STATEMENT OF
JAMES E. HASTINGS, M.D., F.A.C.P.
DIRECTOR, VA PACIFIC ISLANDS HEALTH CARE SYSTEM
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
UNITED STATES
SENATE COMMITTEE ON VETERANS' AFFAIRS

August 27, 2007

Mr. Chairman and Members of the Committee, mahalo nui loa for the opportunity to appear before you today to discuss the state of VA care in the Hawaii. It is a privilege to be here on the Island of Hawaii-The Big Island-to speak and answer questions about issues important to veterans residing in Hawaii.

First, Mr. Chairman, I would like to thank you for your outstanding leadership and advocacy on behalf of our Nation's veterans. During your tenures as Chairman and Ranking Member of this Committee, you have consistently demonstrated your commitment to veterans. As I will highlight later, your vision and support have helped us provide an unprecedented level of health care services for veterans throughout Hawaii and the Pacific region. In addition, I appreciate your interest in and support of the Department of Veterans Affairs (VA).

Today, I will briefly review the VA Sierra Pacific Network that includes Hawaii and the Pacific region; provide an overview of the VA Pacific Islands Health Care System ( VAPIHCS) and the VA clinics here on the Big Island; highlight issues of particular interest to veterans residing in Hawaii, including outreach to the National Guard and Reserves, Compensation and Pension examinations, new State Veterans' Home in Hilo and our important affiliations with our academic partners. I also look forward to addressing any questions you might have for me.

VA Sierra Pacific Network ( VISN 21)

The VA Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21) is one of 21 integrated health care networks in the Veterans Health Administration (VHA). The VA Sierra Pacific Network provides services to veterans residing in Hawaii and the Pacific region (including the Philippines, Guam, American Samoa and Commonwealth of the Northern Marianas Islands), northern Nevada and central/northern California. There were an estimated 1.1 million veterans living within the boundaries of the VA Sierra Pacific Network in Fiscal Year 2006 (FY06).

The VA Sierra Pacific Network includes six major health care systems based in Honolulu, Hawaii; Palo Alto, California; San Francisco, California; Sacramento, California; Fresno, California; and Reno, Nevada. Dr. Robert Wiebe serves as director and oversees clinical and administrative operations throughout the Network. In FY06, the Network provided services to 235,000 veterans. There were about 2.9 million clinic stops and 24,500 inpatient discharges. The cumulative full-time employment equivalents ( FTEE) level was 8,400 and the operating budget was about $1.5 billion.

The VA Sierra Pacific Network is remarkable in several ways. In FY06, VISN 21 was the highest-ranked Network in overall performance (based on an aggregation of quality, access, patient satisfaction and business metrics). The Network hosts the highest number of Centers of Excellence and also has the most highly funded research programs in VHA. In the most recent all-employee survey, staffs in VISN 21 reported the highest overall job satisfaction in VHA. Finally, VISN 21 operates one of four Polytrauma units in VHA that are dedicated to addressing the clinical needs of the most severely wounded Operation Iraqi Freedom/Operation Enduring Freedom ( OIF/ OEF) veterans.

VA Pacific Islands Health Care System (VAPIHCS)

As noted above, VAPIHCS is one of six major health care systems in VISN 21. I am the director and a practicing cardiologist at VAPIHCS. VAPIHCS is unique in several important aspects: its vast catchment area covering 2.6 million square-miles (including Hawaii, Guam, American Samoa and Commonwealth of the Northern Marianas); island topography and the challenges to access it creates; richness of the culture of Pacific Islanders; and the ethnic diversity of patients and staff. In FY06, there were an estimated 102,000 veterans living in Hawaii (representing 8 percent of the total population in Hawaii and 9 percent of total veteran population in VISN 21).

VAPIHCS currently provides care in seven locations: the Ambulatory Care Center ( ACC) and Center for Aging ( CFA) on the campus of the Tripler AMC in Honolulu; and community-based outpatient clinics ( CBOCs) in Lihue (Kauai), here in Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii), Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also has outreach clinics in Molokai and Lanai. The inpatient post-traumatic stress disorder ( PTSD) unit is now also on the campus of Tripler AMC (the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue, Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial support and outreach.

In FY06, VAPIHCS provided services to nearly 22,500 veterans, 19,000 of whom reside in Hawaii. There were 198,000 clinic stops in Hawaii during FY06 (7 percent of Network total). The cumulative FTEE in FY06 for the health care system was 502 employees. The operating budget for VAPIHCS (i.e., General Purpose allocation from appropriated funds) increased from $68.0 million in FY02 to $110 million in FY07-an increase of 62 percent. For comparison, during this same time period, the operating budgets for VISN 21 increased 48 percent and VHA increased 43 percent. (Please note these amounts do not include Specific Purpose Funds and Medical Care Cost Funds.)

VAPIHCS provides or contracts for a comprehensive array of health care services. VAPIHCS directly provides primary care, including preventive services and health screenings, and mental health services at all locations. VAPIHCS does not operate its own acute medical-surgical hospital and consequently, faces challenges in providing specialty services. VAPIHCS recently hired additional specialists in Orthopedics, Ophthalmology, Nephrology and inpatient Medicine ("hospitalist") and is providing selected specialty care in Honolulu and to a lesser extent, CBOCs. VAPIHCS is actively recruiting additional specialists (e.g., Urology) and will continue to refer patients to DoD and community facilities.

Inpatient long-term and acute rehabilitation care is available at the CFA. Inpatient mental health services are provided by VA staff on a 20-bed ward within Tripler AMC and at the 16-bed PTSD Residential Rehabilitation Program (PRRP). VAPIHCS contracts for care with DoD (at Tripler AMC and Guam Naval Hospital) and community facilities for inpatient medical-surgical care.

The current constellation of VA facilities and services represents a remarkable transformation over the past several years. Previously, the VAPIHCS (formerly known as the VA Medical and Regional Office Center [VAMROC] Honolulu) operated primary care and mental health clinics based in the Prince Kuhio Federal Building in downtown Honolulu and CBOCs on the neighbor islands that were staffed primarily with nurse practitioners. Congress approved $83 million in Major Construction funds to build a state-of-the-art ambulatory care facility (i.e., ACC) and a long-term care/rehabilitation unit (i.e., CFA) on the Tripler AMC campus and these facilities were activated in 2000 and 1997, respectively. VISN 21 allocated nearly $17 million from FY98-FY00 to activate these projects. VISN 21 also provided dedicated funds to enhance care on the neighbor islands by expanding/renovating clinic space and adding additional staff to ensure there are primary care physicians and mental health providers at all CBOCs.

Big Island CBOCs

VA operates CBOCs in both Kailua-Kona (75-377 Hualalai Road, Kailua-Kona, HI, 96740) and Hilo (1285 Waianuenue Avenue, Suite 211, Hilo, HI, 96720). VHA also operates Readjustment Counseling Centers ("Vet Centers") in Kailua-Kona (73-4976 Kamanu Street, Suite 207, Kailua-Kona, HI, 96740) and Hilo (126 Pu'uhonu Way, Suite 2, Hilo, HI, 96720).

The Big Island CBOCs serve an estimated island veteran population in FY06 of 14,291. In FY06, 5,081 veterans were enrolled for care on the island and 2,936 received care ("users") at Big Island VA facilities. The market penetrations for enrollees and "users" are 36 percent and 21percent, respectively, and compare favorably with rates within VISN 21 and VHA.

Kailua-Kona CBOC. Since the last time this Committee held hearings on the Big Island (i.e., January 2006), VA relocated the clinic here in Kailua-Kona. VAPIHCS now leases about 5,000 square-feet for the new clinic and spent about $500 thousand to renovate the existing facility. Although the current configuration and size is a vast improvement over the prior clinic location, parking at the new clinic is very limited. VAPIHCS is currently working with an architect/engineering firm to provide an additional 15-20 new parking spaces.

The current authorized FTEE level at the Kailua-Kona CBOC is 12.0, including a full-time primary care physician, psychiatrist and nurse practitioner. Currently, the psychiatry position is vacant and we are actively recruiting to fill it. In the interim, mental health coverage is provided by a mental health clinical nurse specialist (on "loan" from the Maui CBOC) and visiting psychiatrist for the Hilo CBOC. With this staff, the Kailua-Kona CBOC provides a wide array of primary care and mental health services. The Kailua-Kona CBOC also has a formal home-based primary care (HBPC) program that provides clinical services in the homes of veterans.

VAPIHCS provides specialty care services at the clinic by sending VA staff to Kailua-Kona from Honolulu and other VA facilities in California. Services provided by clinicians traveling to Kailua-Kona include cardiology, gastroenterology, nephrology, neurology, optometry, orthopedics and rheumatology. If veterans need services not available at the clinic, VAPIHCS arranges and pays for care in the local community (e.g., Kona Community Hospital) and Honolulu (including Tripler AMC). In FY06, VA spent more than $7.8 million in non- VA care in the private sector (i.e., not including costs at other VA or DoD facilities) for residents of the Big Island.

In FY06, the Kailua-Kona CBOC treated 1,055 patients and recorded 6,779 clinic stops. The clinic has short waiting times for new patients with very few veterans waiting more than 30 days for their first primary care appointment. The Kailua-Kona HBPC program recorded 598 clinic stops for providing home care to veterans residing on the west side of the island.

Hilo CBOC. VAPIHCS spent about $100 thousand in FY01 to remodel the Hilo CBOC and spent additional funds in FY06 to further renovate the clinic. The current authorized FTEE level at the Hilo CBOC is 15.0, including two full-time primary care physicians and a psychiatrist. This is an increase of four staff since January 2006 and reflects the reassignment of staff from the PRRP that was relocated from Hilo to Honolulu. With this staff, the Hilo CBOC provides a broad range of primary care and mental health services. The Hilo CBOC also has a formal HBPC program that provides clinical services in the homes of veterans.

VAPIHCS provides specialty care services at the clinic by sending VA staff to Hilo from Honolulu and other VA facilities in California. Services provided by clinicians traveling to Hilo include cardiology, gastroenterology, nephrology, neurology, optometry, orthopedics and rheumatology. If veterans need services not available at the clinic, VAPIHCS arranges and pays for care in the local community (e.g., Hilo Medical Center), Honolulu (including Tripler AMC) or VA facilities in California. As noted before, in FY06, VA spent more than $7.8 million in non- VA care in the private sector (i.e., not including costs at other VA or DoD facilities) for residents of the Big Island.

In FY06, the Hilo CBOC treated 1,683 veterans and recorded 8,843 clinic stops. The clinic has short waiting times for new patients with very few veterans waiting more than 30 days for their first primary care appointment. The Hilo HBPC program recorded 641 clinic stops for providing home care to veterans residing on the east side of the island.

Special Issues

OIF/ OEF outreach. VA estimates up to 15,000 residents of Hawaii have been deployed to Afghanistan and Iraq as active duty personnel, Reservists or Hawaii National Guard. All VAPIHCS sites of care, including CBOCs, are authorized to provide care to DoD beneficiaries as TRICARE providers under the national "Seamless Transition" initiative between VA and DoD.

VAPIHCS has an active outreach program to inform OIF/ OEF veterans about the availability and scope of VA health care services. As an example, a team of clinical and non-clinical staff from VAPIHCS attend all Post Deployment Health Reassessment ( PDHRA) events. PDHRA is a program managed by DoD and is designed to provide education, screening, assessment and access to care for military personnel who have returned from deployment. The assessment generally occurs three- to six-months after returning from deployment. At the PDHRA events, VA staff is available to answer questions and to enroll and make appointments for interested veterans.

All VA health care systems, including VAPIHCS, have dedicated OIF/ OEF program managers, who help OIF/ OEF veterans receive the services they need. VAPIHCS also has an OIF/ OEF case manager and support from a Transition Patient Advocate in VISN 21. OIF/ OEF veterans who need inpatient treatment for PTSD will be admitted to the PRRP program in Honolulu. Veterans residing in Hawaii also have access to the Polytrauma Unit at the VA Palo Alto Health Care System. This is one of four specialized units designed to meet the needs of the most severely injured OIE/ OEF veterans and active duty personnel.

The total number of OIF/ OEF veterans seen in VA health care facilities is a relatively small proportion of the total "user" population, however, the number is increasing. In FY02, VAPIHCS treated 225 OIF/ OEF veterans; in FY06, the number of OIF/ OEF veterans seen at VAPIHCS facilities increased to 1,137. Very few OIF/ OEF veterans are waiting more than 30 days for an appointment.

VA recognizes that our newest group of veterans has special needs. About 18 percent of OIF/ OEF veterans seen in VHA have a diagnosis of PTSD. There are more women veterans in the OIF/ OEF cohort than the general veteran population. A significant proportion of OIF/ OEF veterans has been exposed to blasts and might suffer from traumatic brain injury ( TBI). Musculo-skeletal problems (e.g., low back pain) are common and constitute the most prevalent reason for seeking VA health care. In response, VA is aggressively screening patients (e.g., for TBI), training staff and hiring additional specialists (e.g., mental health, rehabilitation) to ensure we will meet the needs and expectations of these brave warriors.

Compensation and Pension ( C&P) examinations. Veterans Benefits Administration (VBA) relies heavily on the medical evidence and expert opinion provided by C&P examinations to adjudicate veterans' claims. Consequently, the quality and timeliness of C&P examination results provided by VHA is very important. The quality of C&P examinations performed at VAPIHCS is very good, as measured by Compensation and Pension Examination Program scores (an external review of examination completeness and quality), insufficiency rates and remand rates.

Regrettably, for the past several months, there is a backlog of examination requests and the timeliness of examinations has not met VHA standards of 35 days. The underlying causes of the delays include a surge of requests from VBA, staffing vacancies coupled with recruitment challenges (especially, in more remote locations such as Guam), and space constraints in the ACC.

VAPIHCS is highly motivated to resolve these barriers and has developed a credible plan. VAPIHCS now has made additional examiners available to the C&P unit by reassigning staff, "borrowing" VA physicians from mainland facilities and hiring contract staff. VAPICHS is also conducting C&P clinics on some Saturdays and has plans to renovate the ACC to relieve space constraints. Assuming the number of requests from VBA remains stable (i.e., about 500 requests each month), VAPIHCS is confident it can eliminate the backlog and maintain timeliness standards by fall 2007.

State Veterans Home. The State of Hawaii is planning to open its first State Home in Hilo later this year. This will be the first State of Hawaii facility to provide nursing home and domiciliary care to eligible veterans. The 95-bed facility is on the site of the former Hilo Hospital on the Hilo Medical Center campus. VA awarded a grant of about $20 million for the project to complement state funding. VA is excited about this project and looks forward to our continuing collaboration with the State of Hawaii. I commend the State Advisory Board on Veterans Services for the recommendation to name the facility in honor of Mr. Yukio Okutsu. As you know, Mr. Chairman, Mr. Okutsu was a resident of Hilo and a recipient of our Nation's highest award for valor, the Medal of Honor, for his heroism during World War II.

Academic affiliations. VAPIHCS and the veterans we proudly serve benefit from an array of balanced relationships with academic institutions. One of our most important partnerships is with the John A. Burns School of Medicine, University of Hawaii. Prior to my appointment as Director, VAPIHCS, I was fortunate to have served as Chairman, Department of Medicine at the Medical School. I have seen from both "sides" the value of a strong relationship between VA and academic medicine. VAPIHCS serves as a training site for medical students, post-graduate housestaff (i.e., interns, residents and fellows), dentists, nurses, pharmacists, psychologists and social workers. We also work with the Medical School in recruiting physicians and research investigators. Our patients and staff also benefit from the training programs and other academic programs at Tripler AMC.

Conclusion

In summary, with your support, Mr. Chairman, and other members of Congress, VA is providing an unprecedented level of health care services to veterans residing in Hawaii and here on the Big Island. Our goal is to provide safe, effective, efficient and compassionate care to all veterans. We are committed to and active in our outreach efforts to veterans, including the brave soldiers in the Guard and Reserve, who proudly served in OIF/OEF.

However, VAPIHCS still faces several challenges, in part due to the topography of its catchment area, lack of an acute medical-surgical hospital, limited community resources in rural areas and difficulties recruiting staff. VAPIHCS will meet these challenges by utilizing telehealth technologies, hiring specialists, working with community partners and developing new delivery models. I am proud of the improvements in VA services in Hawaii, but recognize that our job is not done.

Again, Mr. Chairman and other members of the Committee, mahalo nui loa for the opportunity to testify at this hearing. I would be delighted to address any questions you might have for me.