<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:23330.wais]
RURAL VETERANS' ACCESS TO PRIMARY CARE:
SUCCESSES AND CHALLENGES
Monday, August 22, 2005
U.S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, D.C.
The Subcommittee met, pursuant to call, at 9:06 a.m., at
Eastern Maine Community College, Room 501, Rangeley Hall, 354
Hogan Road, Bangor, Maine, Hon. Henry E. Brown, Jr., [Chairman of
the Subcommittee] Presiding.
Present: Representatives Brown and Michaud.
Mr. Brown of South Carolina. Good morning. My name is Henry
Brown and I chair the Health Subcommittee of the Veterans
Committee. I'm from South Carolina.
It is a real pleasure to be up in Maine. This is my first
stop. And, you know, I left that 95 degree heat, it just came
down from a hundred degrees. So, it's been a real pleasure this
morning to wake up and enjoy the nice cool temperatures that you
folks have here.
It's a real pleasure to be here. I know Mike Michaud and I
serve together in Congress, and two years ago we served on the
Veterans Benefits Subcommittee. And then I got to be Chairman of
the Health Subcommittee, and Mike got to be Ranking Member on that
Subcommittee, so it's been a real good working relationship. And
our goal as the chair of the Health Committee is to try and
improve the health care delivery for veterans. And we try to do
some things to get us up with the 21st Century and deal with some
other issues that we have.
And we're grateful today to come and listen to you, the
veterans, and make absolutely sure that this is working; not just
in South Carolina or in Texas, but in Chicago and also in Maine.
Rural healthcare is a big issue for us, because, in a state
like Maine, and even some little areas in South Carolina, where
accessability to good healthcare is a major concern.
We also have with us some staff members of the Senate. And I
know Mark Kontio is here -- Mark, would you raise your hand --
thanks for coming -- from Senator Olympia Snowe's office. Jon
Ford from Senator Collins' office. Matt LaPointe from Thomas
Allen's office.
Although the Senators and Congressman Allen were not able to
come, I'm pleased that Congressman Allen asked us to submit his
statement in the record, and we will certainly be happy to do
that.
[The statement of Thomas Allen appears on p. 33]
Before delving into the subject of today's hearing, I would
like to extend my heart-felt thanks to both my staff and Mr.
Michaud's staff I would like to recognize Jeff Weekly and Dolores
Dunn from my staff - - Mike, if you would recognize your staff --
Mr. Michaud. Yes, Linda Bennett, from my staff, as well as
my staff from the State of Maine, and several are here today.
I would like to thank them -- and your staff, Chairman Brown
-- for coordinating this hearing. I appreciate all of the hard
work.
Mr. Brown of South Carolina. Well, I certainly appreciate
the hospitality that you've shown, Mike, and your staff since we
have been here together. And I look forward to going to Togus
later today and see the medical facility up there.
Today we examine how the VA is providing primary care to
veterans in rural Maine; what challenges the VA confronts in
providing care for veterans in the state; and what unique and
innovative measures serve as potential solutions to meet these
challenges.
The panels we will hear from today, because of their roles
inside and outside of VA, will help us better understand the
current state of play for Mainers and the gaps that have developed
due to the rural make-up of the state.
As Chairman, it is my hope that when gaps in treatment or
clinical care are identified, we put significant effort behind
developing new and innovative approaches to providing care for
those who live long distances from VA medical centers or
community-based outpatient clinics.
We must remember, however, Maine is not alone when it comes
to providing rural care to our veterans. So, the solutions we
consider as policymakers -- those already in use, or new ideas
generated as a result of this hearing -- should be exportable to
other states and localities in the United States, so that all
eligible and enrolled veterans can benefit.
I now yield to my good friend, Mike Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman. And once
again, I want to welcome you, your staff, and staffs from other
lawmakers. I welcome you to the State of Maine, and hopefully
you'll have an enjoyable stay while you are here. I want to thank
Eastern Maine Community College for allowing us to use their
facility here this morning, I really appreciate that.
I also want to thank all of the veterans who are here today.
I know a lot of them have traveled great distances to get here,
several over three hours this morning, so I really appreciate your
time and effort to come here this morning.
Mr. Chairman, I want to especially thank you for agreeing to
hold this hearing in the State of Maine. And there's another
hearing in South Carolina next month.
I know the Chairman and I are definitely united in a
bipartisan effort to look at taking care of our veterans. It is a
high priority for both of us.
It is a great honor to serve with you, Mr. Chairman, in a
bipartisan effort over the last three years to make sure that the
veterans get the services they need.
I'm also very pleased that the Democrats and Republicans came
together earlier this year to correct the shortfall that we
received in the original budget as it relates to veterans.
That bipartisan effort was put forth in a supplemental
budget, that the President signed on August 2nd, and we're very
pleased with the additional funding.
The budget shortfall definitely hurt the veterans' access to
care and quality of care; it was put at risk.
In Maine, the VA had to put a hold on filling many staff
positions until the new funds were released.
I must say I am surprised that the VA Central Office was
caught by surprise by the shortfall in June. The Bangor Daily
News had reported back in January that there was a 14 million
dollar shortfall at the Togus VA Medical Center.
I hope that we can continue working in a bipartisan manner
and keep the dialogue open to make sure that we find long-term
solutions for VA funding.
I'm fully supportive of mandatory funding.
If members of Congress, the President and his Cabinet, and
federal employees are guaranteed healthcare benefits, then I think
veterans should be guaranteed their healthcare benefits as well.
As we tackle the underlying flaws that we find in the budget
process, we also must look at how do we take care of Priority 8
veterans as well.
Mr. Chairman, we have a proud tradition here in Maine in
answering the call to service. One in six Mainers are veterans.
And we are very pleased with that.
We have a new generation of veterans who are risking their
lives in Iraq and Afghanistan.
Americans from small rural towns, in your state and mine,
have taken on more than their share of answering the call to serve
their country.
I think it's important to the returning soldiers who need the
help readjusting once they get back home, that we will provide
that help. We'll be looking at the need also for quick access for
mental health services to prevent the chronic mental health
problems that we are seeing.
We must not fail these heroes by ignoring that need. I look
forward to hearing from Veterans Integrated Service Network, or
VISN, 1 Director, Dr. Post; and Togus VAMC Director, Jack Sims --
looking forward to their testimony, and the efforts to expand the
capacity to serve veterans in the state of Maine, which is
definitely needed.
I'm also looking forward to hearing from them as well on the
opening of CBOCs that were proposed under the CARES
recommendations.
Veterans need these clinics. We must move forward to get
these clinics up and running. Telemedicine is great. I believe
telemedicine is important, but it's not the answer for all of the
problems that we have.
We must make sure that we do not forget that, with
telemedicine, we must have adequate staff -- whether it's
psychiatrists or eye doctors to meet the demand. No amount of
technology will make up that difference.
I'm also concerned about the way mental health patients are
being integrated into primary care. Many veterans suffer from
depression, post-traumatic stress disorder, and other mental
health problems.
There simply are not enough mental health care specialists to
meet the demand. We're looking forward to hearing about that
issue.
If you look at the statistics, Mr. Chairman, last year VISN 1
spent only 60 percent of what it did nine years ago to treat
veterans with serious mental illness.
Also, VISN 1 only had 78 percent of the mental health staff
that it had back in 1996.
I am concerned that this means a reduction in the care for
our veterans. I'm looking forward to hearing the testimony from
the VISN 1 Director and Togus VAMC Director Jack Sims.
I want to thank you both for taking the time to come here
this morning.
Thank you.
Mr. Brown of South Carolina. Thank you very much, Mike.
At this time we'll call the first panel to come forward. Our
first panel is Dr. Chirico-Post, appointed Director Of the New
England Healthcare System in 2000. She oversees a network of
healthcare centers throughout the six New England states.
Mr. John Sims has served as the Director of the VA Medical
Center for 15 years. His leadership has been instrumental in
helping veterans in rural Maine access a broad range of medical
services.
And let's start with you, Doctor.
STATEMENTS OF JEANNETTE CHIRICO-POST, M.D.,
NETWORK DIRECTOR, VA NEW ENGLAND HEALTHCARE
SYSTEM; AND JOHN H. SIMS, JR., DIRECTOR, TOGUS VA
MEDICAL CENTER
STATEMENT OF DR. JEANNETTE CHIRICO-POST
Dr. Chirico-Post. Good morning. Mr. Chairman and members of
the committee, thank you for the opportunity to appear today to
discuss Rural Veterans Access to Primary Care: Successes and
Challenges.
The New England Healthcare System is comprised of the six
states in New England as an integrated health care delivery system
to provide comprehensive quality, innovative care, in a
compassionate manner to all veterans it serves.
We serve a population of 240,000 veterans with a total budget
of over $1.4 billion dollars. Our eight medical centers operate
approximately 1900 beds, and we have about 26,000 admissions to
those beds.
The network is committed to provide the right care at the
right time in the right place and at the right course.
We are committed to the unique healthcare challenges that
Maine faces.
We are fortunate to be affiliated with premier medical
schools in the country, including New England College of
Osteopathic Medicine. And we are a leader in research and post-
graduate education.
I'm pleased today to discuss the many areas in which VA is
excelling in the state of Maine. Currently there are no
significant waiting lists or backlog for new primary care patients
in Maine. 71.6 percent of new patients are seen within 30 days,
and 94 percent of the established patients are seen within 30
days.
We've had outstanding performance in Maine in high risk, high
volume areas, such as cancer screening and diabetic care.
Access is enhanced in New England through a total of 38
operational community-based outpatient clinics, with the quality
at the same standard as it is at the medical centers.
VHA has committed to the expansion of service and the
transformation of mental health care, and the spectrum of services
in Maine include both inpatient and outpatient services.
The network very successfully secured funding recently
throughout the six states in support of those mental health
services.
A grant recently received provides for the expansion of
services to treat additional areas though substance abuse
disorders, but not limited in that area.
We have a number of special programs that were initiated and
flourished in support of the frail elderly in Maine. These home
community-based care programs include other areas such as hospice-
veteran partnerships that exist.
Telemedicine is a strategy to meet some of the rural
healthcare needs in the network, including those veterans who need
special services at a distance.
The goal is to provide an electronic network capable of
supporting the veteran patient wherever they live by providing
innovative means of communication between the patient and the
healthcare provider on site.
Care coordination/Home Tele-health programs provide the tools
to help patients self-manage their care, reducing hospitalizations
and enabling them to live in the least restrictive environment.
A recent article from the US News and World Report entitled,
House Calls, discusses telemedicine and the VA's use of this
innovative medical tool.
And I would like to submit a copy of this for the record.
Advances in telemedicine and technology are included through
the innovative implementation of My HealtheVet, which will allow
the veteran access through the Internet for pharmacy refill
functionality.
In addition to that, through the technology, we are able to
establish consultation for our patients and additional referrals
so the patients do not have to travel long distances.
We work collaboratively with the Department of Defense to
insure a seamless transition for our returning service members.
Our computerized patient record system provides a sharing of data
in a secure fashion.
There are other areas in which telemedicine has provided
enhanced access to the veterans of Maine, including dermatology,
psychiatry, pathology, cardiac monitoring through
electrocardiograms.
VA is committed to ensuring a seamless transition from active
duty to civilian status for our newest veterans returning from
conflict in Afghanistan and Iraq.
To date, over 5,000 veterans are enrolled in the network,
including over 500 in Maine. These veterans are primarily seeking
care through primary care, dental care, and mental health
services.
Additionally, we have 18 Vet Centers located throughout the
network, five in the state of Maine.
In summary, the VA has implemented numerous innovations to
meet the rural health care challenges facing our Maine veterans.
And today's veterans will know, in whatever setting they receive
their healthcare, that they are receiving the highest quality of
healthcare from the professionals who provide that care to our
Nation's veterans.
Mr. Chairman, that concludes my statement. I truly
appreciate the opportunity to share with you how VA New England
Healthcare System provides quality and compassionate healthcare to
the veterans of New England.
Mr. Brown of South Carolina. Thank you, Dr. Chirico-Post.
At the conclusion of Mr. Sims' remarks, we'll then have some
questions. Thank you.
[The attachment appears on p. 38]
[The statement of Dr. Chirico-Post appears on p. 40]
Mr. Brown of South Carolina. Mr. Sims?
STATEMENT OF JOHN H. SIMS, JR.
Mr. Sims. Mr. Chairman, Congressman Michaud, thank you very
much for the opportunity to speak to you today about Rural
Veterans Access to Primary Care in Maine.
At Togus, as well as throughout the entire health care field,
there is now a sustained emphasis on outpatient services, an
emphasis that has significantly reduced hospitalization stays and
more clearly focuses on outpatient clinics and their available
services.
Although we have changed the manner in which we provide our
care, we continue to provide the same broad range of services and
high quality care that we have always provided to an ever
increasing number of Maine veterans.
During my 15-year tenure as Director of the Togus VA Medical
Center, there's been a remarkable and sustained shift in the
delivery of health care services in Maine. In particular, the VA
has been progressive in its attempt to provide rural health care
access.
Today there are five full-time community-based outpatient
clinics -- CBOCs -- in Maine, several of which have been expanded
more than once to meet the increased demand.
These full-service CBOCs are located in Caribou, Bangor,
Calais, Rumford and Saco. And, in addition, we have a part-time
clinic located in Fort Kent which operates as a satellite of our
Caribou CBOC. In addition to primary care, an essential part of
that primary care at our CBOCs is the provision of preventive
health services and health promotions as well, in addition to
disease prevention programs.
We also have two VA mental health clinics located in Bangor
and Portland.
To better serve the Maine veterans, four of these CBOCs were
recently expanded or relocated, and the remaining CBOC in Calais
will soon be in its new location. And we're hopeful that that
will occur in October of this year. We're on schedule.
We've also been able to increase access to mental health
throughout the state. The Bangor CBOC has adjacent mental health
clinic which is fully staffed and operates on a full-time basis.
Mental health support for our Saco CBOC is provided by the
newly expanded and relocated mental health clinic in Portland.
Tele-mental health is in place in Caribou and is planned for
Calais when that CBOC is relocated later this year.
Finally, the Rumford CBOC now has an onsite mental health
clinician one day a week with plans to expand that service when
additional resources become available.
One of the most significant changes in VA health care in
Maine has been the extraordinary increase in the number of
enrolled veterans selecting VA as their preferred choice for
health care services.
In 1999, we had a total enrollment of 19,000 veterans in the
State of Maine. 2004, the end of last fiscal year, that was up to
36,000 veterans seeking their care from VA.
The significant piece then with regards to rural health care
is that, back in 1999, only one-third of the veterans, were
getting their care at a CBOC. In 2004, half of our enrolled
veterans are now getting their care out in the rural areas.
Obviously, that shows that the veterans want to get their care
closer to where they live.
The Togus Healthcare System has been coordinating very
closely with the Maine National Guard and various reserve units to
conduct outreach for the Operation Iraq Freedom/Operation Enduring
Freedom veterans as they're returning.
The outreach efforts include healthcare and non- medical
benefit briefings as well as information on readjustment
counseling by the Vet Centers.
Currently, approximately 550 of these veterans have enrolled
for VA healthcare, and about 80 percent of those are actively
seeking some type of medical and/or mental health care.
At this point, the vast majority of veterans have only
required outpatient health care.
In May 2004, the CARES Decision identified six additional
sites of care throughout Maine, that were authorized pending the
availability of resources and validation with the most current
data.
To better meet the needs of the under served veteran
populations, the majority of these newly authorized sites will be
located in more rural areas of Maine, which would significantly
further the attainment of a primary goal of providing veterans
quality health care closer to their homes.
Togus will continue to closely monitor implementation of
these sites of care.
To date we have about 69 patients receiving various stages of
adjunctive care through tele-health devices. Our Home-based
primary care unit has been using video phone devices for more than
a year to provide follow-up and on-going care to patients in
individual and residential home settings.
Physician assistants and nurses use these devices to review
medications, look at wounds, complete psychosocial assessments,
conduct follow-up reviews for medication changes, and determine if
there have been any other changes or medications have been
changes.
To better serve the veterans of Maine, we must continue to
monitor their needs and find ways to meet the challenges those
needs present.
America's veterans have earned the best care we can possibly
provide, and it's our distinct privilege to provide them with the
highest levels of customer service.
We will continue to coordinate closely with Maine's veterans
and with national and state Veterans Service Organizations, as we
do our very best to address our veterans' concerns.
We certainly sincerely appreciate your interest and support
in helping the VA to successfully accomplish our sacred mission of
providing world-class care to all those who have so honorably
served our great country.
Thank you very much.
[The statement of Mr. Sims appears on p. 45]
Mr. Brown of South Carolina. Let me just say, I thank both
of you for coming today. Also, let me thank you both for
addressing the challenges that we have in rural America to find
the veterans and find some adaptable services, that we are
committed to support and sort of move away from the institutional
type of setting in the hospitals we have in place and try to get
needs and services closer.
I noticed, Dr. Post, in your testimony you talked about the
wait time. I'm just wondering, how is the wait time for
specialty-type performance?
Dr. Chirico-Post. We continue to face significant challenges
in meeting VHAs own standards in providing specialty services
within 30 days.
And throughout the network, there's a variation, if you
would, in those challenges, primarily depending on the
availability of specialist.
We don't have significant delays in neurology -- I happen to
be a neurologist -- but we do have significant delays in
gastroenterology, eye care, orthopedic care.
There are those sub-specialities that are difficult to
recruit in certain areas.
We have in place a system whereby there's a prioritization,
if you would, for the veteran who needs that care, and how that
care might be rendered.
If we can not provide the care in a timely fashion in one of
our institutions, then we seek to do that for that veteran outside
the VA on a fee basis.
Mr. Brown of South Carolina. How about mental health.
Dr. Chirico-Post. Let me speak to mental health as well.
We have an integrated model, if you would, of the delivery of
services of mental health that run the gamut from simple things
that may be managed through -- through a primary care office; like
depression in the early stages can be managed by a primary care
physician.
So, those who are seriously mentally ill, they may require
services of a psychiatrist. I'm very proud, in New England, that
one of the standards that VHA uses to measure how well we're doing
in providing those services, is to look at the percentage of
mental health care visits in our community-based outpatient
clinics, where the enrollees total over 1500. And we do very well
in that -- in that network. We're not perfect. We face
challenges in several of the areas.
And, again, I'll go back to the issue of the principal
resource of the provider being a scarce specialty to get enough
of.
From an innovative point of view, what we have done in the
network is two things. One is that, you're probably very well
aware of our computerized patient records. There's no health care
organization that has a computerized system like this, so that a
veteran who is seen in Caribou, Maine, and has consulted with me
in Massachusetts, I can pull up the record, as well as in
California.
That serves as a basis, I think, for coordination continuity,
especially in referrals.
That's one thing.
The other thing that we have done more recently is establish
direct linkups through telemedicine that Mr. Sims talked briefly
about, especially between Caribou and Togus.
When I was chief of staff at Providence, Mr. Sims and I
established a relationship in dermatology between Providence and
Togus.
The challenge that we faced in psychiatry, I think, is the
gamut of illnesses that the individuals may have when they come to
seek their care from us.
So, we attempt to better coordinate that care. We have other
resources especially in the state of Maine that we tap into,
called outreach centers or Vet Centers.
In all of New England, we have 18, and in Maine we have five.
Recently there's been separate funding for those Vet Centers.
VA New England received a number of those in support of that, and
we have worked very closely with our vet centers in outreach.
Because, sometimes the veteran doesn't want to come to the
hospital, and is much more comfortable seeing a comrade at the Vet
Center, and then can get referred into Togus.
Mr. Brown of South Carolina. Do you experience difficulty in
seeing the transfer between the DOD and the VA as far as their
medical records.
Dr. Chirico-Post. Seamless transition at this time in this
country is the best it's ever been, I think.
The VHA has on the ground folks in Department of Defense to
secure a better coordination of those individuals once they get
out.
We have an office in VHA for seamless transition. I have a
person in the network, Mr. Sims has a person in the facility, that
we rely on as the point person for just that issue.
The electronic medical record is a challenge. There are some
incompatibilities that exist right now, but both Department of
Defense and VHA are committed to enhancing those technical
challenges that we face to improve the response that might exist
there.
We have in the network a standardized system whereby, we go
out to the reserve units, even before they go to discuss what will
be available for them when they come back; we do the same thing
when they come back.
We have readily accessible to them a specific place that they
can call at any one of the medical centers when they call in, so
that we can be there for them.
Mr. Brown of South Carolina. I know that Mr. Michaud has
some questions, too, but let me just ask one further question.
In the four major services, do you have any opportunities to
coordinate services, like with the medical universities, in those
eight regions that you're involved in?
I know in South Carolina, in our rural areas, we have, like,
family health clinics for our newer vets. I'm hearing reports
that they were recommended that we need more coordination between
our county governments and state governments and the VAs.
Do you all have --
Dr. Chirico-Post. On the network side, we're very fortunate
to have relationships, whether it's through the state government
or through the medical schools, and other healthcare partners that
we can partner with.
Just here in the state of Maine, we have a wonderful
relationship with our state veteran homes, from a long-term care
point of view, where we work in conjunction with them.
For the last several years, I've been the co- chair of the
homeless coordinated program through New England. And that brings
to the table the state governments -- all of the New England
states, the chairperson for Veterans' Affairs, for example, of the
state; the VA, and Social Security, to interact and integrate and
coordinate resources and services one with the other.
So, we do try to take advantage of that.
Mr. Brown of South Carolina. In South Carolina we are
looking at -- we also have a VA hospital in the same region or the
same -- approximately in the same vicinity as a medical university
hospital.
We're looking to replace both of those facilities, and move
the VA hospital closer to the medical university, where so many of
the offices are located. And that would help with the cost of the
testing equipment, it would be a good mix to do that.
Dr. Chirico-Post. At the present time, as a consequence of
the original proposals and recommendations out of the CARES
process, we're also looking at integrating, if you would, three of
the facilities in Eastern Massachusetts. And part of the equation
of that is the relationship with the schools. And part of the
equation is, how do you best utilize that technology? How do you
better integrate the research programs?
VA New England has received -- the largest number of dollars
from all of the VHA research comes to New England.
So, we still have a number of those physicians and Ph.D.
Individuals who do the research and observations, if you would, in
the VHA.
But, in addition to that, provide quality care to the
veterans.
Mr. Brown of South Carolina. We also have some outpatient
clinics, but we have a combination with DOD also, with an air
force base in Charleston; and so that's another way of sharing.
Thank you for your patience in answering my questions. And I
think Congressman Michaud may have some questions now.
Mr. Michaud. Thank you very much, Mr. Chairman.
Once again, I want to thank you, Dr. Post and Mr. Sims, for
your testimony. We enjoyed it.
Dr. Chirico-Post, I want to congratulate you. I understand
that you're going to receive the VHA Recognition Award, so I want
to congratulate you.
Dr. Chirico-Post. Thank you very much.
Mr. Michaud. We are here to help you do whatever we can to
make sure that we take care of the veterans.
I want to be more specific to the state of Maine. If you
look at New England, you can practically fit all of New England
inside the State of Maine. Maine's a very large state. We can
drive another hour north of here, and that would be the center
point for the State of Maine. So, it's a big state.
I'm concerned that, with this tight budget, that money for
the clinics that have been recommended under the CARES process,
and the timing to get those programs up and running. My concern
is, whether or not that funding will come out of the existing
budget of Togus VAMC facility. I definitely do not agree with
that.
The VISN will need additional funding for these clinics.
With the supplemental budget that was passed, will that help move
these clinics forward?
Particularly, when you look at where these clinics are
located, whether it's Dover-Foxcroft, Lincoln, Houlton, Lewiston-
Auburn area -- a lot of these areas -- I know the VA has been
working with local healthcare providers to move these clinics
forward, and this will be great.
So, my question is, when will they be up and running?
The second part of that question is, have you estimated the
cost for each one of these clinics, what it will cost to get them
up and running?
Dr. Chirico-Post. Let me begin to answer that question, and
some of the specifics of the resources required to open up the
individual clinics, Mr. Sims may have those specific dollars
associated with it.
Let me also thank you for the 1.5 supplemental that we have
received. I think that -- I have given my professional career to
veteran healthcare.
And to be recognized in that way, to receive the additional
resources, I think demonstrated that, as good stewards of those
resources, which I believe we are in the network, and Mr. Sims is
in the State of Maine, that we will take those resources and do
what's best for the veteran.
So, having said that, the supplemental clearly brings us
closer to the implementation of the recommendation of the CARES
program.
We go back in history to the foundation of the CARES program,
which was to look at the capital assets that we had, and provide
for enhanced services. That's what it was.
And the particular recommendation for -- that affects us and
in our discussion today was, if you look out from a demographic
point of view over the next ten and twenty years, you realize that
the numbers, the sheer numbers that will come to us in VHA, would
increase.
And New England, 25 years ago, we might not have said that.
But, clearly, three years ago, when we started the process for
CARES, and we keep updating our numbers.
And as Mr. Sims has said, in Maine, of the six New England
states, the greatest market penetration is in Maine. So, on
average, about 27 percent of our veterans in Maine come to receive
their care through VHA.
CARES recognizes, given our definition of urban rural and
highly rural, that we could -- I would say for the network, 97
percent of the veterans who seek their care have access to care
within 30 minutes. That's not true of Maine. It's less than 60
percent. I think it's 56 or 57 percent.
So, the recommendations to open the clinics in Lincoln, and
to speak out to those other areas, that probably will be outreach.
We originally, in the CARES proposal, started out looking at
telemedicine throughout Maine. There were other opportunities.
CARES was not saying that you have to do it in one way or the
other.
I think the network, with the facility, will come forward and
say, this is what we would like to do.
So, the first order of business, I think, is to open Lincoln.
And then after that, to take a look at the other access points, if
you would, and what's the best way of doing that.
Clearly, the CARES recommendation came out at the end of --
the middle to end of '04. In '05, the process of protocol we need
to follow is to go back into headquarters requesting to open it.
And one of the issues for us was the financial feasibility,
which we could not do in '05.
We don't know what the budget's going to be for '06. Given
the supplemental that we received in '05, we're fortunate that
we're able to do a number of new things for the organization.
A new CAT scan for Maine. A mobile MRI unit on station in
Togus at least two days a week. We would never have been able to
do that.
I think the total dollars that came to Mr. Sims out of the
supplemental was something like 13 million. And that includes
both the equipment and the maintenance that's there.
To get back to your question. That obviously puts us in a
better position to be able to put together the papers and the
protocol, and we have to see what the budget's going to be for
'06, to move forward in that regard.
Because, we want the same things that you want, and that's
better access for the veterans.
Mr. Michaud. This may call for Mr. Sims to answer. That 13
million, was that FY 05?
Dr. Chirico-Post. Yes.
Mr. Michaud. Now, that 11 million dollars that was borrowed,
was that all for Togus, or was that part of VISN 1?
Dr. Chirico-Post. Let me deal with the 11 million.
Before we got the supplemental back in the spring, we
assessed that we needed 11 million dollars in capital to do what
we considered high priority safety issues for the organization.
We never did borrow 11 million, we only borrowed five
million. And that was to be paid back with the beginning of the
next fiscal year.
So, the 11 million -- and I don't have that figure off the
top of my head, how much of that were for projects here in Maine,
but it was a fair share.
As I look at the budget across the network, the Maine budget
is that it has increased over certainly the five years that I have
been network director. And the apportionment that Maine receives
in equipment and NRN has always been slightly greater, mostly
because there's 36,000 veterans for us to take care of, and almost
1000 employees that we manage in the state of Maine.
Mr. Michaud. The centers, Mr. Sims, how soon can they get up
and running?
I know, it's the goal to come closer, but I don't know when
they're going to be up and running, No. 1.
My next question is, I've been hearing a lot from the
veterans in the Lewiston-Auburn area, and what are your thoughts
about a Lewiston-Auburn CBOC?
Mr. Sims. First of all, we continue to, in anticipation of
being able to get these up and running -- we've had ongoing
discussion in many of the communities already. They've been
identified.
Certainly in Lincoln, with a local facility there. The CEO,
we've had discussion about possibly -- about the possibility of
space, and how we might do that.
In the Houlton area there's a definite interest on the part
of veteran groups there to secure a building and have that be
available for us.
So, there's ongoing planning in place, so that once the
resources are available, we can move quickly and get these up in a
reasonable time.
Now, once we have that final notification, there are other
logistics that are required. Actually getting the equipment,
getting the furniture in place, and having the space open and
ready to work in.
Lewiston-Auburn is an area that I think, certainly now, is a
large demographic area -- second largest population concentration
in the state -- and it's far enough away from Togus and our other
sites that I think that it makes sense for that to be a site for
us in the future as we get to that point in the planning process.
Certainly, again, a fair amount of veteran interest in that
area. We're working very closely with the various grassroots
efforts that are in place there to get a suitable site when that
comes.
Mr. Michaud. I see my time's running out, Mr. Chairman.
But, if I might, Mr. Sims, you testified -- or your testimony
indicates that 22 percent of the newest veterans enrolled at Togus
are using mental health services.
If this rate continues, will VA be able to provide mental
health services without increasing the staff level?
I know Maine has had an increase in funding in the VA. But,
when you also look at Maine, 16 percent of our population is
veterans. Percentage-wise, we're one of the highest in the
country.
Likewise, when you look at those who are actively serving in
Iraq and Afghanistan, we are way up there in numbers. We need the
services. Being a rural state, that makes it much more
problematic.
So, do you think that the mental health resources will be
there?
Mr. Sims. I absolutely do think so. We just recently added
two new psychiatrists to our mental health department.
In fact, one of those just recently came off active duty, and
had served in Iraq, and so is very well qualified to know some of
the things that the returning soldiers are facing.
So, we've added new psychiatrists, other mental health staff.
We are fully staffed in mental health at this time.
We have emphasis on the returning veterans, and the issues
that they're facing, particularly within our PTSD program.
As Dr. Post mentioned, we have other programs coming online
at our outbase clinic as well. And I think we're in a good
position right now to be able to deal with any of those issues
that would come up.
Mr. Michaud. How is Togus integrating mental health services
into primary care?
Mr. Sims. Again, there is close coordination. With the
computerized medical records, the primary care providers can see
what's being done on the mental health side; and the mental health
side can see the progress notes from the primary care providers.
And it's just an integration of the whole services.
They're located at Togus in close proximity to each other,
and so consultation as needed between the providers and -- again I
think, they are very well coordinated, and mental health services
are in good shape.
Mr. Michaud. Would you be able to provide the cost for
clinics as far as what it would cost to get clinics in Lincoln and
Dover and all other recommended sites?
Mr. Sims. We could provide some preliminary costs. Again,
it's going to depend on what the lease cost may be ultimately and,
you know, the size of the clinic when we finally configure it.
But, we could come up with some preliminary costs for you. We
could get that to you, yes.
Mr. Michaud. I would appreciate that.
[The information appears on p. 112]
Mr. Brown of South Carolina. Thanks Mike. Let me follow up
along with that same line of questioning. I think you proposed
five new clinics in -- I think you said 2000, and your patient
load was, like, what, 19,000; and I think in 2004 you had like
36,000.
Do you anticipate by adding these new health centers that
those numbers will go up, or do you think those numbers will be
just shifted around to the new locations?
Mr. Sims. We will do some shifting around, clearly that's
our intent for some of these. But, we know from past experience
that when we open up these outbase clinics, that there will be new
enrollments as well.
And we've had some projections in some areas. And in
Lincoln, for example, we're expecting maybe as many as 400 new
enrollments initially, and then probably some growth from there.
But, certainly, there will be some new growth. As we put
these CBOCs out in the rural areas, as Dr. Post mentioned, the
market penetration greatly expands and grows in those areas
because, when it's there, they come.
Mr. Brown of South Carolina. Are you finding that the
veterans are citizens of Maine, or are they migrating from some
other regions in the United States.
Mr. Sims. Mostly it's Maine citizens, but certainly we get a
wide variety. And we're here to take care of the veterans of the
United States of America, and we do that.
Mr. Brown of South Carolina. I represent the coast of South
Carolina and it's getting to be a destination of choice for
retirees. In fact, I think it would be a good connector if we
could spend winters in Myrtle Beach and summers up here.
Let me ask you one other question. Do you have an idea of
how much you're spending for fee services now?
Dr. Chirico-Post. The network spends over 70 million dollars
in fee services.
Mr. Brown of South Carolina. And how much of that is in
Maine.
Dr. Chirico-Post. About 20.
Mr. Sims. Probably about 20 million dollars, yes. It's a
significant amount here in Maine --
Mr. Brown of South Carolina. Do you see that that is costing
VA health centers more money?
Mr. Sims. That again is our expectation, as we put these
places closer to where the veterans live, because they'll get
their healthcare from us rather than the fee --
Mr. Brown of South Carolina. You understand that this is a
cost saving --
Mr. Sims. Absolutely.
Mr. Brown of South Carolina. Let me ask you just one other
question and then we'll move on to the next panel. Do you have
facility specific data in terms of the numbers seeking enrollment
solely for the purposes of ordering or refilling prescriptions.
Mr. Sims. I'm not sure that we do, quite frankly. It's been
significant, but I think it's tapered off some recently, so --
If we have it, I'll get it.
Mr. Brown of South Carolina. Let me ask another question
then to follow up on that.
I know, I think, in order to get a prescription filled or
refilled, you must see your doctor.
Mr. Sims. Correct.
Mr. Brown of South Carolina. How do you feel about filling
the local doctor's prescriptions; would that help the patient load
some.
Mr. Sims. Well --
Mr. Brown of South Carolina. I know that, as a policy, that
may be something that you'd want to take a look at, but I'm just
curious to have you address that.
Mr. Sims. Well, the VA was established as a healthcare
provider, not a pharmacy. And so, certainly anything that would
deviate from that would require legislation to allow that sort of
thing to happen.
And I think that would be the response. But, there certainly
is a significant amount of co-managed care that does go on in the
VA system, where some veterans prefer to stick with their local
provider, and then come to the VA because of the prescription
benefit.
I think that as we open up additional sites of care, if we're
closer to where the veteran actually resides, that they'll be more
apt to go to VA care initially, and not seek out their local
provider.
I know we have a significant number of veterans who, once
they do come to VA, find out how good the care is, how wide the
variety of care is, and have transferred their care entirely to
VA. So --
Dr. Chirico-Post. A final comment that I will make on that,
VHA, through its extensive performance measurements system has
demonstrated both on the inpatient and outpatient side of the
house that we are a leader in quality, a benchmark for other
healthcare organizations.
A recent study in preparation for this that I looked at was
to compare -- the joint commission publishes a performance through
ORECS and in Togus -- Togus is above other healthcare
organizations in those inpatient performances.
That didn't happen by accident, it's by coordinating the
care.
And for those of us who provide that care -- I think there
has to be a different policy decision to support the prescription
only in the VHA.
We don't have that policy yet.
Mr. Brown of South Carolina. Right. And we've established
that. I was just curious to know how you might feel about that.
I know you said that your mission is to take care of these
veterans and, you know, prescriptions are part of their healthcare
too. I don't know why they would separate that, but I was
wondering if you would just have a response to that.
Thank you all. Mike, do you want to --
Mr. Michaud. Yes. Mr. Chairman, I have, actually, several
more questions, and I would request permission to submit the
questions for the record so we could get the response from Dr.
Post and Mr. Sims.
As well as I want to thank you both for coming today. And I
definitely encourage Mr. Sims to try to get those numbers to us,
and really work hard with the hospitals out there in the
community. I know they're real anxious to do whatever they can to
make sure that they can work with the VA to get the clinics up and
running, because we definitely do need them.
Mr. Brown of South Carolina. Thank you very much. Let's
move up our next panel.
Our second panel is Don Simoneau, Vice Commander of the
Department of Maine American Legion; Mr. Gary Laweryson, Chairman
of the Maine Veterans Coordinating Committee; and Mr. Roger
Lessard, President, of Local 2610 of the American Federation of
Government Employees. And Mr. Lessard has been an employee of the
VA for over 20 years.
And we welcome you guys and we'll ask Mr. Lessard to begin.
STATEMENTS OF ROGER LESSARD, PRESIDENT, AFGE LO-
CAL 2610; DON SIMONEAU, VICE COMMANDER, THE
DEPARTMENT OF MAINE AMERICAN LEGION; AND GARY
Laweryson, CHAIRMAN, MAINE VETERANS COORDINAT-
ING COMMITTEE
STATEMENT OF ROGER LESSARD
Mr. Lessard. Thank you, Mr. Chairman. It's my pleasure to
be here today. Of course, I represent approximately 800 VA
employees in professional and nonprofessional positions at the VA
facilities affiliated with Togus; also including the Bangor,
Calais and Caribou community clinics.
Rural healthcare markets face significant challenges as
compared to urban markets, including a limited number of
specialists, less access to expensive technologies, and a less
affluent patient population.
At the same time, rural Americans are disproportionately
represented in the military. Thus, it is no surprise that a
disparity in healthcare exists between veterans living in rural
areas and their urban and suburban counterparts.
A recent study by public health experts found that veterans
living in rural areas experience a lower health-related quality of
life. As a result, the veterans' health care costs are estimated
to be as high as 11 percent greater in rural areas.
Here in Maine, we are very familiar with these healthcare
challenges. Maine ranks fourth in the nation when it comes to the
share of veterans living in rural areas.
Togus VA Director Jack Sims testified before the CARES
Commission two years ago that only 59 percent of the enrollees
have access to primary care services within the CARES travel time
criteria, and only 52 percent have access to acute hospital care.
The Togus VAMC has experienced a dramatic growth in demand
for services over the last four years. We average between 300 to
400 new enrollees per month.
Similarly, our community based outpatient clinics have
experienced tremendous increases in demand in the past few years.
As a result, our veterans are forced to wait longer for needed
medical care.
For example, there is currently a four-month wait for
ultrasounds in radiology, as well as a wait list for cardiology,
urology, and other specialty care.
The CARES Commission warned the VA of this likely surge in
demand in its February 2004 Report to Secretary. Specifically,
the Commission recommended the addition of five CBOCs in Maine,
including one in Lincoln.
However, due to lack of funding, and contrary to the CARES
Commission's recommendations, no new CBOCs have opened up to serve
Maine's veterans more promptly and closer to home.
If and when we area able to open additional CBOCs, we will
not be able to adequately staff them given the current hiring
freeze.
Since the start of this year, we have only been able to hire
one new employee for every two we lost. If the freeze continues,
our only alternative will be to take staff away from another
CBOCs, causing shortages and delays there instead.
Lack of funding and cuts in FTEs also affect our ability to
deliver timely care in other ways. We have been forced by budget
cuts to delay the implementation of important innovations such as
our nurse case management system.
Also, we had to delay needed capital improvements and medical
equipment purchases, including a much needed MRI machine as
discussed below.
Despite years of short staffing, I am proud to represent a
staff that has been continuously dedicated to the caring of our
veterans. At the same time, I also have to care about our
dedicated employees who become ill and stressed because of
mandated overtime. Prolonged overtime and other pressures also
are causing more or our older staff members to take early
retirement, which further adds to the staffing problem.
These staff shortages have forced us to hire agency staff --
an unsatisfactory stopgap measure which ends up costing the
taxpayer more, while affecting the quality and safety of the
medical care we provide to our veterans.
The veterans in our state need new facilities and more staff
to meet their medical needs. Additional CBOCs will allow us to
provide more timely care and reduce the long distances that many
veterans have to drive to see a doctor.
We will not help the rural veteran -- what will not help the
rural veteran is an increased use of costly fee basis services.
Another VISN recently estimated that fee basis care costs 35
percent more than care provided by a VA facility. One must also
consider the difference in quality in care delivered by an outside
provider who lacks the training and resources available within the
VA.
Finally, veterans and taxpayers in Maine will benefit from
the acquisition of an MRI machine at Togus.
Currently, we have to pay high prices to outside providers
because we do not have our own MRI or PET Scan machines, diverting
scarce health care dollars from other needs.
If we had our own MRI machine, we could save close to a
million dollars a year, even after including the cost of the
purchase. In addition, our veterans would be able to get their
screenings in- house.
This has changed, by the way, because now we are proposing to
get an MRI machine and PET Scan in Togus.
We are grateful for the recent good news that the current
shortfall in VA health care dollars has been partially addressed
through supplemental funding. These additional dollars will
enable us to undertake some of the capital improvements that we
had to delay.
In the long term, there should be a better way to provide
reliable funding for the medical needs of returning soldiers and
other veterans.
Every budget cycle, our dedicated staff as well as the
veterans we serve are left wondering whether there will be enough
funding for hospital beds and doctor visits.
Uncertain funding also takes a toll on our ability to plan
for the long-term needs of current and future veterans.
Thank you again for the opportunity to testify on behalf of
the Maine veterans and thank you also for holding this hearing in
Maine.
We at Togus will continue to provide the best care for our
veterans. I am proud and grateful that as elected officials that
you have recognized how this shortfall has hurt veterans and that
measures are needed to rectify the problems that have resulted.
I pray that our veterans will never again have to experience
these problems in accessing health care.
Thank you.
Mr. Brown of South Carolina. Thank you, Mr. Lessard. And
thank you for your service.
[The statement of Mr. Lessard appears on p. 51]
Mr. Brown of South Carolina. At the conclusion of all three
of these presentations, we'll have some questions.
STATEMENT OF DON SIMONEAU
Mr. Simoneau. Chairman Brown, Congressman Michaud, I thank
you for the opportunity to testify before you today on behalf of
the American Legion, Department of Maine, regarding Access to
Primary Care for Rural Veterans in the State of Maine.
According to the 2000 Census, many rural and non-
metropolitan counties across the nation had the highest
concentrations of veterans in the civilian population aged 18 and
over from 1990 to 2000.
The State of Maine has the fourth highest proportion of
veterans living in rural areas in the nation at 15.9 percent.
Studies have further shown that veterans who live in rural areas
are in poorer health than their urban counterparts.
And I present to you an article from the American Journal of
Public Health, October 2004, to go on record to show that article
and that study.
The Capital Asset Realignment for Enhanced Services, CARES
Commission, report released February 2004 specifically mentioned
the Far North Market, which is Maine.
Only 59 percent of the veterans in Maine are presently within
the CARES own guidelines, to access primary care services.
The subsequent CARES decision released in May 2004 identified
156 priority community based outpatient clinics, six of which are
slated for Maine.
CBOCs were designed to bring health care closer to the
veteran, and that means in the community where the veteran
resides.
After a long, hard fought battle the final commission report
and the CARES decision decided that, indeed, VISN1, and more
importantly, Maine, needed these CBOCs to provide adequate primary
care access to a mostly rural population.
The CARES decision of May 2004 directed that VISN begin
immediate preparation of proposals for development of CBOCs for
that same year. However, upon inquiry to the Veterans
Administration Central Office, the American Legion has learned
that business plans have not been submitted or revalidated during
2005, and are not anticipated until the final 2006 budget
allocations are distributed and reviewed by VISNs.
The CBOCs of VISN 1 listed in the CARES decision are all
designated for the State of Maine. The American Legion does not
understand this delay. Nearly two years will have passed in
preparing the proposals.
Additionally, establishing a CBOC is not a not a short
process, and now the timeline has been considerably pushed back.
The VA can ill afford a time lapse as lengthy as two years when it
comes to providing health care to our rural veterans.
The nation is in the midst of a war on terror, and delaying
the delivery of quality health care is not in the best interest of
any veteran.
Of special note is the provision of mental health services
within the CBOC setting. Mental health specialists within the VA
all agree that CBOC should provide mental health services;
however, they do not.
The committee on care of veterans with serious mental
illness, has been monitoring this issue for years and has
advocated in their annual report to Under Secretary of Health that
CBOCs need to provide mental health services.
It has been reported that up to 30 percent of the returning
veterans from Operations Enduring and Iraqi Freedom will have
mental health problems to include post-traumatic stress disorder.
In 2005, Togus reported approximately 365 Operations Enduring
Freedom and Iraqi Freedom veterans enrolled for healthcare with
approximately 260 actively seeking medical and or mental health
services.
While the VA does not believe returning veterans will have a
major impact on Togus, they are continuing to monitor it.
The American Legion cautions the Togus facility on their
optimistic view of returning veterans and their impact on the
system.
Let us not forget that the returning veteran suffers from
multiple physical and mental wounds and is resource intensive to
treat. Those that put their life on the line so that we may enjoy
our carefree lifestyles deserve nothing but the best, and we can
not deny them their deserve treatment.
What is of growing concern to the American Legion is the
increasing number of veterans who are put on electronic wait
lists. For example, in medical specialities, if a veteran is a
service-connected at 50 to 100 percent, priority group 1, you can
usually be seen within 30 to 45 days. However, if you are not in
that priority group, you can wait up to year for specialties such
as ophthalmology or orthopedics.
The VA budget woes are well documented, and the American
Legion has played a key role in bringing these shortfalls to the
forefront.
The American Legion has advocated for assured funding to
ensure shortfalls such as that experienced by the VA this year
does not happen in the future.
Again, I thank you for the opportunity -- for giving the
American Legion this opportunity to express our views for the
Department of Maine. We look forward to our continued work with
Congress on these important issues.
Thank you, sir.
[Applause.]
[The statement of Mr. Simoneau appears on p. 55]
[The attachment appears on p. 59]
Mr. Brown of South Carolina. I would also like to thank Mr.
Simoneau for the help you put in for locating graves of the
departed veterans.
And I was just curious as I read that last night, that
there's an initiative in other states and other regions to do a
similar thing.
Mr. Simoneau. When I started that a few years ago, it was a
local thing, because my Post said that we need to make sure that
we flag the veterans.
And now I'm getting phone calls from all over the country. I
mean, I've had people from Ohio and Florida contact me and say,
how did you start this, and, you know, where do you go from there.
So -- Thank you, sir.
Mr. Brown of South Carolina. Okay. Mr. Laweryson.
STATEMENT OF GARY LAWERYSON
Mr. Laweryson. Chairman Brown, Congressman Michaud, we
appreciate testifying on behalf of the Maine Veterans Coordinating
Committee. We represent 14 organizations and speak as a united
voice for the veterans of Maine.
The VA CARES program, short for Capital Asset Realignment
Enhanced Services, studied the access to Maine's rural veteran
population and concluded more Community Based Outpatient Clinics -
- CBOCs -- were needed along Maine's North-South corridor and
Western Maine.
These CBOCs would provide a greater number of Maine's rural
veterans the much need access to quality outpatient and specialty
care.
Every CBOC site within Maine is filled to capacity and are in
need of expansion to be able to continue to provide the quality
care Maine's veterans have come to expect. The CARES study shows
Maine is greater in area and rural veteran population than the
other entire VISN 1 areas.
In 2004, the VA's computer projections were 154,000 veterans
in Maine that were eligible for care in the VA system.
These projections did not take into account the veterans who
move to Maine's rural areas to escape the fast life, nor Maine's
growing retired veteran population.
Through the efforts of the Maine Veterans Coordinating
Committee and its subsidiary organizations, Togus VAMROC enrolled
500-700 new veterans each month for over two years.
Although this trend has slowed, Togus continues to enroll new
veterans each month.
Now that Maine's National Guard and Reserve components are
returning from Afghanistan and Iraq, many with wounds and
illnesses requiring VA care, the need for access will again
increase.
Maine's current VA system is stretched to the breaking point,
and it is imperative that new CBOCs are made available to provide
timely access to the services.
Due to Maine's unique geographical size, it is difficult for
many of Maine's veterans to travel to the existing sites. Maine
has no mass transit system. Maine's veterans rely on the DAV
shuttle bus for transport to Togus and the CBOCs.
However, in the northern counties, there is only one bus
available. Many of Maine's rural veterans are on a limited, fixed
income and are unable to afford transportation to Togus or the
nearest CBOC. Nor can these veterans afford health insurance or
access to local care.
The Maine Veterans Coordinating Committee believes Togus
should be expanded to become a full service VA Regional Medical
Center, independent of Boston. Maine's rural veterans must now
travel several hours one way to obtain care at Togus or a CBOC.
To require Maine's veterans to travel three to eight hours
more to Boston for tertiary care is unacceptable. Maine has one
of the top rated Cardiac Surgery Centers in the nation, and is
leading the nation in long-term care and end-of-life care provided
to our veterans.
Sending Maine's veterans to Boston removes the family and
local veteran support system sorely needed to effect recovery of
its veterans.
While the majority of the nation is urban or metro, and have
showed a slower growth, rural Maine has demonstrated a sustained
growth pattern and will continue this trend.
Lastly, the Maine Veterans Coordinating Committee would urge
the VA to open lines of communications to all veterans, not just
in Maine. In the past, the veterans have not felt the VA was user
friendly. As a result, many older veterans and those serving on
active duty have failed to avail themselves of the quality care
provided by the current VA system.
In Maine, the veterans are banding together to educate our
veterans on the many services available to them. Operation I
Served is a joint project initiated to provide information to
Maine's veterans, their spouses and families on services through
the VA system, educational benefits, tax relief, financial
assistance, employment assistance, housing assistance, and long-
term-care options through the VA and Maine's Veterans Homes
systems.
Our program has received requests and been supplied to many
other states.
Again, on behalf of the Maine Veterans Coordinating Committee
and the Maine veterans we represent, thank you for allowing us the
opportunity to speak to you.
The Maine Veterans Coordinating Committee looks forward to
continuing to work with Congress to enable the VA to provide
quality services to all veterans.
[Applause.]
Mr. Brown of South Carolina. Thank you very much. And thank
you for that report.
[The statement of Mr. Laweryson appears on p. 64]
Mr. Brown of South Carolina. We'll continue the questions.
Mr. Simoneau, while this hearing is focused on primary care,
do you think there's any utility in using new innovative
technology such as telemedicine to help fill the current gap of
specialized services you mentioned in your testimony, like tele-
psychiatry?
Mr. Simoneau. Congressman, I guess my own -- my own gut
instinct is that, if I'm suffering from PTSD, or I'm suffering
from mental illness, I want to talk to a person. I don't want to
sit in front of a telecommunication device and testify in front of
something that scares the puppy out of me.
And I believe that a doctor or a therapist immediately for
that patient needs to be there for that type of service.
Mr. Brown of South Carolina. Do you see any line of
treatment where telemedicine might work, like eye examinations,
blood sugar checking, and many other different types of diagnostic
testing situations that you believe it could fit.
Mr. Simoneau. I believe there are places that tele-
communication will work. But I think that we have to be real
careful in placing what items in front of that type of situation.
If we're talking about a doctor being able to look at reports
and do things with telecommunication with a patient that are
paper-work intensive or such, yes.
But, when it gets down to an exam, where you're really
talking about the nuts and bolts of what's going on with the
patient -- a lot of these people have been through stresses
already in their lives.
And to put them under the stress of a television camera I
think is unfair. There are places they can be used, I agree.
But, I think we have to be very careful in picking those areas.
Mr. Brown of South Carolina. Mr. Laweryson, your written
testimony suggested that VA is not notifying younger and older
veterans of the services available through the VA. I know there's
the American Legion and other avenues.
What type of outreaches would you like to see that aren't
currently taking place in Maine or other regions of the nation?
Mr. Laweryson. Well, sir, I think the VA has to overcome the
past transgressions.
What I mean by that is, the communications. The VA right now
is user friendly. From the Vietnam era on, it wasn't user
friendly. And that stigma sat there for a long time. We have
seen an increase of Vietnam veterans coming, and that's due to the
fact that this -- we're used to working with the VA on that.
Communication goes out, and then it's up to the service
organizations to get the word out, and explain to them that this
is a user-friendly system now.
And, as Mr. Sims eluded to, once they get in there they find
out -- you know, it's like Christmas. This place is fantastic.
And then they come back out and spread the word again. But,
it's a fact that we need to get that word to them, especially the
older ones right now with the economy the way it is and the fuel.
There's tough times ahead in the state of Maine, especially -- an
hour north or here, either side of 95, is a bit lonely. There's
not much out there.
And a lot of your combat veterans, not just from Maine, but
from other states, gravitate to this solitude. There's a great
number up there that are hiding.
The 154,000 veterans that we have, and -- we feel it is
higher -- and our objective or goal is to notify as many of them
as we can. That's why we went from 16,000 to 36,000. And we tend
to make Jack earn his money up there, get another 10 to 15,000
enrolled.
Mr. Brown of South Carolina. Mr. Simoneau, do you have any
suggestions of how we might be able to reach the veterans and
notify them of the services available.
Mr. Simoneau. I believe part of our problem in the state of
Maine is how rural we are.
You can go an hour from here and not have cell phone
communication down the street. You can go across the street and
not have communication on the Internet.
There's a lot of people within the state of Maine who don't
have TV cable. There's a lot of access issues within the state of
Maine that are really prevalent to the state of Maine because of
the type of state we are.
Reaching those people is a full-time job, and I'm not sure
how we can better do that.
The veteran organizations go out there, but you need to
understand, some of these veterans are really skeptical about a
veterans organization. You know, what do they want from me.
And they're afraid of the VA system. The VA turned me down
when I got home from World War II. I went over to see them and
they said, sorry, you're okay, go home. And that veteran in 1946
went home.
And now, when he's 80 years old, we try to tell them, you
know, you need to go to Togus, you need to get some help.
He looks at me and he says, but they sent me away in 1946.
And you would be surprised how many veterans that are out
there that are that way. And I'm talking 1946, World War II
veterans.
But, we can do the same thing with the Korean veterans, and
we can do the same thing with the Vietnam era veterans, and I'm
sure down the road with the Iraqi Freedom veterans, we're going to
have that same issue.
How do we do that? I'm not sure.
We've done local areas where we bring in people from the VA,
people from the Maine Veteran Services, and we sit down and we ask
veterans to come to the community to apply for help, to talk to
people. Those fair-type systems work very well.
But, to put them on in a state as rural as Maine is tight
skating.
Mr. Brown of South Carolina. Do you have something like a
mailing list? I know the post office gets to everybody, I would
assume that, even up here --
Do you have up here a mailing list where you have everybody
recorded?
Mr. Simoneau. I believe, under the Freedom of Information
Act, and all of the other requirements for protecting peoples'
rights, that's one of the drawbacks of those rights, and that
protection.
The names are out there, but we don't have access to them.
We have access to the 26,000 members of the American Legion here
in the state of Maine, but we don't have access to the 156,000
that are actually veterans.
Mr. Brown of South Carolina. Okay. Mr. Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman.
Mr. Laweryson, you talked about the Operation I Serve
program. I was really intrigued by that. And living in the state
of Maine all my life, I know how rural the state of Maine is, and
it's problematic particularly when you look at the economic
hardships which we have had over a number of years with mill
closings and what have you.
Currently we're going through the BRAC process and we don't
know how that's going to end up for bases in Maine.
In the program, Operation I Serve, how do veterans know about
that program? I know it's difficult. We do have
telecommunications here, but is there a website, or an 800 number
that they can call in? Do you do mailings?
Can you tell us a little bit more about the program?
Mr. Laweryson. The I Serve, we have a website,
www.mainedvs.org. They get the information from there. The
packets come out in the county where it's most rural up there.
Every town office gets a copy of this on CD as well as the
paper one. And that was done through the coordinating committee.
We got the funds ourselves, and we got a veteran up there, John
Wallace, who's working on his own.
And we've got this as far south as North Carolina now. I
retired from the Marine Corps down there. And when I went down
there this summer, I dropped it off at the VA transition site at
Camp Lejeune.
We also picked up the VA transitional list, and we're in the
process of sending them all over the states, which is the major
military installations.
[To Chairman Brown.] South Carolina will get theirs shortly.
But, the veterans returning from active duty, the ones in
Maine, we got to let them know. Because when I decapped, we knew
nothing about Maine. I grew up here, but I didn't know what the
services were.
And I come back and worked through the system. So, what we
did is put down the state commanders and the Maine Veterans
Coordinating Committee the one with the BBS, and he's sit down and
come up with a list of phone numbers, points of contact in the
state, federal level.
We amend this every three to four months. We're putting on
all of the elected officials now. The governor's on board with
this. He made the announcement the 11th of November. He was
kicking this off. He fully supports it.
We're grass roots. We're paying for it for ourselves. It
isn't costing the state anything.
But, it's helpful to the state because we're getting the
veterans in here. It's a slow process.
At town meetings I think would be the way to go.
The VA wasn't allowed to go up and actively enroll because
they were shut down, because of the waiting list. Our philosophy
was, if you could get the numbers then you could justify them
paying or getting the money to us. And it works.
And Jack Sims down there, at VA Togus, is doing a phenomenal
job taking care of our veterans, and he wants to do a better job.
That's why we're trying to get the veterans in there.
It's a challenge. And other states have asked us for it, and
they're starting to -- I think the key word is you work together.
All of the veteran organizations have to work together. Dance on
the same sheet of music, and we're also building the VAs.
They get this out to the congressmen's offices and the
senator's offices, and they're aware of this, because they're
getting an influx of senior citizen centers, hospitals.
Get it out there and get it in front of them. Things are
getting tight out there, and these people have got to make
decisions. Do put heat in the house? Do I pay for the pills?
And it's getting to the point where some of their kids bring them
in to us.
It works. The CBOCs are critical. If they can't travel down
to Bangor, we've got one in Lincoln, we got one in Houlton --
that's the North-South corridor. And the western corridor goes
across Route 2 and goes over towards Rumford and that area. And,
of course, Lewiston-Auburn is a large city for Maine.
Mr. Michaud. And don't forget Dover-Foxcroft.
Mr. Laweryson. Well, no, we can't forget that.
Mr. Michaud. How would you -- to follow up on that question.
What I've seen, particularly when Great Northern, where I
worked for 30 years, shut down and filed bankruptcy, a lot of the
workers there are veterans.
How do you convince someone who's working currently -- has
good health care benefits, do not need them to go to the VA at
all, how do you convince them to sign up to make sure that they're
taken care of? Is there a lot of resistance?
Mr. Laweryson. It is and it's due to a lot of rumors up
there. And the rumors are rampant.
You can come out here and say, you know, the VA is the way to
go. And someone else is out there saying, you don't want to go to
VA because -- they'll kill you, and it's slow, the waiting list is
prenominal.
Well, in some cases it is and some cases it isn't. It's the
education system. Again, this is part of it.
Category 8s, there's going to be a wait, Category 7s, there's
a wait.
There's a priority list, and the priority list is there for a
reason. There's a priority given your treatment for the VA.
They need to understand this. Once they're made aware of it,
and what's available, there's not a problem. They feel that they
can go down there and get into this.
But there are a lot of veterans out there who really need to
be in there, they're just unaware.
And we need -- as the veterans that are active now, we have
to communicate to them, and do so on a level that they will
understand and are comfortable with, so they you can come to the
VA and get proper treatment.
Mr. Michaud. Mr. Simoneau, in your testimony, you raised
concerns about electronic waiting lists. And, actually, I think
the VA Inspector General came out with a report that says that the
VA is under-reporting the number of veterans on the list, and that
they're over-reporting the number of veterans who are receiving
services within 30 days.
Can you elaborate more on the problems at Togus and at the
clinics?
Mr. Simoneau. I won't elaborate on numbers, because I guess,
as you can see, numbers will tell whatever you want to say.
I'll elaborate on the fact of people that I know of within
the system.
And people I knew within the system get very frustrated.
They think they have an appointment. They think they're all set,
and then all of a sudden they're on this list and, oh, by the way,
your appointment isn't this month, it's not next month. We'll get
back to you.
I get real nervous over electronic wait lists. I'm just not
sure -- once again, we're taking a person out of the middle of
that system.
Mr. Michaud. To follow up on that question that's very
similar, what would you recommend that we would do at the federal
level, in the sense that there are waiting lists, and the veterans
are waiting and going for services after retirement?
Is there something that we could do to help in the short term
to help veterans?
Mr. Simoneau. I believe that we need to come up with some
sort of emergency funding for these veterans. I believe we need
to come with some sort of pilot program where a veteran who
applies for assistance in Togus, or Rumford, or Portland,
wherever, when he applies for assistance, he needs assistance now.
It's not six months from now.
But, he's also not eating well, he's not paying the rent
well, he's not paying the electric bills well. He has no
assistance out there to help him get by, until when he gets his
paperwork done, that says, oh, yes, he's PTSD, a hundred percent,
he should have been qualified for that two years ago.
But, there's no safety net out there for him. When he
applies for it, from the time he applies until the time he
actually sees somebody, where the system is kicking in, time goes
by and the veteran is hanging out there on a thread.
And those are the veterans that sooner or later run away from
the system because, well, gee, I can't do that, and I don't know
where to go.
So, we need to come up with some sort of safety net, be it an
emergency-type funding mechanism, or something that can temporally
get that veteran through a tough time that he finds himself in.
And there's got to be a way to do that. And we need to be able to
sit down and figure that out, because those veterans are walking
away from the system that they need, but they're afraid they're
going to starve to death before they get through it.
Mr. Michaud. My last question is for Mr. Lessard.
Since Congress has provided additional funding--and the
legislation was just signed recently--for the budget short-fall at
the VA, has Togus started to fill some of the vacancies, or
started to conduct some of the needed repairs at Togus?
Mr. Lessard. Congressman Michaud, not as of yet. We have
tried to fill some of the gaps, but they're not fully staffed as
of yet. And I'm sure that we will be working on that in the near
future.
Mr. Michaud. Can you give any examples of lack of adequate
staff? What are they doing to veterans' access to care?
Mr. Lessard. It's delaying some of the clinics, I believe,
in some of the areas where they're short- staffed.
It's also causing -- as I mentioned in my testimony, we are
causing older nurses that would remain for another four or five
years to retire early, due to the mandated overtime due to the
short falls in staff.
It has a great demoralizing effect on the employees.
Mr. Michaud. Thank you.
Mr. Brown of South Carolina. Okay. Thank you very much,
Gentlemen, for your testimony, and for what you do to support our
veterans. I know I had the privilege this past Memorial Day to go
to Normandy and be a guest speaker. And what a moving experience
it is. We saw all those flags, over 9,000, of those Americans who
never got a chance to come home; a lot of 17- and 18- and 19-year-
old kids. The price of freedom of this nation is tremendous.
And I pledge to you, and Mr. Michaud certainly has been
supportive, as part of the Health Subcommittee, assure you guys
and you girls that you'll have support up here.
And it's been a real pleasure for me to come today and be
part of this session.
And you can be absolutely sure that we try to find other ways
to make the problems up here much better, and support the staff
and the various operations around the nation.
But, it can't happen unless we have the feedback from folks
like you. And we thank you for taking your time in coming and
being with us today, and the preparations you made to make these
presentations.
And I do thank you. Thank you all for coming and being part
of this process.
Mr. Sims, I guess I have one other official thing -- I think
you have something you wanted to submit for the record, and I'll
also note that at this time.
Mr. Michaud. And I guess you have been reading my mind, Mr.
Chairman, because we work so closely here, I was going to actually
mention that Mr. Sims wanted that included for the record.
And, once again, Mr. Chairman, I want to thank you for taking
the time to have one of the two hearings that we're having in the
country as it relates to healthcare for veterans in Maine. And
the State of Maine really appreciates that. And I want to thank
all of the veteran organizations and veterans that came out this
morning to be with us.
Thank you for your testimony, it definitely has been
enlightening, and we'll be sitting down with the Chairman to move
forward.
So, once again, thank you very much.
Mr. Brown of South Carolina. This meeting stands adjourned.
Thank you very much for coming.
[The statement of Senator Olympia Snowe appears on p. 35]
[The statement of Ronald W. Brodeur appears on p. 66]
[The statement of COL Edward L. Chase, USAF (Ret.) appears on
p. 70]
[The statement of Roger Landry appears on p. 75]
[The statement of Timothy J. Politis appears on p. 78]
[The statement of Peter W. Ogden appears on p. 86]
[The information appears on p.89]
[Whereupon, at 10:39 a.m., the Subcommittee was adjourned.]