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
GRAND JUNCTION, COLORADO, FIELD HEARING

August 16, 2005

Senator Salazar and other Members of the Committee, I appreciate the opportunity to appear before you today to discuss veterans’ rural healthcare in VISN 19 and in the state of Colorado, in particular.

I will discuss these issues from an overall VISN perspective and defer to Dr. Michael Murphy, Director of the Grand Junction VAMC whose catchment area includes western Colorado, for issues related to that health care facility.               

            In a recent article published by the Washington Monthly, Jan/Feb 2005, “The Best Care Anywhere,” the Veterans Health Administration (VHA) was cited as producing the highest quality care in the country.  In FY 2004, VISN 19 was rated number one within the Veterans Health Administration, as evaluated by the national performance measures and the veteran patient satisfaction scores.

            VISN 19 makes three promises to all our veterans regardless of where they live or where they receive their health care.  These promises will be our measures of success:                            

                        Provide high quality of care second to none,

                        Maintain and expand services and

                        Personal veteran satisfaction

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 contained within VISN 19 varies from highly urban cities, to rural communities, to remote frontier areas.   The terrain varies from arid desert to high altitude mountains, both made more difficult during the winter months.  For FY 05, VISN 19 employs a workforce of 4,650 fulltime equivalent (FTE) employees with an operating budget of $589 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.  Clinics in Colorado are located not only in Colorado Springs but also in Pueblo, Lamar, La Junta, Alamosa, Montrose, Ft. Collins, Greeley, Lakewood and Aurora.

There continue to be many veterans in VISN 19 who are geographically isolated from VA health care services.  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, Goodland, Kansas and Elko, Nevada.  I have personally met and had extensive conversations with many Congressional representatives to discuss the possibility of new CBOCs in several of those and other locations.  

The VA Rocky Mountain Network continues to pursue new and innovative approaches to reach veterans in rural, remote and frontier locations.  VISN 19 partners with Veteran Services Organizations such as the Disabled American Veterans, to provide an external transportation system which is vital to many veterans obtaining their health care at VA facilities.  For the first three quarters of FY 2005, the DAV transported 25,771 patients, traveled 1,372,863 miles, and volunteered 53,684 driver hours for the VA Rocky Mountain Network.   VISN 19 has also been a leader in the development of Care Coordination Home Telehealth programs and other telemedicine initiatives which allow veterans to receive their care in their homes or at remote locations.

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.  Both northwestern and northeastern Colorado may be considered as locations for placement of CBOCs.  The veterans who reside in these areas must travel hundreds of miles to access VA health care often through difficult terrain during the winter months.  We will pursue additional CBOCs throughout the VISN as soon as resources allow.

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.   A CBOC proposal in either northwestern or northeastern Colorado would be evaluated with these criteria and prioritized within the network.

VISN 19 recognizes successful improvement to veteran rural health care requires a multi-faceted approach.  In order to provide veterans with the high quality health care they need and deserve, we will continue to encourage VHA as an organization to fully re-examine our approach to the provision of health care in rural and frontier areas.

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.  Our plan is to continue with the activation of the three CARES priority clinics as resources become available.   Additional clinics sites will be seriously considered, proposals developed and submitted when sufficient funding is identified.

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