-specific ``cultural'' issues.
These questions and concerns cited above argue, in our view, not
only for addressing the kinds of issues we have raised, but for
proceeding cautiously. Rather than directing VA to offer contract care
to all veterans who need treatment for service-connected mental health
conditions (as the draft bill appears to do), we urge consideration of
developing a limited pilot program. Such a pilot could test the
underlying principle of providing service-connected veterans choice.
But that choice should not only be fully informed, but should optimally
offer the veteran a similar range of covered services under a framework
that provides reasonable assurance that they would receive both timely
and effective mental health care.
Urotrauma
H.R. 984 would direct the Secretary of Defense, subject to the
availability of funds for such purpose, to establish a ``Task Force on
Urotrauma'' to conduct a broad study of that subject that includes
analyzing data on incidence, morbidity and mortality; social and
economic costs and effects; evaluation of pertinent capabilities and
programs; and analyses, including an analysis of mechanisms to allow
for enhanced reproductive services for servicemembers.
We note that several of these topics were the subject of relatively
recent study by an Army task force; \4\ as such, we are not clear on
the rationale for establishing the proposed entity. Since that Army
task force completed its report, DoD has developed new policy relating
to advanced reproductive services, and broad legislation has been
introduced in the House that would authorize VA to provide reproductive
services to assist in helping severely wounded veterans who have
service-incurred infertility conditions to have children. \5\
---------------------------------------------------------------------------
\4\ Dismounted Complex Injury Task Force, ``Dismounted Complex
Blast Injury: Report of the Army Dismounted Complex Injury Task
Force,'' I (June 18, 2011) available at: http://
www.armymedicine.army.mil/reports/
DCBI%20Task%20Force%20Report%20%28Redacted%20Final%29.pdf.
\5\ See H.R. 958, accessed at http://thomas.loc.gov/cgi-bin/query/
z?c113:H.R.958:
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In WWP's view, the experience of our operations in Iraq and
Afghanistan has heightened the importance of grappling with the issue
of reproductive services. Blasts from widespread use of improvised
explosive devices (IED's) in Iraq and Afghanistan, particularly in the
case of warriors on foot patrols, have increasingly resulted not only
in traumatic amputations of at least one leg, but also in pelvic,
abdominal or urogenital wounds. \6\ While not widely recognized, the
number and severity of genitourinary injuries has increased over the
course of the war, with more than 12% of all admissions in 2010
involving associated genitourinary injuries. \7\ With that increase has
come not only DoD acknowledgement of the impact of genitourinary
injuries on warriors' psychological and reproductive health, \8\ but
recent adoption of a policy authorizing and providing implementation
guidance on assisted reproductive services for severely or seriously
injured active duty servicemembers. \9\ DoD's policy, set forth in
recent revisions to its TRICARE Operations Manual, applies to
servicemembers of either gender who have lost the natural ability to
procreate as a result of neurological, anatomical or physiological
injury. The policy covers assistive reproductive technologies
(including sperm and egg retrieval, artificial insemination and in
vitro fertilization) to help reduce the disabling effects of the
servicemember's condition to permit procreation with the
servicemember's spouse. \10\
---------------------------------------------------------------------------
\6\ Dismounted Complex Injury Task Force, supra.
\7\ Id. at 16.
\8\ Id.
\9\ Asst. Secretary of Defense (Health Affairs) & Director of
TRICARE Management Activity, Memorandum on Policy for Assisted
Reproductive Services for the Benefit of Seriously or Seriously Ill/
Injured (Category II or III) Active Duty Service Members (April 3,
2012) available at: http://www.veterans.senate.gov/upload/DOD--
reproductive--letter.pdf.
\10\ Dept. of Defense, TRICARE Operations Manual 6010.56-M, Chapter
17, Section 3, para. 2.6 (Sept. 19, 2012).
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For veterans, however, VA coverage is very limited in scope. The
regulation describing the scope of VA's ``medical benefits package''
states explicitly that in vitro fertilization is excluded \11\ and that
``[c]are will be provided only . . . [as] needed to promote, preserve,
or restore the health of the individual . . . .'' \12\ Consistent with
that limiting language, the VA's benefits handbook advises women
veterans with regard to health coverage that `` . . . infertility
evaluations and limited treatments are also available.'' \13\
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\11\ 38 C.F.R. Sec. 17(c )(2).
\12\ 38 C.F.R. Sec. 17(b) (Emphasis added).
\13\ Dept.of Veterans Affairs, ``Federal Benefits for Veterans,
Dependents and Survivors'' available at http://www.va.gov/opa/
publications/benefits--book/benefits--chap01.asp
---------------------------------------------------------------------------
In a departure from longstanding policy, VA stated last year that
``[t]he provision of Assisted Reproductive Services (including any
existing or future reproductive technology that involves the handling
of eggs or sperm) is in keeping with VA's goal to restore the
capabilities of Veterans with disabilities to the greatest extent
possible and to improve the quality of Veterans' lives.'' \14\ In its
statement, VA also expressed support in principle for legislation
authorizing VA to provide assistive reproductive services to help a
severely wounded veteran with an infertility condition incurred in
service and that veteran's spouse or partner have children. It
conditioned that support, however, on ``assurance of the additional
resources that would be required.'' \15\
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\14\ Health and Benefits Legislation Hearing Before the S. Comm. on
Veterans Affairs, 112th Cong. (2012).
\15\ Id.
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Certainly the administration of a VA program that would assist
wounded warriors and their spouses to conceive children would require
careful attention to ethical \16\ and regulatory \17\ issues associated
with providing advanced reproductive services. Economic considerations
certainly can arise in that regard. \18\ But while these advanced
interventions can be quite costly, cost should not be a barrier as it
relates to this country's obligation to young warriors who sustained
horrific battlefield injuries that impair their ability to father or
bear children.
---------------------------------------------------------------------------
\16\ See Meena Lal, ``The Role of the Federal Government in
Assisted Reproductive Technologies, 13 Santa Clara Computer and High
Tech. L. J. 517 (1997).
\17\ See Michelle Goodwin ``A Few Thoughts on Assisted Reproductive
Technology,'' 27 L. & Ineq. 465 (2009). Among these regulatory issues,
VA would have to address the need for physicians providing advanced
reproductive technologies to fully inform couples as to their risks,
including greater health risks in children born through these
technologies. See N.Y. State Dept. of Health Task Force on Life and the
Law, Assisted Reproductive Technologies: Analysis and Recommendations
for Public Policy, available at: http://www.health.ny.gov/regulations/
task--force/reports--publications/execsum.htm
\18\ Id.
---------------------------------------------------------------------------
WWP urges the Subcommittee to take up legislation to enable couples
unable to conceive because of the warrior's severe service-incurred
injury or illness to receive fertility counseling and treatment,
including assisted reproductive services, subject to reasonable
regulations.
CHAMPVA
Under current law CHAMPVA coverage expires at age 18 except in the
case of a full-time student when it may be extended until age 23 if the
student incurs a disabling illness or injury while pursuing a course of
study). H.R. 288 would extend that student coverage until age 26. We
support this legislation, which brings CHAMPVA into closer alignment
with the Affordable Care Act, which allows children to remain on a
parent's health plan until age 26.
Timeliness of Care
H.R. 241 would direct VA to establish a 30-day timeliness standard
with respect to the numbers of days between the date on which a veteran
seeks care until the date on which a visit with an appropriate health
care provider is completed. The measure would also require the
Department to provide a detailed semi-annual report to the Veterans
Affairs Committees of Congress with respect to the waiting times
veterans experience.
We applaud the focus on timeliness of care, but would caution
against establishing in law any single measure of timeliness. Thirty-
days would be an unacceptably long wait in the event of a medical or
psychiatric emergency. Yet it might be an unnecessarily strict standard
with respect to VA's performing a truly elective procedure or providing
health-promotion services, for example.
It is also important that there be rigor and integrity with respect
to any VA methodology for reporting and determining timeliness. The
Subcommittee would surely find instructive the experience associated
with VA's establishment of timeliness standards for mental health care
and the Inspector General's finding wide disparity between VA-reported
timeliness-performance data and its own data analysis. \19\
---------------------------------------------------------------------------
\19\ VA Inspector General, ``Review of Veterans Access to Mental
Health Care'' (April 23, 2012) accessed at http://www.va.gov/oig/pubs/
VAOIG-12-00900-168.pdf
---------------------------------------------------------------------------
Beneficiary Travel
H.R. 1284 would amend current law governing VA's ``beneficiary
travel'' program to cover certain severely disabled veterans' travel in
connection with care provided on an inpatient (or lodger-basis) through
a special VA disability-rehabilitation program.
WWP works extensively across the country with wounded warriors,
specifically veterans and servicemembers who were injured, wounded or
developed an illness or disorder of any kind in line of duty during
military service on or after September 11, 2001. Our warriors certainly
encounter barriers to receiving needed VA services - barriers that
include sometimes-rigid VA appointment-scheduling, long-distance
travel, and instances of inflexible program requirements. We are not
aware, however, of problems that warriors have encountered regarding
receipt of beneficiary travel generally or with respect to travel to
special disability-rehabilitation programs. As such, we have no
position on H.R. 1284.
Thank you for your consideration of WWP's views on these measures.
Questions For The Record
July 11, 2013
The Honorable Dan Benishek, Chairman
Subcommittee on Health
House Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515
Dear Chairman Benishek:
Thank you for giving PVA the opportunity to testify during the May
21, 2013 hearing on pending health care legislation being reviewed by
the Subcommittee. As requested, enclosed you will find the responses to
your follow-up questions from that hearing. Paralyzed Veterans of
America thanks the Subcommittee's for their attention to these
important issues. Please do not hesitate to contact me with any
questions that you may have regarding the responses, or involving
veterans' health care issues.
Again, thank you and we look forward to working with you and the
Subcommittee on these issues.
Sincerely,
Douglas K. Vollmer
Associate Executive Director, Government Relations
Questions for the Record from the Honorable Dan Benishek M.D.,
Subcommittee Chairman and PVA Responses
Draft Legislation, ``The Veterans Integrated Mental Health Care Act of
2013''
1. In a statement for the record, the Wounded Warrior Project urged
consideration of a limited pilot program to test the underlying
principles of the ``Veterans Integrated Mental Health Care Act.''
-Would you be supportive of such an arrangement? Please explain?
PVA believes that timely and quality care, as well as care
coordination are the top priorities when providing veterans with mental
health care services. During the hearing on May 21, 2013, PVA's written
statement to the Subcommittee stated that the Department of Veterans
Affairs (VA) is in the process of transforming its national non-VA care
program in an effort to improve coordination services with non-VA
providers, which includes mental health services. As a result of such
efforts, it is our position that these initiatives should be further
developed before additional resources are put into another program for
non-VA care-coordination. However, we would not be opposed to
incorporating specific provisions from this legislation into one of the
mental health pilots that the VA is currently developing under the
President's Executive Order #13625--``Improving Access to Mental Health
Services for Veterans, Service Members, and Military Families.'' If
such action is possible, we believe that these mental health pilots
serve as a good starting point to test the underlying principles of the
``Veterans Integrated Mental Health Care Act.''
Additionally, we urge the Subcommittee and the VA to consider
incorporating some of the underlying principles from this legislation
into its non-VA care coordination program. As the VA is currently
developing the Patient Centered Care Coordination (PCCC) initiative,
which will manage non-VA mental health services, aspects of this bill
may help improve coordination of such care.
H.R. 241, the Veterans Timely Access to Health Care Act
1. Given Concerns raised during the hearing regarding establishing
a single Department-wide timeliness measure in law, please provide your
views as to how to facilitate timeliness standards that take into
account the need for separate standards depending on the type of care
that is being provided - i.e. primary, specialty, and mental health
care services for both new and established veteran patients.
The establishment of timeliness standards for primary, specialty,
and mental health care services must include, to some degree, clinical
expertise and input. Therefore, PVA first recommends that the
Subcommittee and the VA work together to better develop timeliness
standards for VA services. Second, we suggest defining an
``acceptable'' time frame during which a veteran should be able to
schedule an appointment and have a visit with a medical professional.
As discussed in previous hearings held by the Subcommittee, the VA
defines access standards in many different ways, which leads to patient
confusion and can also be misleading when evaluating timely access,
particularly in the area of mental health.
Lastly, when reviewing H.R. 241, the Subcommittee may want to
consider requiring the VA to make a distinction between the types of
appointments being scheduled. The types of appointments can be divided
into categories that include first time appointments, follow-up visits,
and emergency visits. Each category may or may not have different
timeliness standards. Additionally, as the VA has multiple ways to
provide care, timeliness standards should take into consideration how
and where the care will be provided. Methods to provide care include
telehealth via the telephone and using the computer, or peer
counseling.
H.R. 1284, to amend title 38, United States Code, to provide for
coverage under the beneficiary travel program of the Department
of Veterans Affairs (VA) of certain disabled veterans for
travel for certain special disabilities rehabilitation, and for
other purposes
1. In their written testimony, VA states that, `` . . . VA feels
that the legislation as written would provide disparate travel
eligibility to a limited group of veterans.''
-Do you agree with the Department's assessment?
PVA does not fully agree with VA's statement that the H.R. 1284 as
written would provide disparate travel eligibility to a limited group
of veterans. Ultimately, PVA advocates the VA providing travel
reimbursement to all catastrophically disabled veterans [as defined by
the Secretary] whose travel is in connection with receipt of VA medical
services. However, we believe that providing the veteran populations
described in H.R. 1284 with VA travel reimbursement is a good first
step to eliminating the burden of transportation costs as a barrier to
care for severely disabled veterans, and improving access to VA care.
H.R. 1284 provides travel benefits to specific groups of veterans
that require chronic, expert care from designated VA specialized
systems of care, the Spinal Cord Injury/Disorder System of Care, the
Amputation System of Care, and the Blind Rehabilitation Service. These
groups of veterans can only receive their primary health care services
from a limited number of health care centers that are sparsely located
across the United States. Receiving services from primary care
providers that are not a part of their VA system of care, or from
providers who do not have the specialized expertise will jeopardize the
health and well being of these veterans. For instance, SCI/D annual
exams average two to three days because of the comprehensive testing
that takes place, such as image testing and physical examinations.
Often, our members drive to such visits and return home at the end of
the first day, and return each day until the exams and all required
procedures are complete. Driving to these appointments can be very
costly to the veteran when paying for gas of trips that can range up to
6 hours or more round trip. PVA members choose to drive because they
need accessible transportation and lodging that is safe and
comfortable. Driving is also a much cheaper option than admitting them
into an SCI/D unit for two to three days, and allows them to maintain
their personal independence.
2. In a statement for the record, the Wounded Warrior Project
states that, ``[w]e are not aware . . . of problems that warriors have
encountered regarding receipt of beneficiary travel generally or with
respect to travel to special disability-rehabilitation programs.''
-Please respond to that statement.
At this time, PVA does not purport to have knowledge of problems
that service-connected veterans have encountered regarding receipt of
beneficiary travel reimbursements. However, we do have PVA members who
are non-service connected, catastrophically disabled veterans, who are
not eligible for VA beneficiary travel benefits and have difficulty
affording the costs associated with traveling for medical visits. It is
for this reason, we strongly support H.R. 1284.
3. Do you see other avenues - such as through non-profit entities
or community groups - to provide transport to those certain non-service
connected individuals - that cannot defray the cost of air-fare and
other travel needs themselves?
PVA recognizes that other avenues of transportation are available,
and very much necessary. However, it is our position that many veterans
who have a catastrophic injury or disability, particularly, the three
populations identified in H.R. 1284, require adaptive equipment and
automobiles when traveling. It is not always the case that the
transportation provided by non-profit entities or community groups meet
the accessibility needs of catastrophically disabled veterans. Further,
arranging for accessible transportation can be very arduous and time
consuming, and as a result, it is common for disabled veterans who are
not able to drive themselves to medical appointments to delay health
care until transportation can be arranged, or forgo medical attention
completely. Many PVA members prefer to use personal transportation
options for reasons involving their comfort and safety; H.R. 1284 will
allow severely disabled veterans this option.
Inquiry from: Representative Julia Brownley
Context of Inquiry:
During the May 21, 2013 HVAC Health Subcommittee Legislative
Hearing, Representative Brownley requested updated CHAMPVA data. We
last sent her data on the program in 2010.
Response:
Analysis of the Child Population in the CHAMPVA Program Enrollment
File.
The current program-wide eligible count for CHAMPVA is 378,277 as
of 30 April 2013. This includes all persons that are eligible to file a
claim for healthcare services received during FY13. About 8,942 of
these individuals have already been declared ineligible for further
benefits this year, due mainly to divorce, death, or children that have
lost eligibility due to reaching one of the age restrictions.
The remainder of the analysis will deal with the child population,
and will be based on data that is current as of 5/1/2013. All age
groupings presented below are as of 5/1/2013 and based on the
individual's DOB in the enrollment file.
The number of covered children and students currently eligible for
benefits on 5/1/2013 was 52,975. The current population is slightly
smaller than the population review in FY 2009 that we were asked to
update (55,037). These children can be broken down into the following
groups
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Birth -18th Birthday................................... Children 45,573
----------------------------------------------------------------------------------------------------------------
Age 18 - 23rd Birthday................................. Students 7,362
----------------------------------------------------------------------------------------------------------------
23 - 25th Birthday..................................... Extended Benefit 40
----------------------------------------------------------------------------------------------------------------
CHAMPVA coverage can be extended when a covered child over age 18
suffers and injury, accident or other medical condition that makes them
unable to maintain their full-time student status. By regulation, these
individuals continue to receive coverage for up to two years from the
date of the event.
Based on the current enrollment file, there are 51,599 children
that have lost eligibility under the current CHAMPVA regulations, but
are still under the age of 26. The ``Ineligible'' counts provided on
the table and chart below only include children that have lost coverage
specifically due to age considerations. Other losses of eligibility,
such as marriage, death, or step-children that have left the qualifying
sponsor's household are not included in the ineligible child
population. This ineligible group can be identified by name, SSN and
last known address/phone number in our enrollment file.
Additionally, there is a cohort of children that have never applied
for benefits because their parent became a CHAMPVA eligible sponsor
after the child was no longer eligible due to current age restrictions.
We do not have any way to specifically count these individuals, but we
are providing a best estimate of this group under the category of
``Unregistered''.
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AGE TOTAL 0-17 18 19 20 21 22 23 24 25
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ELIGIBLE.................................. 52,975 45,573 2,648 1,571 1,260 1,070 813 24 12 4
PENDING................................... 163 115 12 9 9 8 6 3 1
INELIGIBLE................................ 51,599 0 3,445 5,033 6,023 6,583 7,077 8,082 7,675 7,681
UNREGISTERED*............................. 2,699 0 92 0 231 365 387 1,021 603
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The following chart provides a graphical representation of the data
in the table.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]