[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
VA HEALTHCARE: MAXIMIZING RESOURCES IN PUERTO RICO
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FIELD HEARING
SAN JUAN, PUERTO RICO
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
MONDAY, MARCH 12, 2018
__________
Serial No. 115-50
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
___________
U.S. GOVERNMENT PUBLISHING OFFICE
35-387 WASHINGTON : 2019
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
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
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Monday, March 12, 2018
Page
VA Healthcare: Maximizing Resources In Puerto Rico............... 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable David P. Roe, Member................................... 2
Honorable Jennifer Gonzalez-Colon, Member........................ 3
WITNESSES
Mr. Augustin MontanezAllman, Puerto Rico State Director of
Veterans Affairs............................................... 6
Dr. Rafael Rodriguez, Puerto Rico Secretary of Health............ 8
Dr. Victor Ramos, Puerto Rico College of Physicians and Surgeons, 11
Dr. Miguel LaPuz, Director of VISN8, the VA Sunshine Healthcare
Network of the U.S. Department of Veterans Affairs............. 13
Accompanied by:
Dr. Antonio Sanchez, Acting Director of the VA Caribbean
Healthcare System
Mr. Luis Ratchford, Jr., Deputy of Second Secretary for
Emergency Management and Resilience for the Department of
Veterans Affairs.
VA HEALTHCARE: MAXIMIZING RESOURCES IN PUERTO RICO
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Monday, March 12, 2018
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight
and Investigations,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:14 a.m., in
the Leopoldo Figueroa Hearing Room, Puerto Rico Capitol
Building, Constitution Avenue, San Juan, Puerto Rico, Hon. Brad
Wenstrup [Chairman of the Subcommittee] presiding.
Present: Representatives Wenstrup, Gonzalez-Colon, and Roe.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. I wish you a good morning, and thank you all
for joining us today. I'm Congressman Brad Wenstrup and I
represent Ohio's Second Congressional District and I'm honored
to serve as the Chairman of the Committee on Veterans Affairs
Subcommittee on health. I'd like to begin by thanking
Congresswoman Gonzalez-Colon for her determination and drive,
and bringing the Subcommittee's focus to the specific issues
faced by what is perhaps our most rural subcategory of American
Veterans, those who reside in Puerto Rico, the U.S. Virgin
Islands, and the Pacific Island Territories of Guam, the
Northern Mariana Islands, and American Samoa.
I'm also pleased to be with the Chairman of the Committee,
Dr. Phil Roe, today, and we are honored to have with us, Nicole
Rosario from Troop 546, and it is the 106th Anniversary of the
Girl Scouts, and we welcome to the dais today.
[Applause.]
Mr. Wenstrup. In so many cases, veterans of the island
territories face enormous challenges while receiving health
care from the VA. From traveling vast distances for care,
hundreds if not, thousands of miles in some cases, either by
boat or plane, to physician and provider shortages which can
cause lengthy wait times, access to VA care for those veterans
can be highly burdensome as many of you know. My goal for this
hearing is to identify opportunities for VA to build and
improve upon its relationships with local public and private
health care entities and hopefully reduce the burden we ask
these veterans to endure.
I also hope to gain a better understanding of what the
immediate needs are for VA facilities to the Caribbean to fully
recover from the devastation of Hurricanes Irma and Maria. In
this discussion we should take the opportunity to look towards
the future needs of veterans of the Caribbean and discuss what
steps VA can take today to address the future needs of the
veterans served here.
Before I finish my opening remarks, I want to take a moment
to bring attention to the Herculean effort put forward by VA
employees, to keep facilities operational both during and after
Hurricanes Irma and Maria. Over 800 VA employees weathered
these storms, leaving house and home to the elements and stayed
at the facilities to be with the veterans they are charged with
caring for. Veteran service organizations of the Islands helped
tremendously in this life saving effort by conducting house
calls and checking in on injured, elderly, and bedridden
veterans. The strength and resilience of the veterans of Puerto
Rico is truly beyond measure and I'm honored to be here today.
We are in this together. We are with you in this recovery.
Estamos juntos en esto. Estamos con ustedes. With that attempt
to Spanish, I'll yield to our Full Committee Chairman, Dr. Phil
Roe for five minutes for any opening remarks he may have.
OPENING STATEMENT OF HONORABLE DAVID P. ROE
Mr. Roe. Thank you, Dr. Wenstrup, and buenos dias. I am Dr.
Phil Roe, representative of Tennessee First Congressional
District and it's the only district in America that has two
Presidents, Andrew Jackson, Andrew Johnson, also Davy Crockett
was a member of Congress from the First Congressional District,
so I have big shoes to fill. You know, as I'm also honored to
serve as the Chairman of the House Veterans' Affairs Committee.
As an Army captain in 1973, I served in the Second Infantry,
Division Medical Battalion stationed near the DMZ in Korea,
Camp Casey and other places there, and I never dreamed years
later that I would find myself traveling to the United States
and its territories, conducting field hearings focused on
veterans' health care for some four and and a half decades
after completing my service in uniform, but here were are
today. Thank you, all for being here and graciously hosting us
this examination of VA Healthcare in Puerto Rico and the U.S.
Virgin Islands.
I want to extend a very special thank you to Congresswoman
Gonzalez-Colon for her, both her help and friendship, planning
this hearing as well as her tenacity and unending support for
American veterans. You have a true champion here, especially
those in Puerto Rico and the Caribbean, and other Pacific
territories of the United States. I want to thank you,
Jenniffer, for that.
[Applause.]
Mr. Roe. The veterans of Puerto Rico have fought valiantly
in every conflict since World War I. Today, your sons and
daughters, brothers and sisters, fight alongside Tennesseans
and Ohioans in lands far, far, away. Puerto Rican shed the same
blood on the same battlefields, on the same foreign soil in
order to keep our collective Nation safe. We are eternally
grateful for the sacrifices made by those who've worn the
uniform, that is exactly why we are here today.
Over the past several months, the people of Puerto Rico
have navigated their way through the worst national disaster to
hit this small island territory since 1928, almost 100 years.
In September a category of four, maybe a five, Hurricane Maria
cost more than 94 billions dollars in property damage and took
at least 112 lives. Throughout Hurricane Irma and Maria, as
well as the during the recovery, the San Juan VA Medical Center
remained open for business, staffed by 800 dedicated employees
and running on generator power.
Think about this, while hurricane force winds and rising
flood waters ravaged neighborhoods and family homes across this
island, over 800 VA employees put the veterans they served
above themselves, left their homes to the elements, and stayed
to accomplish their mission. That, is an amazing story that
needs to be told to the Nation.
Today, I hope to hear a great deal about what resources
were available during those two major storms and recovery, and
how those resources were leveraged to meet the emergent needs
of the veterans and the people of Puerto Rico and the Virgin
Islands. From our short time on this island, it's apparent that
there's much still to do, and I'm eager to jump into that
conversation, with that, Mr. Chairman, I will yield back.
Mr. Wenstrup. Thank you, and I now yield five minutes to
Ms. Gonzalez-Colon for any opening remarks she may have.
OPENING STATEMENT OF JENNIFER GONZALEZ-COLON
Miss Gonzalez-Colon. Thank you, Mr. Chairman, and thank you
to the whole Committee and Chairman Roe and Chairman Wenstrup
to be here on the Island. And, I sent our invitation to know
what's, to be in Puerto Rico after a hurricane, and the needs
of our veterans. For me, it's a pleasure and as a first and
only Member representing Puerto Rico in that Committee, we are
making history today, having the first hearing of this
Committee in Puerto Rico since the, 1946, when the Committee
was created. So, thank you for that.
Today is a historical day for all veterans in Puerto Rico,
not just for having this hearing, but also I'm a proud Member
of the Committee, and have witnessed firsthand the hard work
and unwavering commitment to our veterans shown by Chairman
Brad Wenstrup and Chairman Roe. On behalf of the veterans of
Puerto Rico, and their families, I want to express my sincerest
gratitude for holding this hearing.
I also want to thank our panel, Mr. Montanez, Dr. Miguel
LaPuz, Dr. Antonio Sanchez, and Dr. Rafael Rodriguez, and Dr.
Ramos for their participation and invaluable insight into the
current health care related concerns that affect our veteran
population. I very much look forward for your testimonies and
your opinion on how to improve those services in Puerto Rico.
Puerto Ricans have participated in every armed conflict
alongside our mainland counterpart since World War I. They have
been carrying the U.S. flag and fought and bled for freedom and
values that make our country great. They have also similarity
to all veterans across the Nation, return home with illness,
disabilities, and wounds, visible, and invisible that require
medical attention.
Our veterans and their family members, some of them, men
and women here today have need and deserve to have the best
medical care and attention available. They deserve the best and
we owe them nothing (sic) than that. Puerto Rico currently has
single VA hospital and VA clinics around the Island. They are
at the forefront of the care received by approximately 93,000
veterans residing in Puerto Rico and the U.S. Virgin Islands.
There are some intrinsic challenges with receiving medical
services in these facilities, given the Islands' rural
landscape. For many years, I have heard multiple veterans
state, the issues that they have been with receiving care
through the VA system, often due, to first, the extended travel
time to go to the clinic. Second, which is particularly hard to
our older veterans and their family members, then, second, the
limited provided availability in the physicians that they need
in the hospital, and third, the staffing shortages overall.
To make matters worse, Puerto Rico was struck by two
consecutive hurricanes of historical force. And there still
families without power, more than 130,000 people without power
on the Island, with limited access to drinking water and
communication services. Our veterans were not spared with those
hurricanes. As you can imagine, events like this, exacerbates
any health condition and create even a higher demand on
reliable health care services. Not to mention the PTSD
conditions.
The Hospital continued operating through the storm and even
offered services to nonveteran patients and assisted
neighborhood hospitals and clinics. Nevertheless, it suffered
some structural damage and needs some repairs. And, for that, I
need to commend my fellow chairmen of this Committee, because
during the last supplemental approved during this year, this
Committee recommended and the House approved more than 94
million dollars to the repairs of the VA clinics in Puerto
Rico, U.S. Virgin Islands, Texas, and Florida. With that, they
also included 11 million dollars to services related to VA
system, that are important to our Nation, but specifically to
Puerto Rico.
They also approved in the VA, more than 75.1 million
dollars to repair the Veterans Health facilities in Texas,
Florida, and Puerto Rico, and 93 million dollars for the
response overall. And, 4.1 million dollars to repair Puerto
Rico National Cemetery and Veterans Benefits Administration in
Houston. Eleven point one million to cover the cost of medical
services including transportation, medical supplies, and mobile
medical units during the storms.
This is not enough. It's a good beginning, but I know that
we can identify those resources like the clinic of Arecibo that
this Committee is going to be looking at this afternoon. In
addition to that clinic, Arecibo and Vieques, were still
significantly impacted. Veterans receive care at the Arecibo
clinic are currently being treated at intense. Essentially, a
field hospital on a parking lot belonging to a municipality
coliseum, veterans residing in Vieques are being treated
through the medical home visits, and I cannot stress enough the
importance of every single one of our VA clinics.
It's imperative that we locate new facilities that meet VA
standards, and swiftly as possible, so that our veterans can
receive appropriate care in safe accessible and working
facilities. It is also important that we are aware and
understand the list of health care benefits available to them.
Every veteran population is different, and I have noticed that
most of my constituent veterans prefer to receive care at the
VA facilities on the Island.
It is important for them to understand that there are other
options in the case that the VA facility does not match the
quality of reduced waiting time compared to an outside
provider. However, I hear that many of them do not use it, they
miss information, and medical providers, or other even other
veterans. I look forward to listening to all of those comments
and knowing if we can improve the access provider through
choice, and making sure veterans and providers are aware of the
benefits available through the programs.
Our veterans in Puerto Rico are facing a lot of challenges
and struggles. We have a single veteran home located in the
municipality of Juana Diaz. We have learned that the demands
have exceeded housing capacity, and we have also noticed, that
like many other state veterans' homes, the state shared needed
to compliment the Federal share of cost is becoming
increasingly more challenging to meet, leaving the homes with
issues when trying to maintain an infrastructure and
operational utilities, as well as taking care of our veteran
residence while welcoming new ones.
And, I also want to express out that we finally are working
to have our first Fisher House in Puerto Rico. Since the
hospital is located in San Juan, veterans reside in other
municipalities must travel to this facility without having any
place to their families to stay when they're receiving
treatment. For that I'm pleased to announce that we are working
with the Secretary of Health, Dr. Rafael Rodriguez and the
Governor of Puerto Rico just identified the land in `el
Hospital Psiquiatrico', and we are waiting for the transfer of
those deeds to the VA Administration so we can finally have our
first Fisher House in Puerto Rico.
The reason for that, is because of the land ownership and
I'm proud to inform that on May of this year, the president of
the Fisher Foundation and the VA construction management team
will be visiting the Island to inspect the site and give
feedback on next steps for turning this program into reality on
the Island, finally.
[Applause.]
Miss Gonzalez-Colon. With that I want to conclude saying
thank you to our veteran population and to all of you that are
in the audience today. I want to acknowledge your presence here
with us, and I would love to have you standing to give a round
of applause to the people of the American Legion, to the people
of the Paralyzed Veterans of America, to the people of the
Disabled American Veterans, to the people of the Military Order
of the Purple Heart, to the Blind Veterans Association, to the
Veterans of Foreign Wars, to the Military Officers Association
of America, Military Officers from Mayaguez, the Military Order
of the World Wars, Vietnam Veterans of America, and our
proudest, proudest sons, the people from the 65 Regiment, the
`Borinqueneers'. Thank you, all of you for being here today and
thank you Chairman for your time, and I yield back.
[Applause.]
Mr. Wenstrup. Well, thank you, very much Congresswoman.
Before I introduce our witnesses, I want to remind everyone
here today, that today's event is a formal congressional
hearing. We will have only one panel of witnesses and only
those invited to testify will be permitted to speak. There will
be an opportunity after the hearing for those of you in our
audience to come up and speak with me, with Dr. Roe, with
Congresswoman Gonzalez-Colon, or our staff, if you have any
questions or comments or need further assistance.
With that being said, we're here today with several local
medical leaders who helped guide the ship through many
difficult storms. Joining us on our first panel this morning,
is Mr. Augustin MontanezAllman, the Puerto Rico State Director
of Veterans Affairs, Dr. Rafael Rodriguez, the Puerto Rico
Secretary of Health, Dr. Victor Ramos, from the Puerto Rico
College of Physicians and Surgeons, and Dr. Miguel LaPuz,
Director of VISN8, the VA Sunshine Healthcare Network of the
U.S. Department of Veterans Affairs.
Dr. LaPuz is accompanied by Dr. Antonio Sanchez, Acting
Director of the VA Caribbean Healthcare System as well as Mr.
Luis Ratchford, Jr., Deputy of Second Secretary for Emergency
Management and Resilience for the Department of Veterans
Affairs. Thank you, all for being here today, and for all the
good work each of you do to serve your veteran neighbors in
Puerto Rico and across the Caribbean. Mr. MontanezAllman, we
will begin with you and you are now recognized for five
minutes, sir.
STATEMENT OF MR. MONTANEZALLMAN
Mr. MontanezAllman. Good morning. My name is Augustin
Montanez Allman, I'm the veterans' advocate for the government
of Puerto Rico and a veteran of Persian Gulf War and a
recipient of the Bronze Star Medal. On behalf of our team, we
welcome you to Puerto Rico and we are grateful for the
opportunity we are given. We want to welcome you, Dr. Wenstrup
and also Dr. Roe, and also we are very glad that Gonzalez,
Jenniffer Gonzalez was able to get this hearing here in Puerto
Rico. We appreciate it and welcome to Puerto Rico.
I want to make a disclaimer, I'm not a doctor, nor am I
health professional, but obviously the information I'm going to
bring is what we have observed and also what we have received
from veterans that have come to the office to bring in some
information. First, I would like to talk a little bit about the
mission of the office and how we relate it to VA. Our mission
is to enforce Federal and Puerto Rico laws and regulations
regarding USA veterans living in Puerto Rico, which also
coordinates some social services. Because of its regulatory
functions as Ombudsman, the office operates independently and
is the main government agency that ensures the social economic
well being of veterans and their families.
Our office oversees the management of the Veterans State
Cemetery and the Veterans Home serving 147 veterans. Under my
direction, the Veterans Home regain the VA certification and
has met inspections every year without a single jeopardy
finding. We had the last inspection two weeks ago, and we
didn't have no (sic)jeopardy findings in that inspection.
Our office works with the USA Department of Veterans
Affairs and its three administrations. We refer homeless
veterans to programs of the Veterans Medical Center and we
facilitate VA relations with the community and serve as a
liaison with USA veterans organizations in Puerto Rico. The
Veterans Home has received emergency support from the Veterans
Medical Center, I have to mention they gave us a lot of support
during the hurricane from the San Juan hospital.
I would like to talk about the situation of Puerto Rico,
veterans in Puerto Rico. Veterans living in Puerto Rico come
from the five USA armed forces and are from every war and
conflict since World War I. Some are native Puerto Rican,
others are retired or business owners, some are seasonal
residents, and others are foreign born USA veterans that, from
countries such as Dominican Republic, Mexico, and Columbia.
VA accounts for a population of about 93,000 veterans. Our
office thinks that the population is higher in numbers since
numerous veterans in Puerto Rico are not receiving VA benefits
or services because of different reasons. The current situation
of VA health care, we understand that most of VA health care
service in Puerto Rico are high quality and many cases, better
than most of the private sector, but it should still exist such
as, number one, not enough capacity to serve all eligible
veterans, number two, not all type of services available are
provided. Number three, no specialized health facilities like
trauma centers or mental health centers. Number four, shortage
of specialized medical professional in areas also scarce in the
private sector. Five, location, transportation, and information
issues impacting access to service. Number six, additional
training for medical contractors to manage effectively,
veterans' cases. And, number seven, VA takes too long to take
the payments some times for private sector health care
providers.
Some clinics are still operating from mobile units and
tents due to hurricane damage. The clinics do not provide all
the services of the Medical Center. The Medical Center in San
Juan has only 295 beds for medical patients, and 30 beds for
mental health patients, that is expected to meet all the needs
of over 93,000 veterans. There's a shortage of specialists such
as radiologists, psychiatrists, and hand surgeons. None of the
clinics in the Medical Center have a VA trauma center or mental
health residential facility. Even in contract services, there's
not enough capacity some times. Access to service is an issue
like in the rural areas in the United States. But, like the 50
States, veterans in Puerto Rico do not have the representative
in Congress that can legislate and vote to improve those
situations.
The best practice that we saw during the hurricane, we have
to mention, the hospital was among the few hospitals that was
operating, running during the hurricane and the black out. Its
representative was present at the center of emergency
operations of the government of Puerto Rico to coordinate
efforts. Really, they did a really good job coordinating with
our office and other state agencies.
Our office was allowed to participate in all the VAH daily
briefings and I was given a daily report about the situation of
the veterans and the service of the hospital, and the clinics.
VA facilitated equipment and ITC lines to enable, to set up a
temporary service area where staff assisted veterans with over
900 FEMA claims. We have three persons working at the hospital,
helping the veterans with their FEMA claims.
Some recommendations. In the medical mental health service
operation, we understand that facilitate the state and
municipal agencies, and nonprofit organizations, can submit
proposals for grants for health care created services, that we
can maximize, you know, our resources in the Island.
Number two, implement an integrated holistic approach to
health care, different from other parts of the United States
where you have different types of programs, and here in Puerto
Rico is limited what we have. Number three, expose Veterans
Health Administration orientation for private health care
providers. Sometimes, veterans have come to the office
complaining how the way some of the private provider have been
dealing and, you know, working with them allocate a small space
in the clinics to service area for my office and other agencies
like the one we set up, we have in Ponce, and are proposed for
Mayaguez and Arecibo support the Puerto Rico Department of
Health Plan to expand the state trauma center, to designate an
area that service veterans and military only, and at a later
time, we will serve a backup trauma center to the one that can
be created at the San Juan Medical Center.
Begin a feasability study to build a trauma center at the
San Juan Medical Center. It's something that the veterans have
been asking for many years. Things that we recommend during
disaster preparedness or disaster relief efforts, set up a
reliable communication backup system with satellite phones
between VHA, state agencies, key medical and mental health
service providers, and first responders. Implement a policy
that VHA facilitates equipment, an ITC line to enable my agency
and other VSOs to set up temporary service area.
Provide medical and mental health service to all category
veterans not eligible under normal operations, and I would like
to mention at this part, here in Puerto Rico some veterans of
Category 8, they cannot receive service in the hospital. When
we had the problem with the hurricane that the private sector
was not working completely, some of these veterans were having
problems because they could not be served during the hurricane,
the idea is that during the emergency they can be given
service.
On behalf of the veterans residing in Puerto Rico, we
appreciate the opportunity to share our office insights, and
your efforts to improve the health service provider to our
veterans, we look forward to collaborate on our goals, on that
goal. Thank you.
[The prepared statement of Mr. MontanezAllman appears in
the Appendix]
Mr. Wenstrup. Well, thank you. Dr. Rodriguez, you are now
recognized for five minutes and if we could try to keep it to
five minutes
Dr. Rodriguez. Yes, I will.
Mr. Wenstrup. so we can have time for questions, thank you.
STATEMENT OF DR. RAFAEL RODRIGUEZ
Dr. Rodriguez. I will try. Yeah sure. Good morning, Mr.
Chairman, Brad Wenstrup, Congresswoman Jenniffer Gonzalez, and
a special thanks to Chairman Phil Roe, and Ms. Christine Hill.
On behalf of the Governor of Puerto Rico, Ricardo Rossello,
thanks you for your presence and dedication in supporting
Puerto Rico and our U.S. veterans.
This is a historical Veteran Committee congressional field
hearing, the first that I witnessed and I am honored to have
been asked to participate. Congresswoman Gonzalez, the veteran
community of Puerto Rico is most grateful for bringing the
House of Veterans Affairs Committee here to our State Capitol
and we salute you for this accomplish (sic). On behalf of all
of U.S. veterans residing in Puerto Rico, I want to give you a
warm Puerto Rican welcome.
Today, I come before you not only as a Secretary of Health
of the Government of Puerto Rico. I come as a former Chancellor
of the University of Puerto Rico Medical Science campus, but as
an active reserve component soldier physician for almost 30
years of military service and a veteran. I am, also I am proud
of being an American soldier.
I am privileged to provide testimony for the record, for
this oversight field hearing. President Trump's Administration
and the U.S. Congress have begun the process of funding the
most immediate emergency needs in Puerto Rico. I am sure that
during the short visit to the Island six months after Hurricane
Irma and Maria, you have obtained a deep appreciation and need
awareness that much more remains to be accomplished to
stabilize Puerto Rico, especially in the mountain regions and
to serve the Island on the path for full recovery and
reconstruction.
The scale and scope of catastrophe in Puerto Rico in the
aftermath of Hurricane Maria, knows no historic precedence. The
islandwide, devastation presented an extraordinary challenge to
the U.S. citizens of Puerto Rico, to the local government, and
the Federal government. The hurricanes brought high speed
sustained winds, heavy rain, and the devastating flooding the
likes of which the Island have never seen before. Roads and
bridges fell and roads broken by debris across the Island,
leaving communities stranded and unable to obtain life saving
aid, food, water, and medicine for a period of weeks. More than
472,000 housing units were destroyed or experienced major
damages, forcing hundreds of thousands of U.S. Puerto Rican
U.S. citizens to seek refuge in shelters, home of families and
friends, and in the worse case scenario to migrate to the
mainland.
One of the most distressful situation in providing health
services to the population at large was, did not cease in
communication, further compounded of two neighbor islands,
Vieques and Culebra. Due to the condition they have endured,
many of our citizens decided to relocate in the continental USA
on their own. During my recent visit to Orlando and tour to the
Orlando VA at Lake Nona, we informed that more than 900 of our
veterans have enrolled in the VA Health System, programs in the
State of Florida, of which 300 enrolled in the facility at Lake
Nona. And, just imagine the other states that could be veterans
also like Chicago, Pennsylvania, Texas, New York, New Jersey,
you name it.
Our health situation was concerning even before the storm.
Diabetes and HIV present major concerns to our citizens. Also
we experienced over the last few years outbreak of Zika,
Dengue, and Chikungunya. Thank God, we ended the Zika epidemic
outbreak on last June, and about 2 or 3 months, they removed
the travel advisory for Puerto Rico in terms of Zika infection.
The need of behavioral health services are highlighted
after the passing of Hurricane Irma and Maria. Also, I believe
that more analysis needs to be made concerning the mental
health status in the Island. The data before and after the
storm is concerning. The mental health and suicide hotline
received more than 26,000 calls between October and December of
2017. Of those, 9,000 callers expressed suicidal behavior. Six
thousand were able to verbalize a plan to end their lives and
more than 2,000 had the intention. That is very concerning.
Every single one of those calls is a saved life. However,
not everyone with suicidal ideation called the hotline. In
2017, there is an increase of suicide by 29 percent in
comparison with previous years. There were 196 suicides
registered in 2016, and on 2017 ended with 253 suicides, 57
suicides more. As of February of this year, we report only 24
suicides, a reduction from last year at the same time.
The Department of Family, equivalent to the Social Services
Department in the continental U.S. provide mental health and
care services to elderly and their providers of care. This is
another area where the VA and the Puerto Rico Health Department
should collaborate as all are U.S. citizens residing in Puerto
Rico requiring help. This collaboration can take with the
support with of the best of Puerto Rico Medical Science campus.
Our health care system can assist the VA with their access and
keeping the veteran closer to their homes. Every single town
and municipality in Puerto Rico have a primary care center.
This take care from the state government health centers of
treatment and diagnosis or Federal funded tertiary health
clinics. Veterans can access these clinics and centers faster
and would reduce the appointment waiting time issues as the VA
currently has.
Another area we're over? One? Okay, let me okay, another
area that our government is interested is to import the
potential of transfer land to the U.S. Department of Veterans
Affairs. We are proposing that the Fisher House foundation
build such facility on the VA campus in San Juan which is
adjacent to the Puerto Rico Medical Science campus.
At the end of the day, I am responsible of the well being
of the U.S. citizens residing in Puerto Rico. Veterans are
heroes that have earned a series of benefits, but more
important, they are U.S. citizens that I need to assist in the
maintain the healthy as all U.S. citizens in this beautiful
island and part of our great Nation.
There should be more areas of collaboration than the one we
have. After all, we have the same goals to deliver the best
possible health care service with the limited resources to the
U.S. citizen residing in Puerto Rico. Thank you, so much for
this opportunity.
[The prepared statement of Dr. Rodriguez appears in the
Appendix]
Mr. Wenstrup. Thank you very much.
[Applause.]
Dr. Ramos, you're now recognized for five minutes.
STATEMENT OF DR. VICTOR RAMOS
Dr. Ramos. Thank you, Chairman Wenstrup, Chairman Roe, and
Resident Commissioner Gonzalez and Member of the Committee. My
name is Victor Ramos, and I am the President of the Puerto Rico
Physician and Surgeon College, an organization comprised of all
licensed physicians in Puerto Rico. On behalf of the more than
9,000 physicians in Puerto Rico that I represent, I thank you
for this opportunity to participate in this conversation here
with you today, on maximizing the VA resources in Puerto Rico,
to impact the health of our veteran population.
Also, here with me Dr. Jorge Vidal, of the Puerto Rico
Radiologist Society and Dr. Rafael Zaragoza of the Allergy
Physicians representing the private sector. Chronic
understaffing has been the national problem for the Department
of Veterans Affairs for many years now, and Puerto Rico
unfortunately is not the exception. Ways in which to mitigate
the shortage of providers within the VA Health System has been
a constant topic of discussion at the administrative and
legislative levels. And, many feel initiative have been
implemented which is not the solution found. However, our
demographic and geographic particularities have amplified the
VA Health System national problem of chronic understaffing.
According to the Department of Veterans Affairs, there are
over 93,000 veterans registered as resident of Puerto Rico.
Sixtyfive percent which are over 65 years old, a number
slightly higher than the national average. Although small in
size, our jurisdiction is mostly rural, with VA Health System
treatment concentrated in the San Juan metropolitan area.
Access to this facility is difficult to age related health
conditions of the veteran population, as well as the lack of
integrated public transportation system. And, in contrast to
the stateside population, our veterans use the VA Health System
prior than other health insurance they might possess as their
primary health care provider.
This perfect storm of an aging population which recall in
health intervention, and overall utilization as compared to
other jurisdiction is further combined by the exodus of
physicians in large part of specialty from Puerto Rico. The
staff position in the VA Health System in Puerto Rico remain
open and funded, but requirement hindered by the lengthy and
archaic bureaucratic hurdles that physicians make to jump
through in order to be considered. Employee staff is fuller
subject to high tax in Puerto Rico which are compound by the
economic pressures upon physicians merely because of the higher
cost of living in Puerto Rico. Lateral move within the VA
Health System from Puerto Rico to other jurisdiction
automatically result in the defacto rise with money in
physician's pocket at the end of the day.
Although the government of Puerto Rico has incentivized
physicians to stay in Puerto Rico by granting them special tax
rate for staying in or returning to the Island, more needs to
be done to stop the emigration and bring them back to the
Island. Therefore, the VA must find ways to making more
attractive for physicians to apply for staff positions, and to
remain in those positions in jurisdiction like Puerto Rico with
particular high under staffing issues.
The Veteran Choice program is one of the ways VA is
improving access to care for veterans, but allowing them to
receive care from nonVA facilities, connecting them to timely
and convenient access to health care in terms of waiting for a
VA appointment or traveling long distance to a VA facility.
This program apply in full force in Puerto Rico, however, it
faces the same under staffing problem in countering VA
facilities because of the burdensome bureaucratic requirements
to physicians to participate.
The VA Health System could provide better care to the
patient by opening its program to additional providers, merely
by simplifying the contracting procedure. I am aware of the
budgetary and public policy concern of programs such as the
Veterans Choice program. Our objective is to obtain health
care, however, the effective matters subprogram for example, by
requiring initial referral from the VA Health System to
explicit medical care physician in the community, with periodic
oversight visit to the VA clinics, will greatly benefit patient
by making health care more accessible as well as help resolve
schedule congestion and under staffing.
Easier and responsible access to physician outside the VA
Health System will also help break the circular problem of lack
of ability specialty to treat the veteran population in Puerto
Rico. Physicians and to a larger extent, specialty are leaving
Puerto Rico for stateside jurisdiction because of the hard
cause they've been providing their service in Puerto Rico. In
2016, Puerto Rico has losing an average of one doctor a day.
Last year, prior to Hurricane Maria, 700 physicians had left
Puerto Rico. I estimate that a larger number will leave this
year. Of the 400 cardiologists in Puerto Rico a few years ago,
today we have less than 100. The number of anaesthesiologists
had decreased in the same proportion. Very few neurologists and
surgeons remain. And, in the Island where diabetes is one of
the principle health problems, there is an urgent need for
endocrinologists. It is not a rare occurrence to call a doctor
for an appointment, only to be told that appointments are 3 to
6 months away.
Nor, is it easy to call all the doctors in sustained
specialty in the phone book, only to be told that they are no
longer accepting new patients. Yes, this is partly due to the
local factor suggestive of the cost of living and utility cost.
However, is also due to the inequalities in Medicare
reimbursement rate between our Island doctor in Puerto Rico and
their stateside counterpart for the same service under the same
terms and conditions. For example, after 20 years the district
applicable in Puerto Rico was finally equate to the, of the
U.S. Virgin Islands, although that number does not take into
account the cost associated with the Jones Act, which does not
apply to U.S. Virgin Islands. It is also to the strong market
power of Medicare advantage applied in Puerto Rico, who
regulate by CMS, force the providers to accept rates much lower
than those in similar markets or be driven out of their
practice for lack of patients.
If the VA Health System became a market participant, it
will open a new pool of patients for these physicians, and
provide an alternative to the abuse of both private and public
insurance. It would create a reason for physicians' specialty
to stay in Puerto Rico because they call us to do so. More
physician means accessibility to health care, which translate
to help their patient and lower health care cost. We cannot
lose sight of the fact that a large number of veterans also
posses other insurance. Either private insurance through their
employer or from the government's Medicaid support program. The
overutilization of the VA Health System in Puerto Rico tax
limit resources to the benefits of other health insurance. The
responsible integration of our health care provided into the
care of the veteran population, allows a cosharing of these
expenses, with other health insurance plans correlated cost to
the VA Health System and maximizing results.
As for that Legislator, I know that you face an incredible
challenge in finding a solution that will for approximate 21
million veterans in the United States, throughout the world. I
am grateful for this time you take to come to Puerto Rico and
for your interest to learn about the specific problem facing
our veteran population and for your openness and availability
to do something about it. Our Resident Commissioner is a
tireless fighter for our health and well being and I thank you
for having join our health fight. Respectfully submitted.
[The prepared statement of Dr. Ramos appears in the
Appendix]
Mr. Wenstrup. Thank you. Dr. LaPuz, you're now recognized
for five minutes.
STATEMENT OF DR. MIGUEL LAPUZ
Dr. LaPuz. Good morning, Chairman Roe, Chairman Wenstrup,
and Representative Gonzalez-Colon and honored guests. I
appreciate the opportunity to discuss the Department of
Veterans Affairs Caribbean Healthcare System and the provision
of health care in Puerto Rico. I'm accompanied today by Dr.
Antonio Sanchez, Acting Director of the VA Caribbean Healthcare
System, and Lewis Ratchford, Deputy Assistant Secretary for
Office Operations, Security, and Preparedness.
The health care system consist of a tertiary care, a
medical center, and ten outpatient clinics located throughout
Puerto Rico and Virgin U.S. Islands (sic), the U.S. Virgin
Islands. The Medical Center includes multidisciplinary and
ambulatory facilities and 280 operational acute care beds,
including 12 blind rehabilitation beds and 122 operational
nursing home beds. Services are provided to a population of
approximately 93,000 veterans.
VA's first mission is to improve the Nation's preparedness
for response to war, terrorism, national emergencies, and
natural disasters by developing plans and taking actions to
ensure continued service to veterans, as well as to support
national, state, and local emergency management, public health,
safety, and homeland security efforts. The Health System's
ability to maintain critical operations throughout the
historical hurricane season of 2017, is a testament to VA's
commitment of significant resources and planning to these
efforts.
The 2017 hurricane season was one of the costly season on
record. VISN8 facilities were directly impacted by two major
hurricanes. Hurricane Irma barreled through the Caribbean on
September 8, devastating St. Thomas, and leaving nearly 1
million people without power in Puerto Rico. In the aftermath
of Hurricane Irma, the Medical Center as a key partner in the
national response to disasters, mobilized emergency response
units to the Luis Munoz Marin International Airport to receive
patients from the U.S. Virgin Islands through the activation of
the Federal coordinating center. Through the collaborative
efforts of Federal, state, and local governments and
nongovernment organizations, the unified emergency response
teams received 92 patients. All patients were assessed upon
arrival at the airport, and then transported to multiple
hospitals in the metropolitan area, including San Juan VA
Medical Center.
On September 20, while still recovering from Hurricane
Irma's impact, Hurricane Maria, a category five storm hit
Puerto Rico with forces beyond those imaginable. Tremendous
impacts to critical infrastructure were widespread. Nearly the
entire Island was without power, water, and telephone service
and conditions of roads and buildings were perilous. Because of
VA's investment in emergency preparedness and response
resources, the hospital was able to maintain critical hospital
operations throughout the storm and was able to bring community
based unexpect into operations within weeks.
Additionally, we were in a position to offer assistance to
other health care systems more severely impacted by the
hurricane. These efforts did not come without certain
limitations and challenges. Immediately following the storm, VA
outpatient clinics relied on generator power and limited
communication capabilities including data resources. Roughly,
23,000 appointments were cancelled as direct result of the
hurricane. Staff have reached out to all veterans since
appointments were cancelled, more 21,000 appointments were
rescheduled, but the remainder not indicating the need for an
appointment.
We are currently focused on preparing for this year's
hurricane season. Efforts on the way to preparing advance
include outreach to vulnerable and high risk veteran
populations, building on established relationships and
community partners, updating these agreements to ensure a
timely response after natural disaster and exploring more
reliable voice and data communication strategies.
Most importantly, there are 27 million dollars in high risk
infrastructure improvements that must be completed before the
beginning of the upcoming hurricane season. We remain committed
to providing exceptional health care and emergency
preparedness, pursuing this objective in close collaboration
with our Federal partners, leading national organizations,
local government agencies, veteran service organization, and
other nonprofits.
We welcome the opportunity to expand current efforts as
well as establish new agreements that will benefit veterans
throughout Puerto Rico and the U.S. Virgin Islands. The VA
remains committed to open dialog regarding joint efforts and
enthusiastically encourages their development. While VA
excelled during times of crisis, there is still action required
to ensure the needs of veterans in Puerto Rico and the U.S.
Virgin Islands are consistently met.
Sustaining the momentum and preserving the gains made so
far, requires continued attention and investment of financial
resources. Failure to provide such resources will severely
jeopardize our ability to sustain our progress and will put at
risk thousands of veterans and their families in the future. It
is critical that we continue to move forward after the
hurricanes and continually improve the system of care that is
provided by VA Caribbean Healthcare System. Mr. Chairman, this
concludes my testimony, my colleagues and I are prepared to
answer questions.
[The prepared statement of Dr. LaPuz appears in the
Appendix]
Mr. Wenstrup. Well, thank you all very much for your
testimonies We will now take time for questions and I will
yield myself five minutes for questions, and I would like to
start with you, Dr. Rodriguez, if I may.
Dr. Rodriguez. Sure.
Mr. Wenstrup. You've talked a little bit about academic
relationships between health care systems and also, I know
yesterday, we also discussed opportunities for military medical
personnel to engage as we do say, in San Antonio where the San
Antonio Medical Center provides for the community, trauma, and
everything. And, then there's programs such as the Air Force
has which is the Sea Stars program, centers for sustainment of
trauma and readiness skills, and they embed military personnel
into private level one trauma centers to engage, to provide
care and to train.
And, so in your view, what are some opportunities for
military medical personnel, active and reserve, to train,
provide care, augment care for veterans and residents of Puerto
Rico?
Dr. Rodriguez. Thank you, Mr. Chairman. As we discussed
yesterday the most typical example of that is Brook Army
Medical Center where they, is open for treatment of trauma
patients from the civilian part. By a chance I was staff
neurosurgeon there on 2005 when I was deployed there, so I
know, I worked very closely with that type of endible
(phonetic). In Puerto Rico, we have other VA centers as well
known by you. Academic centers help the VA in order to give
services. They share faculty and also improve the health care
of the veteran population.
We used to have that close relationship many years ago. I
remember when I was in my residency, my residency by that time,
that we rotate and have a formal rotation at the VA, and the
faculty of neurosurgery shared credentialing between both
academic, the academic center and VA. As well, faculty from the
Veteran Administration Hospital also served as teaching there,
in the civilian sector. So, I think that is a thing that we
have to explore to seek again that type of relationship between
the academic and the VA for the well being of the veteran
population. I think that will be fantastic to return that
policy again, and to be sure that we can work as good
neighbors.
Mr. Wenstrup. Thank you. Dr. LaPuz, you have any comment on
that and is there any relationship right now with Fort Buchanan
and the VA from the health care standpoint?
Dr. LaPuz. Yes, sir. There is already an existing
relationship between the DoD and the VA, and I will yield to
Dr. Sanchez who can talk to the specifics of that relationship.
Mr. Wenstrup. Thank you.
Dr. Sanchez. Good morning, Dr. Wenstrup and Dr. Roe, and
Congresswoman Gonzalez-Colon. Thank you very much for the
opportunity. For me it's a privilege to be here, and thank you
very much for yesterday's visit to our facility on behalf of
all the veterans and as well as the workforce that I represent.
For us it was an honor having you there and thank you for the
great work that you have been doing.
The VA Caribbean Healthcare System for many, many years has
been doing a lot of affiliations and collaboration with the
Department of Defense, mainly with the Buchanan base clinic
that we have there. We share some clinics, for example for
phlebotomy labs there. There's a lot of patients that go there
because we had some parking issues in the past, more than now,
and then we have been in that kind of collaboration and
actually our facility trained part of the DoD mortuary
personnel in different partnership of education as well. It is
limited and I welcome all of the possibilities to continue
expanding our services. Three weeks ago, I received a visit of
Commander Lozano who is the Buchanan Clinic director, and he
told me that they are in conversation after the hurricane to
construct probably a new clinic in Buchanan and he wants us to
be part of that planning phase since the beginning, and I think
that is a great collaboration and everything that I am
listening now, I think that we need to take advantage of that
momentum and work all collaboratively.
If we can expand or decompress the facility that we have,
by expanding services for our veterans, it will be a win to win
relation for all the veterans. That is our purpose for that.
Mr. Wenstrup. So, Buchanan is providing some ancillary
services right now. Are they seeing patients as well, veteran
patients as well?
Dr. Sanchez. Yes, they receive for phlebotomy, for
laboratory and we collaborate with our chief of pathology to
help them to maintain the accreditation of their labs, and in
some, while the reservist, that is another agreement that we
have, while the reservist are active, we receive military
active for any emergency care in our facility as well. That is
part of our agreement that we have with the DoD as well. But,
as I said, there is room for continued enhancing all of that.
In the past we had been in conversation to have colocated
clinics. For example, for the compensation and pension exams,
we do those in our facility. Last year we were in collaboration
in the planning phase in using some buildings that they have
available, and had colocated clinics to assure that the soldier
in the transition going out of the military and then becoming
part of the VA System and also with the Veterans Benefit
Administration. One part is done in the Buchanan base and
another part is done by us in the hospital, so we were in those
planning of having the collocation. But, now with the Commander
Lozano thinking, and he has been working with the Department of
Defense, that the clinic could be remodeled and a new clinic,
they probably can have more space, and then we can work other
initiatives at the same time.
Mr. Wenstrup. Thank you, my time has expired. Dr. Roe,
you're now recognized.
Mr. Roe. Thank you, Mr. Chairman and first of all, I want
to just give a shout out to all the veterans that are here and
the Puerto Rican people for undergoing an incredible hardships
during the past several months after not one, but two major
hurricanes that hit this Island, and really devastated much of
your infrastructure, so your patience Job would be proud of
you, I can tell you in the Bible.
Christine Hill is a staff director for the Subcommittee on
Health, but she also is a former B1 bomber pilot. Me being a
infantryman, I stayed a little closer to the ground, myself.
[Laughter.]
Mr. Roe. A couple of things that I wanted to go over just
quickly, Mr. Chairman, is that I heard several things and I
will just mention these. Dr. Ramos brought these out, we heard
this in our VSO roundtable this morning, and we heard it
yesterday, both in the public health hospital and in the VA
Hospital, of chronic understaffing, both in mental health and
in others, so and hiring takes too long. Dr. Ramos, you're
absolutely right, VA is glacial in hiring physicians. We see it
stateside where you get a gastroneurologist and it may take six
months to hire them, and in private practice would take me two
days to hire that person.
The other thing that was brought up about paying in a
timely fashion. Medicare pays about 95 percent of its claims in
a month. The VA is about 60 percent. The Secretary is very
aware of that. That's one of the problems in the Choice Program
that needs to be worked out. So, we hear you loud and clear. I
wanted to share that with you.
I heard something this morning that I'd like Dr. LaPuz get
some clarification on. In your written testimony, you stated
that the VA at the Caribbean Health Center was able to reach
100 percent of over 3,000 veterans identified as being members
of a vulnerable population, which included veterans
experiencing homelessness, those requiring hemodialysis, those
dependent on ventilators, those that are high risk for suicide,
and those with severe mental health issues. Assisted by FEMA,
VA staff used round air sea transportation methods to meet with
each veteran to confirm his or her well being. But, what we
heard this morning though, in the roundtable was is that, as
many as 90 percent of the people that the VSOs met and I won't
mention which one, there was no visit from the VA. And, so how
do reconcile those? One say that they didn't get out to see the
veterans, and you say that you got out to all of them. So, how
do you reconcile that?
Dr. LaPuz. We identified the high vulnerability, the highly
vulnerable veterans, and those veterans that are the homeless
veterans, the ones that are requiring chronic care, the ones
that are actually enrolled in our home based primary care, the
ones that are involved in the Macomb program for example, which
is a mental health intensive case management program. So, in
that category of veterans, we in all of the situations as part
of our hurricane hardening, we reached out to them to make sure
that even before the hurricane hits, that they're actually
prepared for those situations.
So, it is not reaching out to all of the veterans enrolled.
It is reaching out to all the veterans that are belonging to
that high risk population.
Mr. Roe. Do you meet with the VSOs or not you particularly,
because you're the director, but do the local VA maybe, Dr.
Sanchez better for you, but you reach out to these folks to
reconcile these differences because, I think that's extremely
important, because their perception of what happened and your
perception of what happened are two different things.
Dr. Sanchez. Yeah, thank you for the opportunity to clarify
that, and definitely we work very close with the veteran's
service organization leaders and they were part, most of them
were part of this effort of identifying a lot of veterans that
needed our intervention because they needed health care issues,
you know, and a lot of them, thanks to the great job that they
were doing, outreaching. Remember, this was a complete
catastrophe in Puerto Rico, all the veterans and all the
citizens had major, major issues, problem with communication.
So, definitely is part of our process with the VSOs to clarify
what was the total population that we reached out, and there
was a lot of other needs in veterans, that not necessarily was
health care related needs. And, then is when our social work
coordinator with the local agency to help them, let's say,
housing, food, clothing, other kind of things that in our
scope, in our, as a hospital we can't help them, but we helped
them to coordinate with the other agencies through FEMA, and
all of that. But, definitely something that we can clarify more
to them.
We have been tracking and we were tracking all those, more
than 3,000 special or vulnerable patients because of their
condition. Their lives were critical, patients on ventilator,
we needed to assure that they had a generator in their house,
if not and we brought several of them to the facility because
they didn't have a good generator. Patients in anticoagulation
medication, we needed to assure they had, but it took time,
because the roads and the streets were completely impacted.
There was a lot of problem to reach out to them, and that's why
the VSO went to the street and helped us. I received as a
Commander in the incident command post, they were constantly
referring and we were reaching out to them.
But definitely we will accept your recommendation, Dr. Roe.
Actually tomorrow we have already planned what we call a VSO
strategic planning, because prior to the hurricane, the VSO
created what they call a coalition of VSOs. In Puerto Rico they
met with me and we were planning this strategic planning, and
unfortunately because of the hurricane, it was, you know,
delayed, but it is going to happen tomorrow in my facility. In
order to create a strategic planning to address all and
prioritize all of those areas that they have been bringing
because a lot of things that we have been doing through the
years, has been thanks that they have brought out to us and
they have been advocated together with the Federal government,
with their organization, moving among us there is other areas
that we need to continue working all together. So, I will touch
base about that
Mr. Roe. I would say that they are a tremendous resource
for you--
Dr. Sanchez. Oh, yes, definitely, and I'm very proud
Mr. Roe [continued]. --and they can be very helpful, and I
would like to ask, and this my time has expired, I'm going to
yield back, but a question that maybe we can get it from Mr.
Ratchford or Dr. LaPuz in writing, is, what lessons have been
learned with this particular hurricane, the two, and then sort
of an after action report, and then how are you better
preparing since unfortunately the hurricane season is just a
couple months away. I yield back.
Mr. Wenstrup. Thank you. Ms. Gonzalez-Colon, you're now
recognized.
Miss Gonzalez-Colon. Thank you, Mr. Chairman. First of all
I want recognize some people in the audience today, like,
General Isabelo Rivera, our National Guard, general from Puerto
Rico, thank you for coming here. And, I want to thank
Chairwoman from the Veterans Affairs Committee in the House,
Lourdes Ramos, and Chairman of the Veterans Affairs Committee
in the Senate side, Jose Luis Dalmau, Jose Aponte former
speaker of the House and Chair of the Federal Affairs Committee
in the House, is also with us today and with us during the
roundtable, and Representative Felix Lasalle from the western
part of the Island, thank you, for being here today.
Having said that, we got a lot of questions. Yesterday we
went to the VA facilities and we account of the situation
regarding the clinics in the VA System. One of them, we're
going to visit today in the afternoon which is the clinic from
Arecibo, where some, many people are receiving their services
in tents. So, same thing happened with the situation in
Vieques. So, Mr. LaPuz, my first question will be, are we using
the mobile units to serve those areas or not?
Dr. LaPuz. Yes, Ma'am. We're using the, right now what we
have there is a, in Arecibo we have a western shelter--
Miss Gonzalez-Colon. Mmhm.
Dr. LaPuz [continued). --so we have a, almost a complete
clinic which is actually in house, in the western shelter, so
that you will see that shortly. However, we have a contracting,
it's already in contracting, trying to identify a new location
for the Arecibo clinic so we can also begin construction of the
new clinic. So, we expect that, that is going to be before the
end of the month, we'll have a clarity regarding the location
that has been identified through the bid process.
Miss Gonzalez-Colon. Can you answer directly my question,
in terms of how many mobile units are we using in Puerto Rico?
Dr. LaPuz. Oh, I'm sorry, I'll defer to Dr. Sanchez
regarding the number of mobile units.
Miss Gonzalez-Colon. Thank you.
Dr. Sanchez. Yes, immediately after we started to work with
the emergency, we received from the state two mobile units, one
from Tampa, and one from Orlando in the
Miss Gonzalez-Colon. Are they in use right now?
Dr. Sanchez. They are being used.
Miss Gonzalez-Colon. Where?
Dr. Sanchez. One in Arecibo, as part of the compound that
we have there with the western shelters, specifically for the
mental health clinic, and the other one is being used in
Vieques. Vieques, we were doing home visits until like, 3 weeks
ago, when we were able, working with the Puerto Rico Health
Department and FEMA
Miss Gonzalez-Colon. To move that mobile unit.
Dr. Sanchez. and we moved, and the mobile unit and now we
have it there with all the utilities.
Miss Gonzalez-Colon. Okay, how many doctors and nurses are
those mobile units are using?
Dr. Sanchez. Well, in Arecibo we are using all the staff of
the clinic. We have
Miss Gonzalez-Colon. So, besides my question will be, sorry
about that.
Dr. Sanchez. Ahhah.
Miss Gonzalez-Colon. My question will be, besides the
mobile unit and the tents that are, or the clinic that you are
using, do you receive with the mobile unit more human resources
to attend the patients or not? Or you're just using the
physical facility?
Dr. Sanchez. Yes, we are using the same staff from Arecibo
Miss Gonzalez-Colon. Okay.
Dr. Sanchez. all of them are in the compound, and the same
staff that are 3 staff, is a physician, a clerk, and a nurse.
In Vieques, they are the same that they were doing home visits,
now, they are located in just one of the mobile units.
Miss Gonzalez-Colon. The VA and the Congress just approved
11.1 million dollars to mobile units and medical service
including transportation for the areas impacted by the
hurricanes, so I expect part of that money is going to be,
directly to those areas in Vieques and the areas that have been
affected directly by the hurricane here in Puerto Rico, and I
would love to have a report on the issues of those monies to
the Island, if the Chairman of the Committee allows me to
request that information.
The second will be in terms of, how many veterans have been
able to be treated in those 2 facilities, in those 2 mobile
units. Do you have the count of those numbers or not?
Dr. Sanchez. Well, yes, on a daily basis and Dr. Roe and
Dr. Wenstrup yesterday were able to see the tracking that we
are following in the incident command post center. We track on
daily basis all the veterans
Miss Gonzalez-Colon. How many?
Dr. Sanchez. we have seen.
Miss Gonzalez-Colon. How many?
Dr. Sanchez. I don't have it from my, but we can get it you
Miss Gonzalez-Colon. Okay, perfect. Can you provide it
later on?
Dr. Sanchez. Definitely.
Miss Gonzalez-Colon. Thank you. Well, my third question
will be in terms of the VA clinic of Vieques. I know you're in
a process of leasing, finding a new lease, and I know the
challenges in Vieques to establish a new one, so let me know,
just me as a Member of Congress, but to Dr. Rodriguez and Mr.
Montanez, if we can assist in any way with the local
authorities to facilitate that kind of transition. Inclusive
the VA clinic in Arecibo, Arecibo is the major region that
attends people coming from Utuado, although we have a clinic
there, and from the northern part. I heard someone say that
you're willing to move that clinic out of Arecibo. If that is
the case, I will tell you that I'm going be opposed, because so
many veterans in that area, know the place, is more easy to get
to there because of differential rural areas on the side.
My next question will be in terms of the lack, shortages of
professionals. We talked yesterday about ophthalmologist,
oncologist, dermatologist, among other professional in the
health care area, in I receive like many of the people here,
they request that have been waiting for three or four months to
get an appointment. Most of them when they visit a VA clinic in
the States, that's not the case. They may even receive an
appointment less than 15 to 20 days. So, why if we are in an
island, and we can't cross state lines by a truck, or by a
train, just by an airplane, we need to wait 3 and 4 months to
get an appointment when you got a VA hospital here, you got
multiple clinics and the people here deserve to have right away
their appointment, medical appointment. Why is the reason our
people need to wait 3 and 4 months to get an appointment?
[Applause.]
Dr. LaPuz. And, we truly recognize that, but like what Dr.
Ramos is saying, that part of the issue that we're encountering
in the Island is that there are in specific specialties, a
reduction of the available physicians.
Miss Gonzalez-Colon. Can you list that, can you list that
(sic) professionals that the VA is lacking personnel?
Dr. LaPuz. Sure, and I just like to make sure that there is
a common understanding. So, when the VA in San Juan cannot meet
that demand, we are actually utilizing Choice. But, the problem
in the community in San Juan, and you're very aware of this,
Ma'am, that there are situations in which that is also lacking
in the private sector. So, we could not the general problem is,
how do we attract specific specialities in Puerto Rico? And,
because that's the one that will be, the determinant of how we
are going to solve this specific specialty issue.
Miss Gonzalez-Colon. Do you got (sic) the list of
physicians, the list of professionals that we're lacking of in
the Veterans.
Dr. LaPuz. Yes, Ma'am, we'll provide that to you.
Miss Gonzalez-Colon. Okay. And, I know I'm running out of
time, and thank you, Chairman for his indulgence here. I know
that when we visited yesterday the trauma center of the Centro
Medico, and we don't have a trauma center in the VA Hospital in
Puerto Rico. Same thing of the lack of services in surgery,
mental care, and we even received complaints in terms of how
difficult it is for the blind veterans to just cross, pass
across the hospital. Are we looking on those renovations to
accommodate the needs of the blind veterans on the Island,
instead of letting them go through the whole hospital to
receive services.
[Applause.]
Dr. LaPuz. Yes, Ma'am, we're looking at, all of the
enhancement that will be required, including the concerns of
our, the impaired veterans.
Miss Gonzalez-Colon. Please include the bricks (phonetic)
on the entrance, in terms of reviewing the needs of maintained
those bricks that may have put some, a lot of strength and
difficulties to the blind veterans arriving to the VA Clinic.
My last question, but I will provide more questions to the
Committee so they can okay, perfect. So, my last question
during this round then will be the issues regarding the
caregivers. A lot of our veterans are receiving care by the
caregivers, and those coordinators from the VA must conduct
house visits to make sure the veteran is doing well, and the
caregiver is participating as expected.
I know there are two major barriers here. One can be the
language barrier and the other one would be conducting those
visits in the rural areas for the recertification process. In
that term, how can we fix the visits in those rural areas. I
know we got people from the Paralyzed Veterans if I recall
well, that told us that, you're using the VA system, the P.O.
box addresses as their main contact information, and with those
P.O. box addresses, you can't visit a veteran in the Island.
Did the VA so this is a two way question, did the VA correct
those addresses so they can visit the veterans in those areas?
And, the second one, regarding the barriers to the caregivers'
recertification process?
Dr. LaPuz. I'll let Dr. Sanchez speak to the specifics of
the caregiver program.
Miss Gonzalez-Colon. Thank you.
Dr. Sanchez. Yes, in terms of the mail address, definitely
it is a challenge in Puerto Rico because, a lot of
appointments, not only for caregiver visits, we use the mail.
In difference from the mainland, our addresses are HCO1 rural,
very rural and they're not standardize like in the mainland.
So, a lot of letters that we send are returning back, so are
very difficult. So, what we have been doing, we met 2 months
ago with the U.S. Postal Office and we navigate with them
because they have a special software to standardize using the
bar codes in the letters, and we are in the project to adopt
that. While that happens, what we are requesting to all the
veterans is that, every time that they do checkin, in our
facilities, please update their addresses to assure that is the
most updated one, one that is clear enough in order that we can
visit them and not rely on the P.O. box or the rural one for
the boxes that is a challenge for the organization. We receive
a lot of return from the mail because they cannot deliver it.
It happens, you know, constantly.
Miss Gonzalez-Colon. Can you provide the number, telephone
number to all those veterans that are suffering from sleep
apnea and do not have power in their house, to provide any
generators to comply with their care? Like all veterans that
receive that kind of service in Florida, and we're missing that
to a lot of veterans here that are not receiving those kind of
generators, because they're living in a zipcode number in
Puerto Rico?
Dr. Sanchez. We can work with that, generators are issued
by, prosthetic service some eligibility criteria, but at the
same time we recognize the need for some special need for
veterans and we partnered with the Cruz Roja, American Red
Cross and they had a great program that we worked in
collaboration with them and they reached out, a lot of veterans
provide in the generators, so, but it's more to come on that.
We need to continue working collaboratively with the resources
that the law allow us, based upon eligibility and the
community, and the American Red Cross as an example with that.
Miss Gonzalez-Colon. Thank you, Chairman.
Mr. Wenstrup. Thank you. We talked about provider shortage
and the challenges that we face, and it's not just in the VA.
It's across the country. In my district I have an urban area
where there's pretty good access to care, but I have a lot of
rural areas, and we have a hard time getting physicians to
those areas, to want to go there, live there, and practice
there. It is a challenge that we face throughout. And, that's a
whole other topic for another day on how we can increase our
residency programs, people going into medical schools,
expanding our medical schools, etc.
But, I do want to go back to the one thing we talked about.
You know, we have people that, many people have gotten their
medical education through the military, and they serve in the
military. And, there are some medical treatment facilities
where they now serve that are not very busy. And, we have both
active component and reserve component. And, reserve component
are obligated to do a couple weeks a year, weekends, and month,
and to fill in some time. And, that's why I want to take this
situation we're in, and try to see we all work together so that
we can provide care, not only for our veterans, but for our
civilians, and how we can implement that in many ways, and
perhaps use our military to fill some of those voids which will
not only serve the people we intend to serve, but give those
providers and opportunity to see more patients to practice
their craft, to be better at what they do. It's a training
exercise as well. So, I look forward to working with all of you
in that regard, not only here in Puerto Rico, but across the
United States of America where there are some opportunities of
situations we find ourselves in.
I do also want to go back to what Dr. Roe asked about, Mr.
Ratchford, do you you're like the Allstate mayhem guy. You get
to go to all the things, where there's a problem, right?
Emergencies and building resilience, and there's always lessons
learned, so I do look forward to hearing back from you on what
we've learned from this and how we can prepare better, and I
would like to you've come this far to be with us today, and
maybe just take a minute to discuss what you face and what you
look forward to the future as far the service that you provide.
Mr. Ratchford. Thank you, Dr. Wenstrup, and also
recognizing Dr. Roe, and Congresswoman Gonzalez-Colon.
Hurricane Irma and Maria were both challenging events for
Puerto Rico and also the Caribbean. One of the things that the
Department of Veterans Affairs we did and I think it really
changed the outcome of our hurricane response efforts, we
recognized logistical challenges associated with the Caribbean,
is that we had to get ahead of that first, before we can start
talking response and how we were going to help the Island
Nation recover from what was going on.
So, we worked in close collaboration with FEMA, helped the
Human Services and also the Department of Defense to make sure
we were able to move resources to give to our responders on
ground, because people are easy. Goods and services hard to get
here, especially during a crisis. We were fortunate enough, we
moved about 128 short tons of equipment to include several
response vehicles, to mobile medical units, mobile vet centers,
mobile pharmacies, logistic sport vehicles, and other resources
such as generators, AC units, shelters, and trucks to help move
things around the Island, and get response personnel the tools
they need, be part of the solution.
What we've identified in our after action reviews that
we've done, we've done some of them and headquarters, is that
logistics is a integral part of the response effort and you
have to think about that up front. Lessons learned, we also
have noted is been as far as, working with the whole of
government. We're stronger together than we are by ourselves.
We saw a lot of that during response effort at the Federal
level, to where it took us a brief second to come together and
realize, we all have things that we're good at, and we all have
shortcomings that by design, we're not able to do in our
organization makeup, but if bring ourselves together, we fill
each other's gaps, and we work stronger in becoming a viable
force and responding to these types of disasters.
Today, we have our emergency management team from across
the Nation, within the Veterans Health Administration, meeting
right now in Virginia, talking about not only lessons learn
with this type of event, but other types of catastrophic events
that we face across the Nation, and how as a preparedness
community, we can come together, be a part of the solution, and
create the environment so that health care can be provided
without a hiccup, so that restoration services can happen
without a hiccup, so that infrastructure can be restored
without a hiccup we recognize that through emergency management
and preparedness, we create that environment so that others can
be successful.
Mr. Wenstrup. Thank you.
Mr. Roe. Very briefly, I know we have to move on to visit
some other things, but all of that is great, but if the people
of Puerto Rico don't know it, it doesn't do any good. If you
don't know where to go when that event happens, and all that
planning if we keep it to ourselves, doesn't help all these
people sitting out here in the audience at all.
I think that we learned today about informing people about
what they should do in the event of a hurricane in the
neighborhood, and the western part of the Island where it's
less populated, what do they do? Where do they go if something
happens, where can you get water and food, and help, and so
forth. I think that was a, is something we learned and I've
learned in that the things that we've had, the catastrophic
events we've had in my district, is that the people have to
understand.
I want to, Mr. Chairman, thank you, and certainly
Jenniffer, thank you for inviting us here. We've learned a lot
on our visit. We intend to learn some more before we go back to
Washington. We will share these things that we've learned with
our colleagues on the Veterans Affairs Committee which is a
bipartisan committee. We try to check Republican, Democrat at
the door, and do what's right for veterans. So, I'd like to,
again, thank you for the opportunity to be here. I yield back.
Miss Gonzalez-Colon. Thank you, Mr. Chairman, and I just
got two more comments. First of all, I want to recognize Mr.
Bernard Johnson, the VA Regional Director for the Island, thank
you, for being here today. I got two comments and one question.
One is that we need to fight to get Puerto Rico out of the
overseas definition in terms of tricare prime. I mean, our
veterans need to be treated as all American citizens. Not
because their zipcode is different. And, right now, tricare
prime do not apply to the Island, just because under the
Department of Defense, we're considered an overseas territory.
So, that's the first request. I've been writing some letters to
the Department of Defense. It's been contablized (phonetic) at
29.7 million dollars, just including the coverage of Puerto
Rico as part of the tricare prime. So, that's one of the
challenge I will love the Committee to coordinate with me to
try to achieve that kind of equality for the veterans in the
Island.
The second will be, we got a facility state veteran home in
Juana Diaz. It is 20 years old, it's deteriorating. The state
matching requirement has been a challenge for providing
maintenance for all those projects. We need to see how the VA
can help us out in making any adjustment that we can make to
account for houses located in rural areas or impacted by
natural disasters.
In the other hand, I think we should look forward to
enforce any comparative agreement with pharmacies and other
Federal agencies, so no veteran, and no service to our veterans
is turned down during a hurricane or any other period. And,
that's happening in a more frequent way in Puerto Rico, where
pharmacies and doctors are turning down our veterans, and
that's something we need to work together to achieve a better
understanding and a better way to serve our men and women in
uniform. Having said that, I'm looking forward to have the
transfer of the land for the Fisher House so we can finally get
that, not just for the people of Puerto Rico, but for the
people that are coming from the Virgin Islands, to receive
those kind of services.
I want to thank all the personnel from the VA that helped
us out during this hurricane season. I know that most of you
rode out the hurricane in those facilities. I know how hard is
that, because I did that in my own house, but one of the main
issues that remains there, it's how our facilities are going to
comply with the new standards and how our people are going to
receive the service that they need. I hope the allocation of
funds that were included in the third supplemental are going to
be enough for all the VA clinics and the National Cemetery, if
not, feel free to tell me what resources do you need to make
those things happen to our veterans in the Island. With that, I
want to thank all the Members, all people who served and fought
for our Nation. We are grateful for your service and for the
people that are here today, and thank you, Chairman Wenstrup
and Chairman Roe for allowing me, as the only Member
representing 3.4 million American citizens in Puerto Rico, to
have a voice on behalf of our veterans, even when I can't vote
on the floor. Thank you, and welcome to Puerto Rico.
[Applause.]
Mr. Wenstrup. I want to once again thank all of our
witnesses today for your insights and to all those here in
audience for taking the time to be with us this morning, and
thank you for the hospitality and the warm reception that we've
have had here. It's been a pleasure being in Puerto Rico with
you, and I look forward to taking your comments and your
suggestions and your ideas back with me to D.C. This time I ask
you now on consent that all Members have five legislative days
to revise and extend their remarks and include extraneous
material. Without objection, so ordered, the hearing is now
adjourned.
[Whereupon, the Subcommittee was adjourned.]
[all]