STATEMENT OF
LAWRENCE A. BIRO
NETWORK DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK (VISN) 19
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ELKO, NEVADA, FIELD HEARING

May 5, 2005

Mr. Chairman and Members of the Committee, I appreciate the opportunity to appear before you today to discuss veterans’ healthcare in VISN 19 and in Elko, Nevada, in particular.

I will discuss these issues from an overall VISN perspective and defer to Mr. James Floyd, Director of the VA Salt Lake City Health Care System for issues related to that Health Care System, which includes the Elko area.

VISN 19 (the VA Rocky Mountain Network) spans an area of 470,000 square miles across nine states and is, geographically, VA’s second largest health care network. There are over 700,000 veterans residing within VISN 19. VISN 19 serves an area covering all of Utah; most of Wyoming, Montana, and Colorado; and portions of Nevada, Idaho, Kansas, Nebraska, and North Dakota. The geographic area served varies from highly urban areas to rural and even frontier areas. VISN 19 employs a workforce of 4,650 fulltime equivalent (FTE) employees with an operating budget of $560 million dollars. In FY 2004, our facilities provided care to almost 142,000 unique patients, up from 80,000 in FY 1996. The number of patients treated is up an additional 5,000 in FY 2005.

VISN 19 has, from its inception, focused on providing primary care and outpatient mental health services closer to where veterans live. This focus has resulted in the establishment of a significant number of clinics throughout the VISN. There are currently 32 Community Based Outpatient Clinics (CBOCs) in VISN 19. These CBOCs range in size from small contract clinics such as Sidney, Montana, to large and more complex clinics such as those in Colorado Springs, Colorado; Billings, Montana; and Pocatello, Idaho.

In the past several years, there has been significant interest expressed by Congressional representatives, Veteran Service Organizations, and individual veterans in establishing new CBOCs at locations throughout the VISN. These locations include Elko, Nevada; Northwestern Colorado; Eastern Colorado/Western Kansas; and Afton, Wyoming. At the request of stakeholders, VISN representatives have attended town hall meetings in Afton, Wyoming, and Goodland, Kansas. I have personally met with Congressional representatives to discuss the possibility of new CBOCs in several of those locations. Veterans who live in these locations are, in fact, geographically isolated from VA health care services.

In 2003-2004, the Veterans Health Administration (VHA) underwent a landmark study of VA’s heath care infrastructure known as the Capital Asset Realignment for Enhanced Services (CARES). Among the elements of the draft National CARES Plan were proposals to expand the numbers of CBOCs throughout the country. In VISN 19, there were three public hearings at which stakeholders were provided an opportunity to comment on the draft National CARES Plan. In May 2004, the Secretary of Veterans Affairs issued his CARES Decision. In that decision as it pertains to VISN 19, the Secretary identified three new CBOCs as priorities for implementation by 2012. Those were West Valley, Utah, a suburb of Salt Lake City; Lewiston, Montana; and Cut Bank, Montana.

VISN 19 plans to address other CBOC locations after activating the clinics identified as priorities in the Secretary’s CARES decision. We wanted to activate the three priority clinics in late FY 2005. However, resources to undertake establishment of these three new CBOCs are not available in FY 2005, and we do not anticipate that there will be adequate resources available in FY 2006.

Elko, Nevada, is a suitable location for placement of a CBOC. The veterans who reside in Elko County and the city of Elko must travel hundreds of miles to access VA health care. The veteran population of Elko County is large enough to support a small CBOC. VA population projections show that approximately 4,500 veterans live in the county. In FY 2004, 466 veterans from Elko County used VA health care services. Of these, 254 accessed the VA Salt Lake City Health Care System. This number represents a market penetration of approximately 10 percent, which is significantly lower than the 18 percent market penetration rate for all of VISN 19. Only 36 Elko County veterans received inpatient care at Salt Lake City in FY 2004. Based upon past experience, the number of veterans who seek care at newly established CBOCs increases by two or three times within a couple of years following opening of a new clinic. The number of veterans seeking care at an Elko CBOC would likely follow that pattern.

VA criteria for planning and activating CBOCs are contained in VHA Handbook 1006.1. All CBOC business plans must be developed in accordance with this Handbook and approved by VA Central Office. The criteria emphasize the need for sufficient population and workload projections, but other unique factors, such as geographic barriers, travel times, and medically underserved areas, are also taken into consideration. The business plan must also address the costs and benefits of establishing a VA-staffed CBOC or a CBOC based on contracting with local health care providers. VISNs must also ensure that resources are in place to open new CBOCs, including the capacity to manage specialty care referrals and inpatient needs of the populations to be served. Proposals are scored based on these criteria. Proposals with high enough scores are approved by VA Central Office. An Elko, Nevada, CBOC proposal will likely score very well for some of these criteria and not as well for others.

In summary, VISN 19 has experienced a significant workload growth over the past few years. We have established many new CBOCs throughout the VISN. There are locations where additional clinics are needed. Resources are not presently available to activate the three CARES priority clinics. If resources were available for both the activation and operation, VISN 19 would seriously consider a new CBOC in Elko.

Thank you, Mr. Chairman. This concludes my formal remarks. I would like to entertain any questions the Committee Members may have.