<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:26675.wais]
DEPARTMENT OF VETERANS AFFAIRS
COLLABORATION OPPORTUNITIES WITH AFFILIATED
MEDICAL INSTITUTIONS AND THE DOD
HEARING
before the
COMMITTEE ON
VETERANS AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
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MARCH 8, 2006
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Printed for the use of the Committee on Veterans' Affairs
Serial No. 109-37
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COMMITTEE ON VETERANS' AFFAIRS
STEVE BUYER, Indiana, Chairman
MICHAEL BILIRAKIS, Florida LANE EVANS, Illinois, Ranking
TERRY EVERETT, Alabama BOB FILNER, California
CLIFF STEARNS, Florida LUIS V. GUTIERREZ, Illinois
DAN BURTON, Indiana CORRINE BROWN, Florida
JERRY MORAN, KANSAS VIC SNYDER, Arkansas
RICHARD H. BAKER, Louisiana MICHAEL H. MICHAUD, Maine
HENRY E. BROWN, Jr., South Carolina STEPHANIE HERSETH, South Dakota
JEFF MILLER, Florida TED STRICKLAND, Ohio
JOHN BOOZMAN, Arkansas DARLENE HOOLEY, Oregon
JEB BRADLEY, New Hampshire SILVESTRE REYES, Texas
GINNY BROWN-WAITE, Florida SHELLEY BERKLEY, Nevada
MICHAEL R. TURNER, Ohio TOM UDALL, New Mexico
JOHN CAMPBELL, California JOHN T. SALAZAR, Colorado
JAMES M. LARIVIERE, Staff Director
CONTENTS
March 8, 2006
Page
Department of Veterans Affairs Collaboration Opportunities
With Affiliated Medical Institutions and the DOD .............. 1
OPENING STATEMENTS
Hon. Steve Buyer, Chairman ...................................... 1
Hon. Henry E. Brown Jr., ........................................ 3
Prepared statement of Mr. Brown ................................ 52
Hon. Michael H. Michaud ......................................... 4
Hon. Jeff Miller ............................................... 5
Hon. Sylvestre Reyes ........................................... 6
Hon. Corrine Brown .............................................. 7
Prepared statement of Ms. Brown ................................. 56
STATEMENTS FOR THE RECORD
Hon. Lane Evans, Ranking Member ................................. 55
Hon. Tom Udall .................................................. 57
Wiblemo, Cathleen, Deputy Director, Veterans Affairs and
Rehabilitation Commission, The American Legion ................. 87
Paralyzed Veterans of America ................................... 101
WITNESSES
Perlin, Jonathan B., M.D., Ph.D., MSHA, FACP, Under Secretary
for Health, Department of Veterans Affairs ..................... 10
Prepared statement of Dr. Perlin ................................ 58
Winkenwerder, William, Jr., M.D., MBA, Assistant Secretary
of Defense for Health Affairs .................................. 12
Prepared statement of Dr. Winkenwerder .......................... 63
Greenberg, Raymund S., N.D., Ph.D., President, Medical
University of South Carolina ................................... 25
Prepared statement of Dr. Greenberg ............................. 71
Moreland, Michael, Director, VA Pittsburg Healthcare System
Department of Veterans Affairs ................................. 29
Prepared statement of Mr. Moreland .............................. 78
Smithburg, Donald R., Executive Vice President, Louisiana
State University System, CEO, Healthcare Services Division ...... 31
Prepared statement of Mr. Smithburg ............................. 81
INFORMATION FOR THE RECORD
Department of Veterans Affairs Report to Congress on Plans
for Re-establishing a VA Medical Center in New Orleans ......... 108
POST-HEARING QUESTIONS FOR THE RECORD
Department of Veterans Affairs Report to Congress on Plans
for Re-establishing a VA Medical Center in New Orleans ......... 157
DEPARTMENT OF VETERANS AFFAIRS
COLLABORATION OPPORTUNITIES WITH AFFILIATED
MEDICAL INSTITUTIONS AND THE DOD
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Wednesday, March 8, 2006
House of Representatives,
Committee on Veterans' Affairs,
Washington, D.C.
The Committee met, pursuant to call, at 2:00 p.m., in Room 334, Cannon
House Office Building, Hon. Steve Buyer [Chairman of the Committee]
presiding.
Present: Representatives Buyer, Baker, Brown of South Carolina,
Miller, Campbell, Michaud, Reyes, Brown of Florida, Udall, Berkley,
and Boozman.
The Chairman. The House Committee on Veterans' Affairs, Full
Committee, will come to order March 8, 2006. We are here today to
learn more about the promise and progress of collaboration in the
provision of healthcare.
I would like to thank all of our panelists today for their testimony,
and we especially welcome the Assistant Secretary of Defense,
Dr. Winkenwerder, who I believe is making his first visit to the
Committee in this second session.
We appreciate your presence, and Dr. Greenberg, Mr. Moreland, and
Mr. Smithburg, who are also on the next panel and who travelled to
Washington, so we can learn more on a topic that grows more important
by the minute and one that holds great promise for the future of VA
and perhaps your own institutions.
Dr. Perlin, as always, you have become a favorite face when it comes
to the topic of the healing arts, and to Mr. McClain, my respect for
you continues to grow and we appreciate your presence here today. I
want to thank you for your role in the Gulf Coast Planning Group and
your leadership with regard to the ``Charleston Model.'' It is kind
of interesting that this is what everybody seems to be calling it,
Dr. Perlin, the Charleston Model. And both of you are to be
congratulated for your work with the Medical University of
South Carolina.
I look forward to hearing about your experience today, especially with
regard to the Gulf Coast Planning Group and the Charleston Model.
The complexity of medicine today is unprecedented, so it is very
expensive and so is the expectation among Americans that when they
need medical care, it will be there for them. This has become a
reasonable expectation among Americans, an expectation that in
practice is usually fulfilled, and that is a profound blessing of
our economic, technological and cultural progress. We cannot permit
this progress to lapse.
Along with the complexity and escalating costs, the very nature of
healthcare delivery has been revolutionized in the last 15 or 20
years. The rise of outpatient medicine and the fruits of preventative
care have rendered much of our inpatient facilities perhaps obsolete.
As we look to expand VA's outpatient capabilities, we also look to
enhance and modernize its inpatient care. Conceivably it is the more
critical of the two, for it is the most acutely ill patients who are
admitted to the hospital.
I believe that the idea of collaboration, whether it is the
collaboration between government agencies or between the public and
state entities, promises significant efficiencies as we move down this
next stretch in the path of the 21st Century health system.
Of course, sharing is not a new concept. With its affiliations among
the nation's teaching universities, the VA has been sharing human
capital for years. Half of the doctors in America were trained at
some point in VA hospitals.
In Charleston, South Carolina, some 90 percent of the doctors at the
Medical University of South Carolina also practice medicine at the
Ralph Johnson VA Medical Center, just a stone's throw away.
VA and DoD began sharing resources in 1982, with the passage of a law
that directed them to pool resources, increase efficiencies and
reduce redundancies. In a sign of progress, the 2002 agreement
between the Navy and the VA to share facilities in North Chicago is
much closer to being fulfilled. Collaboration with the military helps
perfect the seamless transition of servicemen into the VA and back
again to active duty or back to the civilian world.
Collaboration with medical universities is a logical next step from
shared personnel to shared facilities. This benefits veterans in the
country with better access and enhances the quality of care. It is
our goal that this may be perfected.
If we can do this and at the same time, save money, increase the life
cycle of these facilities and increase the quality of care, it is a
win/win situation for the Federal Government and the states. And we
are building from the win/win situation that we have with regard to VA
and DoD facilities.
So the challenge, as we know, is not determining if this is feasible
or a worthwhile concept. It is determining where an already proven
concept, it can next be applied and how best we can apply it to
achieve greater efficiencies, better quality of care, improved access
to care and still retain the identity of VA's healthcare system.
I will hazard a guess that the testimony submitted today from the
veteran service organizations will urge us to ensure that in any
collaborative undertaking, the VA retains managerial control and ensures
the veterans are seen in a uniquely ``veterans' environment.'' Those
are appropriate concerns, and I think they are also manageable
concerns.
The high expectations among those whom we serve, be they Dr. Perlin's
veterans or Dr. Greenberg's patients, are established, will grow and
must be met with state-of-the-art service and be provided on a
sustainable basis.
I believe that taking advantage of the leverage of local healthcare
economies through strategic collaborative partnership is one powerful
approach to accomplishing a mutual goal.
I ask unanimous consent that a statement by the Ranking Member Lane Evans
be submitted for the record. Hearing no objections, so ordered.
[The statement of Lane Evans appears on p. 55]
The Chairman. If any member would like to have an opening statement, I
will yield. I recognize Chairman Brown for an opening statement.
Mr. Brown of South Carolina. Thank you, Mr. Chairman. As you know,
the Committee has expended a great deal of effort over several years
to ensure the VA considers all alternatives when contemplating new
facilities in delivery of healthcare.
I am excited about today's hearing as it will allow us a good
opportunity to hear from department affiliated organizations and the
Department of Defense on the progress that has been made across the
country.
Mr. Chairman, I am especially pleased that Charleston is well
represented here today by my friend, Dr. Ray Greenberg, President of
the Medical University of South Carolina. I would like to welcome him
back to our nation’s capital and to this hearing today. While it is
always good to see friends, I am especially interested in sharing
information with our colleagues regarding the collaborative model that
has been successfully developed in Charleston between the VA and the
Medical University. I am equally interested in completing the model's
development and exporting it to other areas of the country where
similar collaborative efforts may be appropriate, not the least which
may be New Orleans. While this model has already served the VA well,
I expect that over time the department will find increasing utility in
it. To that end, I look forward to engaging Mr. Smithburg from
Louisiana State University during the second panel in order to get a
clearer picture of what a collaborative facility may look like in the
Gulf Coast region. I appreciate him joining us today and I hope that
the work we have done in Charleston helps to fuel his efforts in
Louisiana.
In a similar vein, I am thrilled to have Dr. Winkenwerder with us here
today to speak to some of the collaborative opportunities that have
been undertaken by the VA and the Department of Defense. Like the
Charleston Model, I'm interested in finding out what types of models
may help fuel additional collaboration between the departments,
whether it's North Chicago or Las Vegas or something in between.
In my mind, and I think you share this view, Mr. Chairman,
collaboration is becoming increasingly essential in delivering
healthcare across the nation. So long as we remain true to the
distinct identity of the VA, and so long as we ensure the continuing
quality associated with VA care, we should embrace opportunities to
maximize local health rated economists.
Now the Charleston experience has taught us a lot. We can improve the
quality of care delivered, the efficiency of the care delivered and we
can accomplish it without dramatically increasing the life cycle cost
of the new facility.
Again, Mr. Chairman, I appreciate your leadership in this area, and I
stand ready to assist you in leveraging our work in Charleston
against future collaborations around the country. And I yield back
the balance of my time.
The Chairman. Thank you. Mr. Michaud.
Mr. Michaud. Thank you, Mr. Chairman. I also would like to thank
Chairman Brown for his hospitality when he went to Charleston to look
at the collaborative effort as well as Chairman Buyer. Mr. Chairman,
since we have Dr. Perlin and Dr. Winkenwerder with us today, I would
like to actually -- they don't need to respond -- but I would like to
ask them, use my time for opening statement to request some important
data that you could aid the Committee as it works to provide
appropriate mental health services to returning OIF and OEF veterans
which actually could help us if there might be a potential to look at
other collaborative efforts as we deal with the mental health issue.
And, Dr. Perlin, if you would provide the Committee with OIF and OEF
healthcare utilization data generated by your office for public
health in environmental hazard, that would be helpful.
And, Dr. Winkenwerder, would you please provide the Committee with an
analysis of the outcomes of DoD health reassessment surveys of OIF
and OEF veterans particularly pertaining to their mental health
concerns. And I do want to thank both panels, members, for -- or
panelists -- for coming today. Looking forward to your testimony.
And, Mr. Chairman, as we receive the information from both doctors,
particularly in light of the recent Army study which shows one in
three veterans have sought veterans mental health services, I think
it is important that probably the Full Committee have a hearing on
this and see if there are ways that we can look at making sure that
the services for returning veterans or troops meet thier needs and
the two agencies are able to respond to the needs of men and women
returning home. So I think it would be important if we could have a
hearing on that and also to see if there are ways that we might be
able to assist in collaborative effort, you know, in this particular
area.
So, with that, I want to thank you, Mr. Chairman, for having this
hearing and will yield back the balance of my time.
The Chairman. I appreciate the gentleman's contribution.
Chairman Miller, you are now recognized.
Mr. Miller. Thank you, Mr. Chairman. We have all seen some of the
benefits of collaboration in our country. And in the time when the
need for more efficient spending could not be more evident, it is
refreshing to see opportunities for our nation's citizens to get the
most for their tax dollars.
As we find the healthcare needs of our nation's veterans changing
every day, it is imperative that we in Congress work with the
Department of Veterans' Affairs to ensure delivery of the new
healthcare needs. And collaboration with medical institutions as
well as the Department of Defense are two of the best ways of going
about this.
Equally important is providing access where veterans need it most.
Our nation is a constantly changing landscape, and so VA must
maintain a sense of flexibility in anticipation as demographics
shift. That is certainly no easy task, but it is still an aspect of
the VA's mission to serve those who bravely have served this country.
I would like to thank all who are testifying before us today as they
outline ways to better accomplish this mission. But I would also
like to emphasize that collaboration should not be forced. The
collaborative conditions need to occur where we know the veterans
are, where we know more veterans will be coming.
You all know that my district in Northwest Florida is home to one of
the largest veteran populations in the nation, as well as home to
five military installations. Some of these installations will become
dramatically larger over the next few years as a result of the 2005
BRAC process.
Already in an area specified in CARES as an under-served market,
anyone can now see that Northwest Florida is going to become even
more under served. The growth rate of the veterans' population was
strong long before CARES came out, and long before BRAC, and it is my
hope that VA will continue to focus on an efficient delivery of needed
healthcare by looking at the future as well as the present. Yield back.
The Chairman. Mr. Reyes, you are now recognized.
Mr. Reyes. Thank you, Mr. Chairman. I would like to join you in
welcoming our guests here today on the three panels, but I would like
to associate myself with the comments of my colleague, Mr. Miller,
from Florida, because my area, my region, like his, will be seeing
some substantial growth under the decisions of BRAC, and so I would
hope that we are able to work as additional troops come in with both
the VA and the Department of Defense to do as much as we can to
facilitate both active duty and the veteran population.
My region has about between 70 and 80,000 veterans, and we have one
of the projects -- in fact, we just celebrated the tenth anniversary
of the partnership -- for me it is not a collaborative effort -- is
it a partnership between the VA and William Beaumont Hospital. And
while I will have some questions when it is appropriate,
Mr. Chairman, I understand that some Committee staff during the last
break went to El Paso to look at the VA Beaumont relationship, and I
was wondering, Mr. Chairman, would it be possible to better
coordinate that with the member from the area, because -- and the
reason I ask you is because as you know I have requested a field
hearing for the El Paso area for my district again because of the
large population of veterans in the region. And it would have been
helpful for me to know that they were coming because I would have had
the opportunity to show them a little bit more than just that
relationship between the VA and Beaumont, so if we can do a little
better job of coordinating, I would appreciate that in the --
The Chairman. Mr. Reyes, that is unfortunate. It was Committee
travel of the O&I Subcommittee of which you are a member, and the
minority was invited to participate in that trip by staff and declined.
We will improve the direct relationship with the member office and
that should not occur.
Mr. Reyes. Okay. And I only mention it because of that pending
request that I have. But I appreciate the opportunity to make those
observations in terms of the expected --
The Chairman. Mr. Reyes, please recognize, though, the O&I
Subcommittee, of the years that I participated, was a very good
Subcommittee and you know this is a very good Subcommittee.
Mr. Reyes. Yes.
The Chairman. And that staff from both sides try to cover the
waterfront, and so majority might be going this way, and the minority
is going that way, and they do talk to each other. But with regard
to going to a Member's district, they should let you know.
Mr. Reyes. Yeah.
The Chairman. I apologize for that.
Mr. Reyes. Oh, no. Well, and I wasn't seeking an apology. I just
hope that we can maximize those trips because it is a big country and
there are a lot of issues all over the place and it is a good
opportunity that we would have to show them some more --
The Chairman. Well, it is a great facility.
Mr. Reyes. Yes.
The Chairman. Even when I was on the Armed Services Committee, I --
Mr. Reyes. Absolutely.
The Chairman. When I was in charge of personnel in the health
delivery system, Secretary Winkenwerder, I went to that facility at
El Paso. They do a great job, and they were one of the early
facilities, early on. But thank you very much.
Mr. Reyes. We are very proud of it, and thank you, Mr. Chairman.
The Chairman. Thank you.
Ms. Brown of Florida. Thank you very much, Mr. Chairman. I
certainly want to thank the Under Secretary and the other members
of the VA staff for being here today to present their testimony.
In Mr. Perlin's testimony, he touches on an issue of great importance
to veterans. The need to improve access to healthcare via
collaborative efforts. I am not sure -- and maybe you could
elaborate on this in your testimony if this concept has been picked
up any other place, and that is certainly whether it is Ms. Berkley's
area or Mr. Miller's area or Mr. Reyes's area, where there is
growing population and more and more veterans moving in, if any of
the developers have said we will build a clinic if you will staff it.
We did that in the villages and I would just like to know if you are
taking this concept anyplace else. While it is not direct
collaborative healthcare -- it provides everything you need except
for the equipment and the staffing and as, you know, bricks and
mortar are expensive and if you can work with various developers, it
seems to me as if it is a win/win situation of having the developer
donate the land, put up the building and have greater access to
veterans' clinic facilities.
As you know, we are not building the mass of Hospitals that we once
did. Long before I was here, we went to the community-based
outpatient clinic which really provides quicker, less expensive care
than in a hospital setting. So I would just encourage the VA to
pursue this in other growing veteran areas because it really is a
win/win situation.
I thank you very much, Mr. Chairman, and I look forward to hearing
their testimony.
The Chairman. Thank you. Mr. Udall, you are recognized.
Mr. Udall. Thank you, Mr. Chairman, and rather than giving an
opening statement, I would like to, Mr. Chairman, just offer my
opening statement for the record, and then just a couple of comments
about collaboration in the Louisiana, New Orleans context.
It seems to me that the briefings that we have received from Members
of the House that have been down there on co-dels, the opportunity to
talk with Members of Congress who represent this area, they are in a
very dire, dire situation down there, and anything that you can do in
terms of working with other institutions and other medical centers in
trying to provide the care, I think is something that is very welcome.
So I want to thank you for that, and we will also be visiting with
you in the question section, and I am just introducing my statement
for the record. Mr. Chairman, thank you.
The Chairman. Hearing no objection, your written statement will be
submitted for the record.
[The statement of Mr. Udall appears on p. 57]
The Chairman. Ms. Berkley, you are now recognized.
Ms. Berkley. Thank you, Mr. Chairman. I was at another hearing when
my staff notified me that Las Vegas was mentioned in my colleague,
Mr. Brown's statement, and I felt the need to come here and clarify
some things.
As you know, and I have said this on the record many times, Southern
Nevada has one of the fastest growing veterans populations in the
country. Currently Southern Nevada is struggling, and I mean
struggling, to meet the needs of the population growth which has been
compounded by the evacuation of the Addeliar D III Guy Ambulatory
Care Clinic, outpatient clinic, and its replacement with ten clinics
scattered across the Las Vegas Valley.
My veterans also seek care at the Michael O'Callaghan Veterans
Hospital at Nellis Air Force Base where the Chairman was kind enough
to spend a day with me, seeing exactly what the critical situation is
at the VA.
I must state for the record that while in some communities shared
facilities between the DoD and the VA work well or may work well, it
is not a one-size-fits-all solution for all of us. Las Vegas has had
shared facilities. It does not work for communities that are growing
the way Las Vegas is.
Nellis Air Force Base wants its own facility. They need their own
hospital. They have got a very active Air Force base, one of the
primary Air Force bases in the country. Every bed is filled all the
time and we are on divert. The only problem is that every other
hospital in Las Vegas is currently on divert.
So we -- while I understand that in perhaps South Carolina the
shared facilities work very well, they would not work well in
Las Vegas, and we are looking forward to our full-service medical
complex with an exclusive VA hospital, outpatient clinic and
long-term care facility, and it cannot come soon enough for the
veterans that live in my community. We are in a critical situation
in Las Vegas and shared facilities don't work.
The Chairman. As well.
Ms. Berkley. At all.
The Chairman. At all. No, I don't believe that -- you can't say
that.
Ms. Berkley. Well, in my community, I think it is -- I think it was
demonstrated.
The Chairman. I have been there with you, and it was great, and --
Ms. Berkley. I think you shared our pain on that day.
The Chairman. All right. Let me now, before we begin, extend a
welcome to our new Committee member, Mr. John Campbell of
California. John Campbell took over the district of the former
member Chris Cox, when he went over to become the Chairman of the
Securities and Exchange Commission.
John Campbell brings to the Committee a strong business background.
He received a bachelor's degree in economics from UCLA and has a
master's degree in public taxation from UCS. Prior to his public
service, he was employed as a CPA at the firm of Ernst & Young, and
he was the CEO and president of Campbell Automotive Group, which
included Saturn of Orange County and Saab of Orange County.
His public service includes serving in the State House as a
California State Assemblyman and as a California State Senator.
Mr. Campbell resides in Orange County, California, and he has one
wife and two sons.
[Laughter.]
The Chairman. Is that what it says? That makes you a conservative
in the State of California.
[Laughter.]
The Chairman. I can't help myself. I apologize. We welcome the
gentelman to the Committee.
Now we will turn to our panel, and let us see, who do we give
deference to, DoD or VA; gentlemen, you decide. Dr. Perlin.
STATEMENTS OF JONATHAN B. PERLIN, M.D., Ph.D., MSHA, FACP, UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY
TIM S. McCLAIN, GENERAL COUNSEL, DEPARTMENT OF VETERANS AFFAIRS; AND
WILLIAM WINKENWERDER, JR., M.D., M.B.A., ASSISTANT SECRETARY OF
DEFENSE OF HEALTH AFFAIRS, DEPARTMENT OF DEFENSE; ACCOMPANIED BY
JOHN L. KOKULIS, DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR HEALTH
BUDGETS AND FINANCIAL POLICY, DEPARTMENT OF DEFENSE
STATEMENT OF JONATHAN B. PERLIN
Dr. Perlin. Well, thank you, Mr. Chairman. Members of the
Committee, good afternoon. I ask for our full statement to be
submitted for the record.
The Chairman. Your statement will be received. Hearing no
objection, so ordered.
Dr. Perlin. Thank you. Veterans' Health Administration understands
the benefits of collaboration for VA, for veterans and for the
American taxpayer. We are proud of our expanding partnership with
the Department of Defense, and I would like to personally acknowledge
and thank Dr. Bill Winkenwerder for his leadership in that regard.
We are in the process of creating new and fruitful partnerships with
other healthcare providing as well, especially our critical and very
valued medical school affiliates.
Let me begin by discussing our work with the Department of Defense. As you
know, there have already been a number of successful examples of VA/DoD
sharing, and perhaps the most far reaching and ambitious is Chicago,
where the partnership between our North Chicago VA Medical Center and
Naval Hospital of Great Lakes will result in a joint federal facility.
Six working groups are now addressing human relations, information
technology, leadership, finance, budget and clinical and
administrative management issue. In Alaska, the Anchorage VA
Outpatient Clinic and the Elmendorf Air Force Base have a
longstanding joint venture to serve veterans and DoD beneficiaries.
Anchorage and Elmendorf are also looking for new areas to collaborate
and are currently the site of a budget and financial management
demonstration project. In addition, the VA is opening a new
outpatient clinic in 2008, next to the Elmendorf Hospital.
In El Paso, VA has an outpatient clinic, co-located the at Beaumont
Army Medical center, as Mr. Reyes alluded, and that is a very
successful partnership. Beaumont provides inpatient services to VA
patients as well as Department of Defense beneficiaries in two
facilities which really pioneers an implementation of medical record
sharing between our two systems, as we work through the total joint
interoperability or our electronic health records.
I would note in passing that is the site of one of the pilots in the
Bidirectional Health Information Exchange, which I am proud to report
won an excellence dot gov award for departmental data sharing from
the American Council for Technology.
Our agencies, working together, is serving as a model for our nation
to demonstrate how the President's goals and Executive Order to
make electronic health records available to most Americans by 2014,
can be met. And I am honored to serve with Dr. Winkenwerder as a
commissioner on the American Health Information Community, which is
composed of eight private and public sector healthcare leaders.
In Charleston, VA and DoD are constructing a $40 million consolidated
medical clinic at Goose Creek in Berkeley County. VA's portion is
funded through our minor construction program. By joining forces, VA
and DoD have removed their need for separate ancillary and support
services and construction will start this fiscal year, anticipated to
wrap up in the Fall of 2008.
VA is pursuing collaborations with other healthcare providers, and
recently we, and the Medical University of South Carolina, conducted
a joint review to identify options for collaboration and sharing in
Charleston.
The structure used for that review provided useful information that
enabled us to identify viable sharing opportunities. The process
consisted of a steering group with representation of national and
local VA leaders and USC leadership and leadership from the
Department of Defense.
They reviewed data, including quality indicators of population
statistics, care volumes and costs.
Mr. Chairman, let me take this opportunity to thank you and
Chairman Brown, the Chair of the Health Subcommittee, for your
leadership in support of this endeavor. I would also like to thank
Dr. Ray Greenberg, the president of MUSC, for his exceptional work
and collaborative attitude which has greatly contributed to a
successful outcome.
An underlying process critical to the steering group's success was the
use of the cost effectiveness analysis. This provided insight into
both estimating initial capital costs and the potential savings and
life cycle operational costs. The group identifies some short-term
options for resource sharing that have already been initiated. I
have asked Mr. Moreland to provide you with an update on the status
of that activity in his remarks.
The model functioned so well in Charleston that I recently charged
the group to conduct a similar review in New Orleans, where the
tragedy Hurricane Katrina brought, made restoring in patient services
an urgent priority. It offered us an unusual opportunity for new
collaboration.
This group will study collaborative opportunities between the
New Orleans VA Medical Center and Louisiana State University. I was
honored to sign a memorandum of agreement with LSU two weeks ago to
evaluate possibilities to realize efficiencies through partnership.
VA's strong partner in this effort, Mr. Don Smithburg, executive vice
president of LSU and CEO of their healthcare services division,
provided outstanding support and leadership, and he and I look
forward to sharing the group's finding with you later this year.
Mr. Chairman, VA will continue to look for opportunities to leverage
our abilities to improve our ability to provide world-class care to
enroll veterans. Thank you for this opportunity to describe our
progress to you.
The Chairman. Thank you. Secretary Winkenwerder.
[The statement of Jonathan Perlin appears on p. 58]
STATEMENT OF WILLIAM WINKENWERDER, JR.
Dr. Winkenwerder. Thank you, Mr. Chairman. I appreciate the chance
to be here today and a chance to testify together with Dr. Perlin.
Let me also thank you for your leadership and for the other members
of the Committee for your interest and coaxing, persuading, cajoling,
the VA and DoD to continue to work thing. I think we have
established a good track record and I very much would like to see
that continue.
Having submitted our VA/DoD Joint Executive Council Annual Report for
Fiscal Year 2005, the accomplishments of the past year are fresh in
our minds. We continuously explore new avenues of partnership with
the VA through our Executive Council, the VA, DoD Executive Council,
and the associated work groups.
And just for everyone's benefit, this involves a meeting of
Dr. Perlin and myself and our staffs. We meet approximately every
two or three months, and it really is an excellent formal structure
and a great vehicle for both departments to jointly address issues,
set priorities and strategic goals, as well as to monitor the
implementation of these priorities and to ensure that people are accountable for executing what we're asking them to do.
As a companion to the annual report, the VA/DoD Joint Strategic Plan
for 2006 through 2008, was just published. This is a roadmap that
was recently reviewed and updated to incorporate lessons learned as
well as to set more concrete milestones and performance measures.
Resource sharing is a vital component of both organizations'
healthcare delivery systems. At the end of Fiscal Year 2005, VA and
DoD had 446 sharing agreements, covering nearly 2,300 services, and
136 VA medical centers reported reimbursable earnings during the year
as TRICARE Network providers. This is an increase of 59 percent over
the previous year.
My written testimony provides the details on a number of joint
facilities with regard to collaboration to improve access to care and
John has covered those well. I will say that I am in total agreement
that a great model for resource sharing is the first federal
healthcare facility, with a single management structure.
In October, I joined John and Deputy Secretary Mansfield and attended
a ceremony in Chicago to mark the creation of this innovative
initiative. The North Chicago Veterans' Affairs Medical Center and
Naval Hospital, Great Lakes, are going to integrate all clinical and
administrative services under one line of authority.
This is a new venture. It is a new way of doing business, but we
absolutely believe in it, and we believe that it takes constant
oversight to make sure that the people on the ground get the job
done.
Another example, and I agree with Dr. Perlin, is the opportunity for
the Keesler Air Force Base, VA, Biloxi, campus area with the fact
that our healthcare facilities in the area received damage and
there's an issue there with respect to how to go forward.
DoD and VA have established a joint task force to explore the
potential for a joint venture medical center. This task force has
identified several options for a significant partnering. We are
committed to moving forward within the next several weeks with the
best design for the beneficiaries of the region and for taxpayers.
DoD and Navy are also collaborating to finish the DoD/VA Joint
Ambulatory Care Center in Pensacola. This project represents one of
the largest joint collaborations to date and was made possible by a
land-use agreement that grew from the VA capital asset realignment
for enhanced -- or services or CARES decision to expand services in
the Florida panhandle.
The facility is currently under construction with a completion
expected in January 2008.
Another important collaboration is planned in South Carolina. As many
of you may know, the 1993 base realignment and closure BRAC action
significantly decreased the work load for the 500-bed naval hospital
in Charleston. Currently, this military treatment facility is a
hospital in name only. Inpatient services are performed at a nearby
civilian hospital.
But what we now have underway is a 35 million Fiscal Year 2006
construction project that includes approximately 164,000 gross square
feet of clinical space. The 4.4 million, that VA portion was funded
with, with their minor construction program, includes approximately
18,000 gross square feet. By joining forces, VA and DoD have removed
the need for a separate ancillary and support spaces.
Mr. Chairman, again, thank you for the opportunity to speak with you
today. DoD is committed to continued collaboration with the VA.
There are some other things that just in the interest of time, I will
not touch on, but I do want to mention in the area of health
information, the fact that we are now really picking up speed with
respect to moving clinical information, health information, on
separated service members to the VA, and we have moved 3.1 million
information on 3.1 million, unique patients to the VA electronically.
We are now moving pre and post employment health assessment
information and nearly half a million of those assessments have been
moved electronically. And, again, I endorse John's comments and the
Commission. We are really being looked upon as leaders in this whole
area of developing electronic, since we both have electronic health
records, as to how to share that information and to do in a seamless
and interoperable way.
We have got really smart people working on this. They are up to the
task, and so we are excited about that. With that, I will conclude
my remarks and look forward to any questions.
[The statement of William Winkenwerder appears on p. 63]
The Chairman. Let me pick up right where you just left off on IT.
We have some ways to go. Our staff had returned from Tampa at the
Polytrauma Center where they were pleased to see you have the
seamless transition of the electronic medical record. That is our
goal. It is going to take us some time to get that throughout the system.
Dr. Perlin, Chairman Walsh and I met with the Secretary this morning.
I want to thank you for your leadership on the IT. I know you are
being responsive to those in the field, are given tremendous push
back, and the Secretary was very complimentary towards you and wanted
me to appreciate what a difficult position those in the field are
also putting you in. He also wants me to trust you to do that which
is right.
I trust you to do that which is right, because I know you are coming
my way. You are coming the Committee's way. And so he told me about
the -- that you are all going to go off and you are going to do your
two-day -- I don't want what you want to call it -- summit or whatever
you are going to call this -- but the Senior Leadership Council is
going to sit down and you are going to work this thing through and
make the right judgments, and I believe that is going to happen.
We don't have to pound this anymore. You know the desires of this
Committee, and but we have got to see it through. There is a
cultural thing. We have to get through this barrier so we can begin
to work on these relationships between two major departments of
government.
So I am a good listener to the Secretary, and he was very
complimentary towards you, along with our CIO. And he does want to
see the two of you go to dinner. Okay?
Before I yield, I want to let the members know we are to have votes
around the 3:15 to 3:30. We will push that to probably about 3:40.
Secretary Winkenwerder, you have to leave about when?
Mr. Winkenwerder. Approximately 3:15 to 3:20.
The Chairman. All right. We will please try to accommodate the
members as much as we can. I'll tell you what. I will reserve my
questions, because I can have a pretty quick access to both you
gentlemen. Let me yield to Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. I have several questions for
Dr. Perlin. If I can, and I am going to focus specifically on the
report to reestablish a medical center in New Orleans.
Was Baton Rouge an expansion of the Baton Rouge CBOC considered
instead of, again, I am going back to the issue of the veterans that
evacuated and left and nobody can tell with certainty who is coming
back. There is significant discussion about accelerating CBOCs in
the outer region because of the increased need for medical care, but
it seems to me if you are increasing the size of the CBOCs for the
veterans that the assumption would be that they are going to stay;
and, therefore, if you rebuild a medical center in New Orleans, you
are overbuilding.
Or if you are sure that these veterans are going to go back to
New Orleans, then you are overbuilding CBOCs. And I am trying to
figure out which is it. And in the same question, if you could
answer for me the question of what consideration was given to
Baton Rouge in regards to expanding their sea bock and making it a
larger facility?
Dr. Perlin. Thank you, Mr. Miller. Those are absolutely excellent
questions. Let me just start by offering the comment that the
Baton Rouge Clinic is actually operating beyond its capacity in
addition to the expanded new CBOC that is there. We were able to
obtain a lease on our old CBOC and they are operating both.
It is clear, just as you have indicated, that some veterans from
New Orleans proper, from St. Bernard's Parish, and Orleans Parish,
have likely moved to the periphery of that area, and they are being
supported.
I think what is so compelling about the New Orleans situation is
whether or not those veterans actually returned to Orleans Parish and
St. Bernard Parish, I think what the data reveal, is that there is
need for a tertiary medical center in the region.
Your question of whether that should be located in New Orleans or
Baton Rouge is also an excellent one as to what would have the
greatest centrality to the population and where would the resources
be in place to support the tertiary care needs.
I think that it is fairly evident that there are longstanding and
very effective relationships with Louisiana State University and
Tulane University in terms of providing this sort of specialty
expertise and subspecialty care that make that aspect fairly self-evident.
In terms of the centrality, I think that there is also a good history
of referral patterns and catchment that shows that New Orleans is, in
fact, a good and central location. So both on the geographical test
and the resource test, it would meed the need and even absent the
population being fully restored in the two major parishes, it would
still meet the need in terms of population.
Mr. Miller. If there was never a New Orleans Medical Center, would
you be putting one there today?
Dr. Perlin. I think again I come back to the issue that --
Mr. Miller. No. The question is if there was not a New Orleans
Medical Center, would you build one there today?
Dr. Perlin. Yes, sir, we would.
Mr. Miller. Why?
Dr. Perlin. Because of the ability to affiliate and deliver
efficiencies --
Mr. Miller. Would Tulane and LSU be there if the VA Medical Center
had not been there?
Dr. Perlin. I would have to go back and research the history. I
think they predated us, though. So the answer is yes they would.
Mr. Miller. You are sure?
Dr. Perlin. Our building is 50 years old. I believe that they are
extant before us. But, Mr. Smithburg would be --
Mr. Miller. So we are doing this -- I am looking through the
memorandums between LSU and VA, and I am looking for, you know, where
the veteran gets the best, you know, deal without having to get in a
car and drive, you know, an inordinate amount of time. And I am not
seeing that. I am seeing a if we build it, maybe they will come back.
And, you know, I want you to convince me that the taxpayers of the
United States of America should spend $600 million, which is what I
understand is coming into the emergency supplemental, to rebuild a
medical facility in a declining population.
Dr. Perlin. Your question is absolutely a fair and appropriate one,
and in the central, southern market area, in fact, there are 377,000
veterans in total. And while it is true that under any scenario,
hurricane or not, there would be some decline.
There clearly is a population as well in that report. I am glad you
have had a chance to look at it. You will see that there are a
number of options, including not being actually close.
Part of the rationale for both VA, and I believe for Louisiana
State University, is the ability to share capital equipment and
reduce significantly the capital investments. Share infrastructure,
share staff, and actually get the taxpayers the best deal on location
that you fairly ask is appropriately close and accessible for veterans.
Mr. Miller. And I looked in the report, and you talked about two
independent towers, one for LSU, one for VA. The parking lot would
be shared and all the administrative areas, and I understand that.
But we are talking about healthcare for veterans and where the
veteran population is, and I find it difficult to understand why we
are forcing the issue of going back in with 600 million -- the
original request was 825 million -- but we are looking for 600
million now.
Thank goodness it appears that it will require authorization from
this Committee to be done. But I have a long list of questions that
I would like to submit for the record in regards to proof of the
numbers that are being used to support what is being requested. And
my time is out, and I yield back.
The Chairman. Chairman Miller, you may submit those questions for
the record, and please also recognize that Chairman Brown has the
responsibility for holding his Subcommittee hearing, along with
Mr. Michaud on the construction. So you are right. We will take up
these issues in further detail, but you have your right to ask any
questions you like and you may probe. Sir?
Mr. Miller. May I respond?
The Chairman. Yes.
Mr. Miller. Given the way appropriations are done at this current
time, in this Congress, it is nice to see that the appropriators
recognize that we have a role as authorizers of the money to be
spent. Ordinarily it would not happen that way. The appropriators
would appropriate the funds without it ever coming before this
Committee, and so I am saluting our Chairman for getting us back in
the loop.
The Chairman. Thank you. Mr. Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman. Dr. Perlin, the
CARES decision identified 156 new CBOCs by 2012. VA has not funded
the bulk of these CBOCs and it is related to some of the concerns
that Mr. Miller has.
How will VA keep these CBOCs a priority while pursuing a
collaborative effort with limited funds? Will the new collaboration
mean that the efforts to open up the needed CBOCs will be delayed?
Dr. Perlin. Thank you, Mr. Michaud, for that question. I think just
the opposite is apt to be true. If we can free up resources through
some effective synergies that fundamentally serve veterans, and let
me be very clear that we appreciate that the collaboration doing many
great things, but ultimately our first responsibility is veterans.
We are glad that all these sorts of collaborations will also serve
others, but those synergies will allow us to operate more efficiently
and provide resources for things such as CBOCs.
The other thing that I think is important in terms of the
affiliations is that as healthcare moves from the hospital to the
clinic, one of the sites for expansion of residency programs, an
appropriate site for training, something that improves service to
veterans, but also improves efficiency all around, is the
collaborative opportunities for training experience as in those
outpatient clinics as well.
Mr. Michaud. Thank you. Mr. Chairman, in essence of time, I
request permission to submit the remaining questions in writing.
The Chairman. Yes.
Mr. Michaud. For the record. Yes, without objection. You have that right.
Mr. Michaud. Thank you.
The Chairman. Chairman Brown, you are now recognized.
Mr. Brown of South Carolina. Mr. Chairman, thank you. Dr. Perlin,
overall, what lessons can be learned from the VA's experiences with
the joint venture proposal in Denver and in Charleston? And I know
we had some differences in the collaboration there.
Dr. Perlin. Well, thank you, Chairman Brown. I know that your
exceptionally familiar with the Charleston Model, and I think the
fact that is now called the Charleston Model is really testament to
it being both a documented process that captures the best of the
experience.
It really, I think, showed us how important it is to bring together
leadership at the very beginning to be able to discuss what the
particular needs of each entity are and understand operational
realities, capital realities, funds flow, service needs, in ways that
can potentially be synergistic.
I want to commend, again, not only Dr. Greenberg for his leadership
in that effort, but Mike Moreland on the next panel, who I think can
elaborate on what really now is, and should be a standard for
evaluation of potential collaborative opportunities.
It is a systematic ability to review finance, government, human
resources, and clinical services, and provide a cost effectiveness
analysis, not only to look at initial capital outlay, but how to
improve efficiencies.
Mr. Brown of South Carolina. Thank you. And, Mr. Chairman, one
further question. What are the advantages and disadvantages for VA
medical centers to enter into a sharing agreement to become TRICARE
providers? Is that something that we might work into --
The Chairman. Well, let me respond that I think there are
advantages. The common denominator among veterans is that they were
service members, and to the extent that we can work together, I
believe that we should be working together, and I appreciate the
great partnership that has been evidenced by DoD as a whole in the
person of Dr. Winkenwerder, and as he noted in his testimony, a 59
percent increase over the last year alone.
Dr. Winkenwerder. Congressman, I will also just add that certainly
from my perspective for the DoD entitled beneficiary population,
retirees, as well as active duty and their family, but retirees and
their family members, where there is a VA facility available, we
encourage that to be used as part of TRICARE Network.
We have contracts, and we have also sometime ago, one of the first
things we did was to set the payment rate so that it was equal
between the VA to the DoD or DoD to VA, and in the past we have had
problems with disputing, you know, who should get paid what. And we
said this is crazy. Let us just have one payment amount that we
agree to.
And that has, I think, helped, but we continue to encourage, from my
standpoint, you know, we have got fixed assets and our charge is how
to fully utilize those fixed assets. And frankly where we don't need
fixed assets, let us not build them. I mean that has been our approach.
We, of course, with the BRAC process, we are consolidating
Walter Reed in Bethesda. We are consolidating Brook Army in
Wilford Hall and we are closing ten other hospital inpatient
facilities. And in some of those locations, we will be looking to
the VA as a source for inpatient care. So that is our view of the
world, and we want to just keep pushing forward with that.
Mr. Brown of South Carolina. Well, thank you, Mr. Chairman. I know
it is real refreshing to have both of you at the table and certainly
with that cooperative effort, and thank you very much for both coming
in. Mr. Chairman, in the sake of time, I will just submit the rest
of my questions.
The Chairman. Thank you, Chairman Brown.
The Chairman. Mr. Reyes, you are now recognized.
Mr. Reyes. Thank you, Mr. Chairman. And I will have just a couple
of questions, and then have some questions for the record as well.
The first one is Dr. Winkenwerder, how will the Defense health
program funding be allocated to respond to the population shifts due
to BRAC in the armies overseas rebasing initiative? I am
particularly concerned about that because we are going to see growth
of between 21 to 24,000 new troops in our area.
Will funding for military construction to expand and build new
medical facilities be funded out of the existing DHP military
construction account, or will they be funded from the BRAC accounts?
Also have these projects such as the expansion of the Beaumont Army
Medical Center in El Paso, been included in the services' BRAC
military construction plans?
And then, secondly, can you please tell us how you and your staff are
working with the services, from my perspective especially the Army,
which will see major growth in several CONUS bases, to ensure that
medical services will be available for troops and for their families
when they arrive at their new duty stations?
Dr. Winkenwerder. Thank you, Congressman, for that question there.
The short and quick answer to where are the funds coming from is that
they are coming from the BRAC funding, the designated BRAC funding.
Some will be paid for with our ongoing military construction account
and some, as I understand it, John, would be through the Army
Modularity, would be sources of funds as well, so all three of
those.
But we clearly have a challenge in front of us, and we are thinking
actively right now as we look at the whole issue of BRAC and we are,
as you know, moving towards more joint operation of medical facilities.
And traditionally, these have all been funded through individual
service lines, but we are giving serious thought to if we are going
to have it jointly operated and staff facility, should we think about
a joint funding mechanism and oversight process to ensure that we
don't get undue competition between the services and that we ensure
that we expend these funds in the most efficient way. Sometimes
giving somebody an authority to do that, really helps arbitrate the
process. So we are doing that.
Your second question had to do with how to -- I am sorry?
Mr. Reyes. With working, especially with the Army, in terms of
addressing the growth in the bases to ensure medical services to
both the troops and their families when they actually arrive.
Dr. Winkenwerder. When they come back. Principally, we are looking
to the Army and to Surgeon General Kiley, Army Surgeon General, to
identify where there may be a need for more medical resources, be it
people or facilities, to handle the additional workload that we do
anticipate in certain places. Yours might be one of those locations
and at Fort John, New York, Fort Carson, there is a handful of locations.
But we will be prepared. We are not taking this off our radar screen
at all. But if there is more detail about that, that we might be
able to provide for you subsequently, we would be glad to do that.
Mr. Reyes. And I will have some additional questions, but I
appreciate the time, Mr. Chairman. I yield back. Thank you.
The Chairman. Thank you. Mr. Campbell.
Mr. Campbell. I have nothing.
The Chairman. Let me ask you a few questions here before we break
for our vote. I would like to address the Charleston Model for a
second, because what I am sensing is that our Collaborative
Opportunity Steering Group meets we have a great investment; we
have no idea where this is going to take us; we jump into these is
pretty exciting.
So when it is all done, you know, the three of us are standing
there, General Love and Mr. McClain and Dr. Perlin and I don't
remember which one of you turns and says we have broken a paradigm.
I don't remember which one of you said that.
And I have never forgotten it, because I was just as stunned, because
I had sensing, but it wasn’t even where I thought it was going to go,
and how it got defined was pretty exciting, and I could sense that in
the room, Dr. Greenberg.
My question is, though, where do we go from here? So we have this
Charleston Model, we have something we are sort of excited about, and
we talked about how it can be leveraged and before we can even define
it and proceed with it in Charleston, it then gets leveraged into
this idea with LSU, because of what has happened, and this is called
an opportunity.
And my gut is telling me that what we did in Charleston is we went
through the heavy lift, but there is still work yet to be done. And
so are we now getting ahead of ourselves? So where are we "on the
next phase" with regard to the Charleston Model? Dr. Perlin.
Dr. Perlin. Well, thank you, Mr. Chairman. And, you know, I think
if there is a completed product, initially, part is the model itself
for evaluation.
The Chairman. Yes.
Dr. Perlin. So let me put that aside and come back to Charleston
specifically. I think I may have used the term that this is a new
paradigm, and it really was a new lens, a new way of looking at
collaboration.
I am extremely excited about what it brought us in terms of
opportunity. Seven million dollars has been transferred to the
Charleston Medical Center, and they will, as quickly as the federal
processes allow, contract for the new services which will bring great
new technologies to both veterans and the citizens of the state.
The tomotherapy, a type of radiation therapy that is available
nowhere else in the state currently, will come to veterans and
citizens as result of this collaboration as will two angiography
suites. So I think the model of putting the capital investment there
and receiving reduced rates on services in return, is absolutely
fantastic. So the $7 million are already transmitted.
Now the assessment brought forward a number of different proposals.
Admittedly some were permutations of the others, particularly if you
remember the "A" group of models. I have concurred that the analysis
is effective. I have nothing to add to it in terms of believing that
I can out think the great work that the group did.
And I have submitted a forward to the Department's Capital Asset
Management board for prioritization among all of the construction
projects to capital investment activities in the Department that the
Secretary might consider.
The Chairman. My gut is also telling me we haven't defined criteria
on how and where to use such a model. I mean, I look across the
landscape out there, and say, okay, let us see. In Charleston, the
Medical University has a construction project that is on a time line.
Yes, we are able to provide quality services. When does the model
fall into that time line? That is an unknown.
We know we are constructing a new hospital in Orlando. We have one
in Las Vegas. We have one in Denver, and now we have this in
New Orleans. So these are very large construction projects.
We have not been in the building business since, what, '92, '93? So
it has been a while since we have been in the building business, and
we are about to get into the building business in a very large way.
So when we look at this, and we go, okay, in Orlando, the State of
Florida wants to build a medical university. So my gut is telling
me, try to move into that in close proximity, and when they can move
together it is a good thing.
I also learned then when I am out with Ms. Berkley in Nevada, that
the chancellor of UNLV wants to do a medical university. It is a
good thing, you know what I mean, to do that collaboration.
We didn't do so well in Denver with regard to these initiatives, but
it did give us the opportunities to progress because Dr. Greenberg
hired the same firm that was used in Denver, and we had the VA
working with Dr. Greenberg on matters we were able to work through in Colorado.
And now we have New Orleans. We have Mr. Miller dancing on the edge
there with regard to New Orleans, and it was about right to go
through the door of something very challenging. The President of the
United States has said that we are committed to help rebuild New Orleans.
And so now we have this task, and I understand the sensitivities. I
don't live in the Gulf region, such as Chairman Miller, but the
sensitivity is to trying to service veterans there and at the same
time, LSU has a challenge. They want to progress. They want to move
into the future. If we can do that in collaboration with them, and
define where it is going to be, I understand where we want to go.
Okay. I can embrace that, while I am also equally as sensitive to
Chairman Miller's concerns.
So now let me dance -- let me try to go in with Chairman Miller for a
second. Now we are going to do this with regard to New Orleans, and
we are closing Gulf Port and enhancing Biloxi. What are we doing
about having a joint facility with Keesler? I don't understand that.
Dr. Perlin. I am sorry. I am not sure I understand, because we are
doing a joint facility with --
The Chairman. Why? That is my question. Why? I mean the close
proximity of it, with only the available dollars -- I guess I don't
know what you mean by joint facility with Keesler.
Dr. Winkenwerder. What we mean is this, and I don't want to get to
far ahead of where the work group is, but the Air Force has a
hospital base at -- hospital -- at the Keesler base. It was
scheduled to become a clinic, originally with a BRAC process, rather
than a hospital, because of the level of utilization and the
relatively small population of people being served.
One of the thoughts is rather than to rebuild -- and it was
damaged -- significantly damaged in the storm. As I understand it --
and I visited the hospital -- I didn't visit the VA right after the
storm -- is that the VA facility is on higher ground, is very nearby.
Rather than our, again, trying to reconstitute and build and invest
heavily in a new hospital structure, we may want to consider using
the VA and partnering with the VA to use the VA for an inpatient
facility.
And even -- and then I don't know about the outpatient piece yet,
whether we build something alongside it or have it on the base or how
all it would work, but the point is it is an opportunity to think
freshly rather than both systems just going down their merry paths
to recapitalize and rebuild.
The Chairman. All right. Right before I yield to Mr. Baker of
Louisiana, Dr. Winkenwerder, I would like you to know this, that when
we went through the budgetary process last year, we learned in
greater detail how DoD was really cost-shifting dental into the VA.
And that was a great concern of mine and in the 14 years that I have
been here on Capitol Hill, I have never had a general officer be non-responsive.
Twice my staff put in phone calls to the Surgeon General of the Army,
General Kiley, and I have never been stiff armed before,but now once
in November and once in December, and I have never heard from him.
So let me tell you what that means. That means that he has invited
this Committee into his business, that is what it means.
So I have assigned the O&I Subcommittee to do an investigation on the
issue. So you can please take that message back to the Surgeon
General of the Army that we don't appreciate that type of -- well --
conduct.
This moment, let me yield to Mr. Baker.
Dr. Winkenwerder. Thank you. Mr. Chairman, if I might just respond
to that. I wasn't aware that there was a concern, and I do find it a
bit unusual that General Kiley wouldn't respond to you, not a bit.
It is -- I don't have an explanation for that.
The Chairman. The invitation has already been out there.
Dr. Winkenwerder. Yeah, but we will convey the information, and we
have been working together in the dental issue. To my knowledge, it
has been worked and worked out. So, but we will --
The Chairman. Well, if that in fact is true, I will find out, I have
never been stiff armed before, and that is really insulting.
Dr. Winkenwerder. Okay.
The Chairman. Mr. Baker.
Mr. Baker. Thank you, Mr. Chairman. In light of the votes pending,
I shall be brief. I understand also that LSU is scheduled to appear
at later time during the hearing today, and it would be appropriate
for me to speak further at that time.
But I would like to point out that with regard to resolution of
veterans' healthcare in the State, we are still at a very unsettled
time in our State. A housing resolution is pre-imminent of
importance. There have been literally hundreds of thousands of
people dislocated with not the ability to return as of this date and
likely for the foreseeable future.
Although I will be quick to point out that the dislocation is not
permanent, nor does it mean that individuals have left the State. It
is my hope that LSU and the necessary healthcare professionals and
the VA can work together cooperatively going forward, but I would not
want to arbitrarily forgo a load of bricks anywhere else right at the
moment.
Until appropriate professional assessment is made of the continuing
need within Louisiana, our recovery effort is likely to be decades
long. It looks as if the supplemental now pending is subject to some
controversy, and if we are unfortunate enough not to receive
additional assistance, it is going to be extremely important to have
every other federal agency cooperating with us to the maximum of
their legal authority.
So I wanted to just put a statement on the record that I don't have
the answer. I don't know what should be done today, but I don't have
access to anyone who can tell me. And I am going to await the
professional judgment of those to tell me what future needs may look
like and what it makes sense in the way of deployment of strategic
federal resources and certainly not to put people back in harms way
of a future storm. That would be the least level of responsibility
that would could exhibit.
So Mr. Chairman, I appreciate the courtesy of allowing me to make
this statement. I understand that LSU is to be heard later, and I
may revisit the subject at that time. Thank you, sir.
The Chairman. Thank you very much. Does anyone have any follow-up
questions with this panel?
[No response.]
The Chairman. If anyone has questions for the record, please submit
them. We are going to have six votes. Is it up right now?
We are going to have six votes. So this first panel is excused, and
I apologize to the second panel. Dr. Greenberg, when is your flight?
Dr. Greenberg. No problem, sir.
The Chairman. All right. We will stand in recess, and we will
return immediately after the sixth vote.
[Whereupon, at 3:15 p.m., the Committee recessed to reconvene at
4:30 p.m., the same day.]
The Chairman. The full Committee of the House Veterans' Affairs will
come to order. The second panel will please come forward, Please
take your seats at the witness table.
While the second panel moves forward, let me provide a brief
introduction of each of the panelists. Mr. Michael E. Moreland is
the director and chief executive officer of the VA Pittsburgh
Healthcare System. Mr. Moreland oversees the management of three
campuses with 692 operating beds, distributed among medicine,
surgery, psychiatry, immediate care, nursing home care, and domiciliary.
Dr. Ray Greenberg became the eighth president of the Medical
University of South Carolina and is the professor -- I didn't know
you were still teaching -- of biometry and epidemiology. I guess I
just didn't know that. I thought the whole admin kept you so busy,
but you are still in the classroom. Well -- not very often? That is
a nice title to have on the side. I don't mean to bust you publicly,
but congratulations.
We also have with us Mr. Donald Smithburg, who currently serves as
the chief executive officer of Louisiana State University, LSU,
Healthcare System Division, headquartered in Baton Rouge, responsible
for nine hospitals across Southern and South Central Louisiana. LSU
provides the vast majority of care to the uninsured and working poor
in the State of Louisiana.
Gentlemen, I want to thank you for making the trip here to
Washington, D.C., to testify before the Committee. May I also extend
an apology. Sometimes you get six votes in the middle of a Committee
hearing, and members, get all together, and then they scatter. We
had such good rhythm going, so hopefully some members will return.
What is most important is, that we are able to get this on the public
record. We can have a good discussion and I am pleased that Chairman
Brown is here.
Let me turn to the witnesses for the second panel and, Dr. Greenberg,
you are recognized for testimony.
STATEMENTS OF RAYMOND S. GREENBERG, M.D., PH.D., PRESIDENT, MEDICAL
UNIVERSITY OF SOUTH CAROLINA; ACCOMPANIED BY JOSEPH G. REVES, M.D.,
VICE PRESIDENT FOR MEDICAL AFFAIRS AND DEAN, COLLEGE OF MEDICINE,
MEDICAL UNIVERSITY OF SOUTH CAROLINA; MICHAEL MORELAND, MSW, CHE,
DIRECTOR AND CHIEF EXECUTIVE OFFICER, VA PITTSBURGH HEALTHCARE SYSTEM,
DEPARTMENT OF VETERANS' AFFAIRS; AND DONALD R. SMITHBURG, EXECUTIVE
VICE PRESIDENT AND CHIEF EXECUTIVE OFFICER, LOUISIANA STATE
UNIVERSITY HEALTH SCIENCE, CENTER HEALTHCARE SERVICES DIVISION
STATEMENT OF RAYMOND S. GREENBERG
Dr. Greenberg. Mr. Chairman, Chairman Brown, Members of the
Committee, it is a privilege to appear before you this afternoon on
behalf of the Medical University of South Carolina. The message that
I wish to convey to you is that we greatly value our work in
relationship with the Department of Veterans' Affairs, and we look
forward to the opportunity to expand that relationship.
As we explore opportunities to build on our already existing
collaboration, we are driven by one primary motivation and that is to
improve the care of the veteran population that we and the Veterans'
Affairs serve.
Let me be clear here. Veterans in the Charleston area today in my
opinion get absolutely excellent medical care. So why then if things
are going so well would be motivated to make any changes.
To me there are really two fundamental reasons for this.
The first is that hospital care is becoming increasingly complicated,
in part because today only the sickest patients are admitted to
hospitals. And secondly the technology that is used to care for
these patients has grown evermore complex and expensive.
Personnel shortages and expensive technology drive up the costs of
healthcare, and you as legislators and we as healthcare providers
have a shared mutual interest in assuring that healthcare delivery
operates as efficiently as possible.
So how then can we be more cost effective?
As Mr. Moreland is going to describe in more detail in his testimony,
one of the most attractive opportunities for us is to avoid
redundancy in building and operating separate expensive highly
specialized diagnostic and treatment equipment and facilities.
By sharing resources, we can save an avoid duplicative capital
investments. This type of partnership has been undertaken
successfully by the Department of Veterans' Affairs elsewhere on a
somewhat limited basis. What we are proposing is to build upon
those successes by expanding the level of collaboration and we are
prepared to be an immediate test case.
The opportunity to take our working relationship to a higher level
was created by the Medical University's decision to replace its
50-year-old teaching hospital. The site for the new hospital,
presently in the first phase of construction, is immediately adjacent
to the VA Medical Center.
In the 2004 CARES study, a replacement VA medical center was not
proposed in Charleston, but a specific recommendation was made to
explore enhanced collaborations with the Medical University.
In August of 2005, Under Secretary for Health of the Department of
Veterans' Affairs, Under Secretary Perlin, cited the recommendations
of the CARES report and charged representatives of the Department of
Veterans' Affairs and the Medical University, and I am quoting here,
to determine what if any mutually beneficial consolidation should
occur between the Charleston VA Medical Center and MUSC.
A working group was formed to study that. I was privileged to
co-chair it with Mr. Moreland, the director of the VA Pittsburgh
Healthcare System. With your indulgence, Mr. Chairman, I would like
to take this opportunity to thank Mr. Moreland and his colleagues
from the Department of Veterans' Affairs for the diligence that
they approached this assignment with.
By December of this past year, a final report was prepared which
summarized our findings. With your permission, I would like to
submit a copy of that report which I have with me for the record
today.
The Chairman. Hearing no objections, so ordered.
Dr. Greenberg. The steering Committee focused on --
The Chairman. Will the gentleman pause for just a moment. This is a
pretty long document, right?
Dr. Greenberg. It is about 40, 50 pages.
The Chairman. So if you would revise your request, if you would make
this submitted for part of the written record of today -- no, that
won't do it either.
All right. Let us do this. I would ask unanimous consent that this
be made -- that your proffer be made part of the official record, but
not part of the published record. Would that --
Dr. Greenberg. That would be perfect.
The Chairman. All right. Hearing no objections, so ordered.
Dr. Greenberg. The steering group focused on collaborative efforts
that would increase the quality of services, lower overall facility
and operating costs an ensure optimal use of the land resources.
It was agreed that any model of integration would be essential -- it
would be essential for the VA to have its own bed tower, including
general medical and surgical ICU beds. This facility would be
clearly identified and designated as the VA Medical Center. Veterans
would be housed with other veterans and would not be intermingled
with other patients.
Staffing on these wards would continue to be provided by VA
personnel. All of these were issues that were expressed to us as
important by the Veteran service organizations and the employees of
the VA Medical Center.
The opportunities for sharing come in the various support areas and
in particular the expensive technology intensive areas such as
operating rooms and cardiac catheterization labs. In scheduling the
use of these resources, veterans would be given the same or higher
priority as non-veteran patients.
By sharing these resources, both the VA Medical Center and MUSC could
lower their operating costs. In the process, we could also assure
that the latest technology is available to both patient populations
and in particular that local veterans would not have to travel great
distances to get these same specialized services.
With agreement to this basic concept, we then explored several models
of sharing, and at the risk of oversimplification, let me say that
these models differed with respect to the size and contents of the
facility to be built by the VA Medical Center.
A very interesting observation that came out of this was that despite
initial significant differences in construction costs for the various
models, if you looked over the 30-year life cycle costs, there were
really very modest differences between them.
For example, if you took the most extensive model and then you
compared that to not replacing the VA Medical Center at all, over 30
years of life-cycle costs, it was only about a 10 percent
differential. In other words, for a premium of about 10 percent,
veterans could receive care in a brand-new state-of-the-art facility
as opposed to one that is today 40 years old, and by the time of that
30-year period, it would be 70 years old.
There was further good work that came out of the evaluation, in that
the group focused on governance issues concluded that we could create
an advisory structure for sharing opportunities without undermining
any of the existing authorities of either the VA or the MUSC
executive leadership teams.
And the work group on legal matters concluded that all of the
necessary authorities required for both construction and contracting
already are well-established so there should not be a requirement for
any additional statutory changes.
In choosing between the various models, at least two important
considerations surfaced. First there is the very pragmatic question
of the amount of money the Federal Government can afford to invest in
constructing a new VA medical center facility. This is a resource
allocation question that clearly went beyond the scope of our
assignment as a steering group.
The second key issue that arose during our evaluation was whether
VA facilities would be required to be built to the new federal
guidelines for homeland security. These guidelines while
understandable and defensible for safety purposes, raise construction
costs an estimated 30 percent.
Thus, it would be more expensive for the VA medical center to build
shared space than for an outside entity to do so.
For the purposes of our analysis, we assumed that the safety
standards would have to be met. If it turns out that those
guidelines are not required, our estimates of VA medical center
construction costs can be revised downwards by about 30 percent.
A related issue is the fact that the existing VA medical center is in
a flood zone, and as it was designed more than four decades ago, it
is vulnerable to a major hurricane. While we are about to hear about
the situation in Hurricane Katrina, it seems particular prudent at
this time, to make sure that similar disasters don't occur to other
VA medical center facilities that are in hurricane areas.
If the Committee and the Department of Veterans' Affairs find favor
in our recommendations, there clearly is further work that needs to
be done. We need to move from the macro level of the initial
evaluation that has been completed to the micro level of really
focusing on operational issues.
Our suggestion is that we formalize an initiative as a demonstration
project. We appoint a working group to develop an implementation
plan and we allocate appropriate resources for that effort.
Mr. Chairman, thank you very much for your time.
The Chairman. Mr. Moreland, you are now recognized.
STATEMENT OF MICHAEL MORELAND
Mr. Moreland. Thank you, Mr. Chairman and Members of the Committee
for this opportunity to testify on the important topic of improving
veterans' access to care through collaborations.
In my experience as the director of the VA Pittsburgh Healthcare
System and at other facilities, I have participated in a number of
positive collaborations. I also am familiar with a variety of
collaborations that have worked well for my VA colleagues.
Today I will share a few examples and provide an overview of the
collaborative study that I was privileged to co-chair with
Dr. Greenberg, and I, too, congratulate Dr. Greenberg for such
wonderful staff and the great work we did together. But I will go
ahead and talk a little bit about that and the potential sharing
opportunities between the Charleston VA and the Medical University of
South Carolina.
First I want to outline in general terms the process I have used to
determine whether particular collaborations were likely to in the
best interest of veterans. For a collaboration opportunity to be
considered favorably, it should increase veterans' access, improve
quality through service enhancements and provide VA with improved
efficiency.
As one would expect, if two organizations can share a capital expense
rather than duplicating it, they will save money on equipment and
buildings. Those funds can then be used to enhance services. When
deciding whether to consider sharing a given resource, we first
determine the cost providing that service independently. Then costs
are developed for joint delivery of that service.
For a collaboration to be considered a good sharing opportunity for
VA, it must be more efficient for VA to deliver that service in
collaboration with another entity, or the sharing might provide an
enhancement to care that VA could not offer independently.
The quality of the service delivered has to be as good or better than
what is currently provided. The best sharing opportunities improve
services while saving cost. To make these comparisons, data relating
to demand and capacity for particular types of care, trends in the
quality of service delivery and cost information are reviewed.
A good example of a sound collaboration is the Charleston VAMC and
MUSC planned sharing of high tech equipment. Veterans and patients
of MUSC will have access to care enhancement and the cost of each
organization will be improved by sharing the equipment and the expense.
The type of sharing arrangement used in this case allows the VA to
make a capital investment up-front that is then recouped through
revenue that supports operating expenses for several years.
In Pittsburgh, VA collaborated with the Commonwealth of Pennsylvania
in providing long-term care to the State's veterans. VA provided the
State with land on the grounds of the Pittsburgh Healthcare System
and a grant for the construction of a long-term care facility. The
State, under a sharing agreement, purchased services from VA to
assist in the operation of that facility. This facility offers
several levels of care that are in great demand in Allegheny County
with this large population of aging veterans.
The Buffalo VAMC contributed $250,000 toward the purchase of a new
PET Scanner for University Nuclear Medicine, Inc. VA's purchasing
power resulted in a lower price. The University Group operates the
scanner and VA purchases services at a negotiated reduced rate.
Again, the community and its veterans benefit from additional
services and both organizations reduce cost.
I completed a similar arrangement while I was the director of the
Butler VA, in which VA purchased a CT scanner that was installed in
and operated by the community hospital. VA then received access to
very low cost CT services for veterans and the community benefitted
through the availability of high tech equipment that local
facility -- that that local facility could not readily afford.
In all of these arrangements, there are numerous legal and technical
details that require careful planning. In each instance, the
arrangements are a good financial deal for veterans. For funds that
are saved through these collaborations support other service
enhancements. Savings like these assist us in maintaining and
enhancing care in an era of bourgeoning demand for VA care and
continually escalating healthcare cost.
On occasion, I have been presented with opportunities for
collaboration that were presented as good deals for the VA. However,
financial analysis revealed the proposals to either increase
operating expenses over current expenses or to require up-front
financial outlays without a reasonable return on investment. While
this may seem obvious, it is important to note that any prospective
collaboration must be considered on its own financial merit.
The Collaborative Opportunity Steering Group that developed sharing
options for the VAMC in Charleston and MUSC presented an opportunity
to consider taking this type of sharing to a much broader level.
This Group developed options for joint construction, as Dr. Greenberg
described, of new facilities that would maintain both organizations'
identities and independent mission while sharing some of the enormous
cost burden associated with replacing aging healthcare facilities.
The Group was able to identify viable models for such construction.
By sharing some of the higher cost infrastructure, both VA and the
University could reduce the investment required to build and operate
new facilities.
As I mentioned earlier, this Group identified opportunities to
collaborate in the purchase of high-tech equipment that will make new
state-of-the-art services available to veterans and other residents
of South Carolina that might not otherwise be feasible for either
organization to provide independently. The successful experience VA
has had in this type of sharing at other facilities enabled this
Group to recognize this opportunity in Charleston.
The plan for equipment sharing in Charleston is in the process of
being implemented. I believe Dr. Perlin mentioned $7 million in
equipment funds have already been transferred to the VA in
Charleston. Draft documents are being prepared to complete this
process.
Collaborative opportunities abound as private and public sector
facilities across the nation are seeking to upgrade aging
infrastructure and bring state-of-the-art care to their communities.
With thoughtful planning, these collaborations can be mutually
advantageous and provide VA with opportunities to assure that
veterans have access to the latest technology at a more efficient
cost. Thank you, Mr. Chairman.
The Chairman. Thank you very much. Mr. Smithburg, you are now
recognized.
[The statement of Michael Moreland appears on p. 78]
STATEMENT OF DONALD R. SMITHBURG
Mr. Smithburg. Thank you, Mr. Chairman. I am Don Smithburg, CEO of
the LSU Hospitals and Clinic System in Louisiana. I thank you for
your interest in healthcare in Louisiana after Katrina and Rita in
particular.
I also thank you for the invitation to appear today and the
opportunity to answer any questions you may have about Louisiana
State Public Hospital System, especially as a potential partner with
the Depatrtment of Veterans' Affairs in New Orleans.
I represent nine of the eleven State public hospitals and over 300
clinics that traditionally have been called the Charity Hospital
System in Louisiana. I would like to briefly describe that for you.
Our hospitals and their clinics constitute the healthcare safety net
for the State's uninsured and under-insured, particularly the working
uninsured. Fully two-thirds of our patients are hard-working Americans.
In your States, this role is generally a local government function,
but in Louisiana it is the responsibility of a State-run and
Statewide hospital and clinic referral system, under the aegis of
Louisiana State University, LSU.
This system has been in place for 270 years.
The LSU hospitals also have had an integral role in supporting the
education programs of our medical schools and training institutions
for generations, and that includes not only LSU, but also Tulane
University and the Ochsner Clinic Foundation.
Our system flagship is in New Orleans and commonly is known as Big
Charity, which is actually two hospitals, Charity and University,
operated under one medical center umbrella. Big Charity has been in
operation since 1736, making it the second longest continuously
operating hospital in the United States.
At our New Orleans facility alone, there were over 1,000 Tulane and
LSU medical students and medical residents in training and many more
nursing and allied health students, plus thousands of staff when
Katrina struck and then her floods devastated our institution. Some
of these very same students and faculty had rotations at the VA
Hospital in New Orleans as well.
As a flagship of our Statewide system, Charity Hospital sits just a
stone's throw from the VA Hospital. Big Charity operated the only
level-one trauma center that served South Louisiana and much of the
Gulf Coast.
Today these facilities sit in ruins. Charity Hospital has been
deemed uninhabitable and unsalvageable for healthcare by consulting
engineers. And a somewhat younger University Hospital that we
operate -- it is only 35 years old -- although severely damaged and
not viable in the long term, will be temporarily propped up as an
interim solution toward New Orleans' critical need for health services.
And we are seeing our patient population grow steadily every day, up
to 300 patients a day that we are seeing in tents; a series of ten
tents currently operating in the convention center, which are about
to be relocated to an abandoned department store.
Time does not allow me to go into detail about what we are seeing in
terms of the population change and demographic nature of our
community, but I can tell you that a replacement hospital is
absolutely critical.
We see the potential collaboration with Veterans' Affairs and
Louisiana State Public Hospital System as one propelled by
unintended opportunity. With both systems' hospitals in New Orleans
devastated by Katrina and her floods, we stand at a rare moment in
time, a chance to jointly design and cooperatively operate a new
facility that meets the needs of both institutions and the patients
they serve while at the same time achieving significantly enhanced
efficiency, cost savings, and quality healthcare.
The integrated structure and vision of the VA system has permitted it
to become a leader in the development and use of electronic records.
You know this. It has made tremendous progress in this and other
areas in the last decade. Electronic medical records also are a high
priority for LSU, although we are not as far along as the VA. In
fact, in my view, the VA is more advanced in information technology
than most in the healthcare industry.
The collaboration of the VA and LSU in the narrowest view offers the
opportunity to solve the immediate facility problem of the two
systems in New Orleans, but it is also an enlightened and visionary
step that will create a major asset for rebuilding community and a
base from which to better serve the patients who depend on us.
Governor Blanco and our legislative leaders from both sides of the
aisle, have recognized and embraced the benefits of collaboration
with the VA. The media has extolled the virtues of this potential
collaborative, despite so much coverage about what has gone wrong in
dealing with the hurricane zone. Thoughtful editorials have
applauded this effort as a real diamond in the rough.
We welcome involvement from other allies and together we can take
advantage of an historic opportunity to improve care for those we
serve and at the same time help to rebuild a major American city.
Thank you, again, for your interest for this opportunity to share
LSU's perspective on this critical matter.
The Chairman. All right. Thank you very much. I want to get this
right in my mind. We, on the Committee, are moving in this sort of
trend, from the collaboration with personnel and equipment, and then
to facilities, with university hospitals.
So my sense here is, that this is not all really defined that well at
the moment. So you have a university hospital in New Orleans,
correct? You have University Hospital and you have Charity?
Mr. Smithburg. They are both one institution with two names -- there
are two buildings with distinct names, but they are one medical
center that serve as an academic medical center. One happens to be
called University Hospital, but they are both the primary teaching
hospitals for LSU and Tulane.
The Chairman. All right. You know, we kind of have this also in
Indianapolis. We have the University Hospital next to our VA, and we
have Wishard, and Wishard is sort of the safety-net hospital.
Mr. Smithburg. Mr. Chairman, we are both.
The Chairman. But your Charity Hospital is also run -- is owned by
the State of Louisiana.
Mr. Smithburg. The Charity Hospital and University Hospital are, for
all intents and purposes, one and the same.
The Chairman. Oh. You can't answer like that.
Mr. Smithburg. Well --
The Chairman. Tell me what the legal standing is.
Mr. Smithburg. The legal standing is that they are both one Medicare
provider number which identifies the institution. They are both
entities of LSU, which is an instrumentality of State Government.
The Chairman. All right. There we go.
Mr. Smithburg. They are both, via contracts, teaching hospitals for
LSU School of Medicine, dentistry, nursing, allied health, and their
counterpart is at Tulane. All of the primary training programs of
those institutions go through Charity. There is one management
team. The CEO of what we call the medical center of Louisiana,
New Orleans, is Charity University Hospitals. It is one medical
center, has one management team that reports to me.
The Chairman. Well, I don't want there to be confusion out there
across the country in different cities either. If we are going to do
collaboration and we do it with medical universities, we want to make
sure that -- are you going to change the names on any of these things?
Mr. Smithburg. We are certainly open to that, sir.
The Chairman. You are open to it. Great. I just want to make sure
that our collaboration -- I mean if we are going to do our
collaborations with university hospitals, I don't want some other
city to go, well, you know, I still have got my non-for-profit over
here, and why can't -- I don't want to do that.
We can get away --
Mr. Smithburg. Could I try to --
The Chairman. Our trend line here is, is we do collaborations with
agencies of Federal Government, which isn't as easy as I just said
it. It amazes me. But it should be a lot easier, right? So then we
say you know what? There should not be anything wrong with a
relationship between the Federal Government and State Government with
regard to facilities.
But I don't want to send the wrong message out there in the country
that we are going to do a collaborative effort with Charity
Hospital. Names are pretty doggone important. I just want to let
you know. I would love to make sure that we label and title this as
a collaborative effort between the VA and the University Hospital at LSU.
Mr. Smithburg. I can tell you right now, Mr. Chairman, the MOU that
the VA signed with us --
The Chairman. Yes.
Mr. Smithburg. -- is with LSU Healthcare Services Division. It is
with LSU.
The Chairman. All right.
Mr. Smithburg. And that will be the arrangement going forward.
The Chairman. Thank you. All right. You just put me at rest. I
appreciate that.
Mr. Smithburg. Sorry for the confusion.
The Chairman. No, no, no. That is all right. And your present
University Hospital you are going to utilize -- you can't go back
into Charity? That's correct?
Mr. Smithburg. Correct. Yes, sir.
The Chairman. And why can you utilize part of the University Hospital?
Mr. Smithburg. Well, it was not our first choice. There are very
few physical assets that can be used for healthcare purposes in the
market right now. We are leasing a building from another institution
that was not badly flooded to prop up a temporary trauma center. It
is actually not even in the City of New Orleans.
And then we searched and searched to see if there was another
building we could lease, renovate, with FEMA's help and prop up as a
temporary hospital until we got a permanent replacement.
Such assets were not available to us, and so our last ditch effort
was to look within our own asset base and see what it would take and
FEMA has helped us figure out what it would take to temporarily use
one of our buildings which is called University Hospital to provide
about 200 beds.
The jury is still out as to whether we can really do it, but FEMA has
approved a work order to try to make that happen, and it will take
some doing, and it will probably cost tens, if not, over a hundred
million dollars just to temporarily prop it up.
The Chairman. Mr. Moreland, let me go back to this. I come to see
you as one of the more forward thinkers in the Department, and I am
thankful for your involvement in working with Dr. Greenberg and
having spoken with Dr. Greenberg. His feelings, I think, reflect
mine about you.
Given Dr. Greenberg's testimony, he says our suggestion is to
formalize this initiative as a demonstration project and appoint a
working group, to develop an implementation plan and allocate
resources to that effort. The word "our" -- let me hit both of you
here -- the word "our," Dr. Greenberg, means who? Does that mean you
and Mr. Moreland or does "our" mean you at the university?
Dr. Greenberg. Mr. Moreland and I agree on many things, but I am
speaking only for myself in that instance. "Our," I am speaking on
behalf of the University.
The Chairman. Okay. Now, Mr. Moreland, let me ask for your counsel
with regard to Dr. Greenberg's suggestion.
Mr. Moreland. My understanding of the project and where it sits at
this moment, is the report that we, Dr. Greenberg and I, submitted,
has been reviewed by Dr. Perlin, and it has now been forwarded up the
chain to the Secretary's Capital Asset Board. My understanding is,
is that that board will then review that and they will propose further
action. And so that is where I understand the process to be.
The Chairman. You know, we have got ourselves in this situation,
Dr. Greenberg, where you and Mr. Moreland, are working on a
particular project, and are you about to be overtaken. And I look at
this, as your work product is of tremendous value because you have
front-loaded an ambition with regard to New Orleans.
But your work is not done, and as we take your work to a second
stage, that continues to be helpful to us also in New Orleans, as we
also then get judgment on what actions to take in Charleston. So,
you know, someone made a comment one time saying, well, Charleston
wasn't in CARES on hospital priorities. I don't think that is
completely accurate at all.
You are right. Charleston was mentioned in CARES to do this
collaborative effort, to do the investigation, and now this is what
it is showing us to do. So when I look out there in the horizon of
the hospitals that we need to build, there are five of them. And
they are Las Vegas and Denver, and Charleston, Orlando and
New Orleans. Those are the five that are in front of us. That is a
very large dollar figure to do this, and so the Committee wants to
make the best judgment in the interest of veterans.
The challenge here is how we step into the next phase, and continue
your work. The question is what time line does it strike that
benefits your construction time line in Charleston? That is a
challenge, Dr. Greenberg.
Dr. Greenberg. Yes, it is, Mr. Chairman, and I guess I would start
by saying to me the development in New Orleans with respect to LSU
is both good news and bad news. I mean the good news is that already
the Department of Veterans' Affairs and another academic medical
center have recognized the value of the partnership that we have begun to develop.
So we have talked about this as a national model. Today was the
first day I heard it really described as the Charleston Model, but we
have always thought of this as a test case for replication elsewhere.
And the fact that it is so quickly, the ink is hardly dry on our
December report and it is already being proposed elsewhere, to me
suggests the obvious value and benefit of it. I mean it is already
being emulated. We don't have to wait for years for somebody to
emulate it.
On the other hand, I think your point is extremely well taken that we
are only the first step or two into a multi-step process, and it
would be discouraging to me if we didn't take further steps down that
implementation process. And that is complicated by the fact that we
are in the process of building a replacement hospital right now that
will be -- the first phase of which will be completed within a year.
This opportunity is really in the second phase, which we would like
to undertake in about three or four years, begin the construction of
that. So the longer the delay, the less likely that we could
actually do a project on the time line that would make sense both for
the Department and for the medical university. To me that would be
an opportunity lost, because I think the ideal thing is to bring the
time lines as close to mutual interest as possible.
The Chairman. Well, Mr. Smithburg should say "thank you" to you,
because actually you are designing the blueprint for what could
happen in New Orleans. So what we kind of have here is that it is in
your interest to continue to do the lift for which you do not receive
the immediate benefit. It is kind of weird, isn't it? You know what
I mean?
But what you are doing is right, because you are developing the model
to be leveraged, but you don't get to be first.
Dr. Greenberg. Right.
The Chairman. I know you would like that. But there is an immediate
need right now and a national focus in New Orleans. That is the
reality I think that is in front of us. I mean wouldn't you agree to
that?
Dr. Greenberg. Absolutely. I think ever leader of every academic
medical center in the United States would say that our colleagues in
New Orleans deserve every consideration. I mean especially those of
us who live in an area that has been severely hit by hurricanes in
the past. And so we know what damage can result. We have tremendous
empathy for our colleagues in New Orleans and if there is any part of
the country that deserves special consideration right now, it
certainly is New Orleans.
The Chairman. You know, Mr. Moreland, Dr. Greenberg, what you do here
is you design it. You build the model. You do the blueprint, and
LSU, guess what? You get to go first. My benefit comes from any
mistakes that you make.
I mean you are going to get some benefit out of this, but there are
going to be some challenges. Ten thousand decisions to be made. You
hope for the best, right, and there is a great learning curve that we
are going to have through it. Right? Don't you agree, that is kind
of where we are going here? I want to talk this through.
Mr. Moreland. Well, I can only share with you that in setting up the
Collaborative Opportunity Steering Group in New Orleans, I have
already in my discussions with Mr. Smithburg, we have identified
some adjustments and minor modifications to the process from things
that Dr. Greenberg and I learned in the first process. So I do think
that, you know, some of the lessons that we learned in that process
will transition to make the next review even better.
Mr. Smithburg. I would submit to you, Mr. Chairman, that about the
last thing I would want to have happen is for our potential endeavor
to supplant slow or erode the progress in Charleston. Unfortunately
Mother Nature kind of didn't pick her timing and so regrettably the
New Orleans VA and the LSU System is out on the street.
But I think at the same time, because we are forced to be in a fast
track situation, that hopefully that while we are going to take a
number of pages out of Dr. Greenberg's play book, we may help write a
few for him as well along the trail, and we will have --
The Chairman. All right. So let me do it like this. So I am trying
to figure this out. Mr. Moreland, you are intimately involved in both?
Mr. Moreland. Yes, Mr. Chairman, I have been provided the wonderful
opportunity of being the chair of both --
The Chairman. I am proud of you.
Mr. Moreland. -- collaborative opportunities.
The Chairman. I am proud of you.
Mr. Moreland. Yes, sir.
The Chairman. Now you have your work you have done in Charleston.
Charleston is getting a little impatient. They want to go to the
next phase. They want to proceed on. You have New Orleans going on
over here. What is the best way to proceed?
Are we really going to say we take your work product that you have
from the Steering Group, the Charleston Model, now you take that over
to the LSU model, and the second phase we are talking about, where do
we need to go next to drill it down from macro to micro? LSU perhaps
could go first, is that what we need to drill it down with them as
opposed to drilling it down with Dr. Greenberg? I am trying to
figure out methodology here.
Mr. Moreland. Yeah.
The Chairman. Have you thought about that?
Mr. Moreland. I am not sure I can answer that question today. I
think that is an excellent question, and, you know, I am not sure --
The Chairman. Because his is on the fast track.
Mr. Moreland. Right. And I am not sure that one necessarily has to
delay consideration of the next phases in Charleston while we are
doing the evaluation in Louisiana. The funding issue is outside of
my purview, you know?
The Chairman. I understand.
Mr. Moreland. My issue is to go down to New Orleans and get this
first step in New Orleans started, and then I will certainly do that.
The Chairman. So with regard to Dr. Greenberg's suggestion then, to
formalize the initiative as a demonstration project, to appoint a
working group that drills down into the next phase is what you are
talking about, right, Dr. Greenberg?
Dr. Greenberg. Yes.
The Chairman. Is that what you mean by this?
Dr. Greenberg. Yes, sir.
The Chairman. To develop the implementation plan. So, Mr. Moreland,
do you concur, that we can do that while you are also then drilling,
because you are replicating.
Mr. Moreland. What I am suggesting is, is that the Charleston project
has been sent to the Secretary's Construction Advisory Board.
Depending on what happens at the end of that process, what
Dr. Greenberg proposes may be very appropriate to proceed independent
of New Orleans. But that depends on what happens at the Secretary's
CAB.
The Chairman. Well, I want you to help us here. I mean you are in a
very unique position. You are going to give counsel to this
Committee. You give counsel to the Secretary. You are sitting in
the hot seat between Charleston and New Orleans. New Orleans has the
priority in the country and they are two of five to be built. So I
am going to drill this down.
Your counsel to us would be that this Committee should embrace the
suggestion of Dr. Greenberg as we continue to the focus on
New Orleans. If I have missspoken, correct me.
Mr. Moreland. I would say that the Committee report that we provided
to the Under Secretary has been forwarded to the Secretary --
The Chairman. Oh, no, no, no.
Mr. Moreland. And they need to provide their -- I am not really in a
position to recommend what happens with Dr. Greenberg's proposal,
because that is really outside of my scope. What I am focused very
much on is evaluating opportunities for collaboration and putting
that discussion together so we can then move that analysis forward.
The Chairman. All right. I know you don't want to get out of your
lane. Your testimony, though, to us is that it is possible to do
both of these at the same time, right?
Mr. Moreland. Yes.
The Chairman. Okay. I have no interest of getting you in trouble.
You are in a really unique position here for counsel.
Mr. Moreland. Yeah.
The Chairman. But I can read between the lines. Okay? Let me yield
to Chairman Brown, for questions he may have.
Mr. Brown of South Carolina. Mr. Chairman, let me apologize first to
the panel. We have a bill on the floor. This is close to my heart,
and I had to go make testimony there, and I apologize for not having
the complete dialogue, but I really do appreciate you coming and
being a part of the first panel. You had privy to that, that
dialogue, too, and, Mr. Chairman, I know that you have asked some
good leading questions, and I don't want to go into part of
duplicating those questions, but I know that I just would like to
thank the whole group for working.
And, Dr. Greenberg, I don't know whether anybody has asked this
question or not, but which model include in the final report as
MUSC identified as being the most viable?
Dr. Greenberg. Chairman Brown, I think they are all viable in a
sense. I think it is very difficult for someone sitting outside of
the appropriation process to ask the question what is a reasonable
investment to make because there clearly are resource differences.
I think when one makes that appropriation decision, I hope the
focus -- inevitably I understand the political realities of having to
look at how much is spent in a particular year. But the reality is
what I learned in this process, and I would not have guessed till we
got into the analysis is that if you look over the long haul, the
cost differential is really relatively minor between these, and so I
would hate for that to be the deciding factor between them.
Personally, I think that the model, I think it is described as A-1,
in which the VA builds its bed tower, plus the shared resources, and
the medical university builds its separate bed tower, probably is the
most logical way to proceed as long as you can coordinate the construction.
But I do think a significant open question at the moment is what
security standards the VA facility will have to be built to because
the estimate, and it is only an estimate at this point, because no
facility has yet been built to those standards, is that it will
inflate the cost about 30 percent, and so that would shift you
towards having another party build that shared component and save
the differential in cost.
So I think that question does need to be answered and I realize that
there are other considerations involved in answering that question.
But it is hard to give a final answer without knowing.
Mr. Brown of South Carolina. I know this past Friday I met with the
City of Charleston, concerned about just normal flooding when there
is high tide and, you know, abnormal -- little abnormal -- rainfall,
and I know that the VA Hospital is actually sitting in the middle of
that, you know, that problem. And so I am just amazed that, you
know, seems like something must be done. If in effect we had
anything close to Katrina, that the, you know, the Veterans' Hospital
would be really in serious trouble and I don't know whether that is
being evaluated as we look at the, you know, the overall need to
address, you know, some modification, and so I know it is a major --
a major problem is the drainage problem and --
Dr. Greenberg. Well, it is an important question because the GAO has
studied the state of the existing facility and they said it is, you
know, in adequate condition. It doesn't need immediate replacement.
But that same conclusion might have been reached in the VA facilities
in New Orleans before Hurricane Katrina. I mean all it takes is one
extraordinary adverse event to completely destroy the facility. We
have seen that. So just as in all aspects of medicine, I think we
have to focus as much on prevention as we do on treatment after the
fact, after the disease has already taken place, in this case the
natural disaster.
We need to do everything we can to bring the facilities up to speed
in New Orleans, but we also need to make sure that we don't find
ourselves in the same position in other communities that had just the
same level of exposure in the future. We don't want to be dealing
with the same kind of reality that Mr. Smithburg is dealing with
right now.
The Chairman. Will the gentlemen yield? Your hospital, is it at sea
level or how many feet above sea level is your hospital?
Dr. Greenberg. The new hospital is raised 15 feet off the ground,
plus it has gone through extensive hurricane testing. There is a
facility in Florida where they shoot projectiles at it at 200 plus
miles an hour. So it has been rigorously tested to withstand this
kind of storm.
The Chairman. Mr. Moreland, do you know whether, the VA Hospital in
Charleston is at sea level?
Mr. Moreland. I don't recall. I know that in our evaluation, we did
look at that, and I also am aware that when -- that VA is in the
process of evaluating hardening of VAs in coastal areas that are in
danger of hurricane and flood damage.
The Chairman. All right. Thank you. Mr. Brown.
Mr. Brown of South Carolina. You know, I don't know exactly the sea
level yardstick, Mr. Chairman, but I know it is -- just visibly, it
is a good bit lower than the facilities being built by the Medic
University. And like I said, I met with those people on Friday. The
whole region down there, and across town and Cannon and Spring Street
are all impacted by this flood problem.
But, Mr. Smithburg, if I could ask you a question. I know we had the
privilege to go down with the Secretary to take a look at New Orleans
and Biloxi and Beaumont. But can you describe LSU's relationship
with Charity Hospital in New Orleans, and how will Charity play into
the collaborative project envisioned by LSU and VA? I know they are
all basically all there together in the same block.
Mr. Smithburg. First I would say by way of governance structure, the
Charity Hospital System is LSU. It has been for centuries branded.
The hospital system has been branded informally as the Charity
Hospitals, but it is LSU, a State-run, land-grant institution.
In terms of the collaborative that we have envisioned, it is really
building upon a set of relationships that have been in place for a
long time as you know, having toured the area. Near the Super Dome
downtown, there is a medical district that is comprised of the VA,
LSU, all of its health sciences schools, Tulane University, all of
its health sciences schools, and the Delgado Community College and
its health sciences training programs, and I am sure I am leaving
somebody out inadvertently. We are a true medical corridor if you
will.
What we have preliminarily discussed, and it is still very early in
this potential marriage, but what we have discussed so far is a
collaborative where, since the VA needs to place itself, it has
determined, we clearly determined have that there will be some real
synergies in doing some things together like one common power plant,
maybe one common cafeteria, other hotel-like functions that we might
be able to collaborate on together, but at the same time, not
necessarily having to deal with formal governance issues for the VA
has a very rock solid governance structure and we think we do on the
LSU State side.
So this is the beginning of a journey where we want to explore
opportunities for collaboration, and it could get much deeper,
penetrate much deeper in terms of integration collaboration, or not,
depending on what makes the most sense.
Mr. Brown of South Carolina. And one further question. I know we
have talked about this before, and I know the population base in
New Orleans is you live someplace else, and it seems like to me it
would be pretty difficult to track the patient demand in the near
future, and I don't know whether you can project it into the distant
future or not, but at this point in time, what kind of model would
you develop, based on limited information?
Mr. Smithburg. Thank you, Chairman Brown. That is an excellent
question, and it is very difficult to crystal ball the future
population of New Orleans proper, but there are some that would
expect that the population may not be localized as it was before,
kind of inside, below sea level, inside the soup bowl, but a ring
of new suburbs that are above that area, yet New Orleans will
continue to thrive as a cultural and industrial center. It just
won't have as many bedroom communities inside the donut, if you will,
but outside of it.
Who knows? But this we expect, whatever it is we design, it will
need to be scalable. I also am responsible for other markets in the
State and have seen a real population surge in Baton Rouge and
Lafayette, and our public hospitals there have seen almost a doubling
in their patient population.
What that tells us is that a lot of people are staying in State, and
we know that there is a very strong desire for New Orleanians to get
back home whether the levees are replaced or not. We think that
people are going to come back home.
And so whatever it is we design and build, as Dr. Greenberg alluded
to with his institution, it will be hurricane hardened and it will be
flood proof and will have a connection to a flyover interstate that
is already adjacent to our medical center. But scalability is what
is top priority for us, whatever we build. Easy to say, not so easy
to do, but it needs to be able to flex up or flex down, depending on
what the population will bring to us.
Mr. Brown of South Carolina. If you had to make this projection
today, I think the population around New Orleans is what, around
600,000 --
Mr. Smithburg. In the parish itself.
Mr. Brown of South Carolina. Right. And now it is less than 200,000
I believe.
Mr. Smithburg. Yes, sir.
Mr. Brown of South Carolina. And with those numbers, you know, do
you think it is going to take you three years or five years to get
back to the 600 or -- I guess my question is, I am trying -- I am not
trying to lead you into some decision that I want to hear, but I
guess my question is, is the location where the present hospitals are
today, is that the best location for the next 10 to 20 years?
Mr. Smithburg. It is a very good question, one that we want to study
through this process. This I will tell you. There are hundreds of
millions, if not billions, of dollars of investment in facilities
already on the ground in the medical school, the research facilities,
same with Tulane, that are okay, relatively speaking. Okay to us
means we can get back in them in a year.
And so that investment is there and so to relocate our hospitals to
another geographic location will have some -- that decision will have
some bearing on how we look at ourselves as an academic institution.
And proximity to our researchers who use our hospitals extensively
and to our training programs who staff our hospitals primarily is an
important factor to take into consideration. That is why hurricane
hardening and flood-proofing is absolutely essential if we stay where
it is we are going -- we have been traditionally.
Mr. Brown of South Carolina. It appeared to me that the hospital
itself was structurally sound. But I know there is probably some
mold and some other problems. Do you plan to raze that hospital and
start over? Is that part of the plans? Or do you plan to try to
save some of the structure itself?
Mr. Smithburg. The two buildings, primary hospital buildings, one is
called Charity Hospital and one is called University Hospital. In
the case of Charity Hospital, extensive engineering reports have been
conducted and they show that the building is absolutely unsalvageable
for healthcare use. Maybe there is some other reuse.
But the damage to the mechanical, electrical, plumbing and energy
systems is pervasive. The extent of black mold and other molds which
you may not be able to see in the naked eye permeates 21 stories of
HVAC systems and the like, extensive damage, because we were under
water for three weeks, and concerns about the stability of
foundation. It is a very old building.
And so we do not necessarily intend to raze that building at this
time. Frankly, it is an art deco kind of icon of architecture in the
community, greatly loved, and so if there is a reuse for the
facility, we are open for that.
But razing it is not necessarily on our radar screen right now. But
there are other sites on the campus that we have already identified
that would be ideal, we think, for a major medical center.
Mr. Brown of South Carolina. Thank you, Mr. Smithburg, and thank
you, Mr. Chairman.
The Chairman. Thank you, Chairman Brown. Dr. Greenberg, I want you
to think about this, and I am going to do a unanimous consent. I
want you to think about -- I am going to ask you a question in a
little bit on if I were to do this demonstration project as we move
from the macro to micro, what are the principal areas for which you
are considering?
So I want you to think about that for a moment, and I ask unanimous
consent that minority counsel be recognized, ask questions on behalf
of the minority. Hearing no objections, so ordered. The gentleman
is recognized for five minutes. Counsel for the minority.
Mr. Tucker. The GAO report, or I should say the GAO testimony from
September 26, 2005, offered a hypothetical. VA may decide to
purchase operating room services from MUSC. If the sharing agreement
were dissolved at some point in the future, it would be difficult for
VA to resume independent provision of these services. Mr. Moreland
how do you, working through these study groups, plan on addressing
these issues? They would seem to be very difficult.
Mr. Moreland. That was one of the basic concepts that we tried to
put into place in this study group was that, you know, what happens
and how do you set up a situation so these sharing agreements don't
end up that one party can take advantage of the other.
And so essentially what we did was build in, I think we called it
mutual dependency, so that if MUSC is running the operating rooms,
hypothetically, and the VA is providing laboratory services, there is
a built-in incentive for MUSC to have a good working relationship
with us in the operating room because they need to have a good
working relationship with us in the laboratory. So that was the
basic premise, that in order to set this up so that one party would
be fair with the other.
Mr. Tucker. Thank you very much. Also, you state in the December
report, Mr. Moreland, also Dr. Greenberg, that under Model "A" that
was proposed that there was a need for legislation. Can you be more
specific on what legislation you think might be needed?
Mr. Moreland. I was looking for my counsel.
Mr. Tucker. I think it is looking at 38 USC 8153, which is a
sharing agreement provision, that there was just -- I noted in
reading the report that it said that you recommend legislation. So I
was curious as to what that legislation might look like.
Mr. Moreland. I don't think we proposed legislation. I think what
we did was we proposed that there would be an issue that would
require legislation, but we did not get to the point of actually
developing what that legislation should look like.
Mr. Tucker. So you haven't actually got to that point of specificity
yet?
Mr. Moreland. Correct.
The Chairman. Is that what Phase 2 is about?
Mr. Moreland. That would be part of a Phase 2, yes, sir.
Mr. Tucker. Also let me ask you again, Mr. Moreland. I am sorry
that you seem to be the one I keep asking questions of. You state in
your testimony that previous collaborative arrangements are a "good
financial deal for veterans," how the funds saved through these
collaborations support other service enhancements.
Can you really offer explicit examples of these service enhancements?
It is held out as one of the promises of collaboration that money
will be saved. The VA will save resources. But where do these saved
resources go -- do they disappear in a hole? Is there any really
specific examples of how these things have worked out in the past and
as a model for the future?
Mr. Moreland. Yes. And if it is all right, I will use the one that
was really the simplest, because I think that is the easiest one to
provide a good answer to your question.
When I was the director of the VA in Butler, I needed a CAT scan.
And in evaluating how much it would cost to purchase a CAT scan and
put it in my building and hire the staff to operate that CAT scan and
the cost of the service agreement for maintenance of that CAT scan, I
calculated how much it would cost to do that.
Then I sat down with the CEO of the community hospital, who also
wanted to upgrade and buy a new CAT scan. And I was currently
purchasing from him CAT scans. And so when I sat down and did the
math comparison, what would it cost if I put one in my building and
ran it, what would it cost if I just keep buying them from the
community, and what would it cost if I were to purchase a CAT scan,
place it in his building, have him operate it and give the CAT scans
with interpretation from me, one dollar each.
When you sit down and did the math, I ended up it was much cheaper to
put that machine into his building. What that did then was that my
operating budget was reduced. Now could I track where that dollar
went? No, sir, I could not.
What I could track, though, was that I treated another veteran. I
provide more medication. I then turned around and enhanced my
nursing staff on my inpatient unit for my nursing home. So I could
point to what did I do with that money, and it did go back into
enhancement of services.
Mr. Tucker. Thank you very much. Also just a general question on
the tomotherapy suite, the $7 million piece of equipment. I
understand that it is not available anywhere in South or North
Carolina. It sounds very interesting. What is the track on this?
How is it moving forward? Have you worked out arrangements, because
it is not available to make it available to other facilities and how
do those arrangements work legally?
Dr. Greenberg. First, let me say that it wasn't available at any
other facility at the time of this report. I can't tell you whether
it is today or not. It is a new emerging therapy and it is basically
radiation therapy that can give and be given very precisely so that
what it does is limit the damage to normal tissue around the cancer
that you are trying to irradiate. So it is much more precise
targeting of the cancer; and, therefore, it really is a huge step
forward in the advancement of such treatment.
When you look at it from the VA point of view, they don't have a
large enough patient population to justify purchasing this equipment
for their own patients, and I am not sure if even in the vison there
is available. So it is not even a question of the distance that
someone would have to travel to access it.
At the Medical University, we would probably have the volume. We
would probably purchase this on our own, but this is an opportunity
to, it strikes me, to benefit the veterans population at the same
time we would be installing this for our own use.
Of course, we see ourselves as a referral area for the entire State
and so it would, of course, be a resource through our operation of it
that would be available to patients throughout the State of
South Carolina.
Mr. Tucker. Thank you. One more question, Mr. Chairman? Thank you
for your indulgence.
Adding on to that, I think one of the problems that some have in
addressing or looking at collaboration efforts is whether veterans
get priority and how that priority works out, especially when you are
dealing with a population that may have a more -- I don't know --
fundamental legal contractual obligation for their healthcare - they
buy insurance or they have some sort of provider relationship with a
university hospital.
Have you worked the details out in how that has worked out?
Dr. Greenberg. As a general principle, we have certainly said that
this does not make sense to go forward in a sharing relationship if
veterans are treated as anything other than first-class citizens. I
mean the goal is to make sure that they have at least the access they
have now.
I would actually argue this increases their access because what it
does it bring specialists and special equipment that they don't
otherwise have access to in the local marketplace. They might if
they went to Atlanta or somewhere else.
So to me, and when we sat down and talked with local veteran service
organizations, they quickly have appreciated the fact that this
brings more opportunity to them rather than a limited opportunity.
Your question, I think, leads us immediately, though, to the
implementation questions. How do you monitor that you are actually
doing that, and I think that really is the next phase. We didn't get
to that point in our initial descriptions, but I think there would
have to be some accountability; and, of course, this is all becoming
now automated, so it would be fairly easy on a regular basis to
review waiting times for VA patients versus non-VA patients, and I
personally would be dissatisfied with the outcome if we found that
there was any differential between the two patient populations.
The Chairman. Mr. Moreland, could you also respond to this question?
Mr. Moreland. Yeah. That is part of the agreement that is set up in
the contract which essentially says this piece of equipment continues
to be owned by the VA. It is just in your building. You are
operating it. And the university gets benefit and non-veterans and
the VA gets benefits and veterans.
But essentially the time line standards are part of the negotiations,
so that I know that if refer a veteran into that machine -- and I use
the example I gave you earlier in Butler as an example -- if I refer
a veteran there, I expect them to get seen quickly. And you can
identify that by the number of hours and the number of days, and you monitor that.
And I just have found that if you do that and you provide that
feedback, there is no interest in that not working well, because
Dr. Greenberg doesn't want that to not work well and nor do I. And
so I don't think that will be really an issue.
And I agree with you. It meets all the tenets. It increases access
because currently veterans don't have access to that machine in
Charleston. It enhances quality because you have access to that
machine, and at the end of the day, it is going to be a financial
good deal. It meets all three components of what we are trying to
do, so I think this is an example of a win/win for everybody.
Mr. Tucker. Thank you, Mr. Chairman.
The Chairman. I thank the minority counsel for the questions,
because you are going right to the heart of it. If the university
builds a bed tower and the VA builds a bed tower, and then on the
inside you share some of is medical equipment that then escalates the
quality of the care, veterans are going to want to make sure that
they have the access. They are treated like they would be treated in
a VA hospital, and so your question went right to the heart of it.
So I appreciate the gentleman's question, and I appreciate the
answers you have just now given.
I think where we are, Mr. Brown, is as you develop your construction
budget, we are going to need to be some very good listeners here with
regard to how we handle this, meaning where are we with regard to
Charleston and the Collaborative Working Group? What does Phase 2
mean? And what is this fast track now that Mr. Moreland had to do
with regard to New Orleans?
So to help us in this, Dr. Greenberg, help me -- help the
Committee -- sort of define what is a Phase 2? If we move to a demo,
what do you have in mind, and I am also interested in your counsel to
us, Mr. Moreland.
I don't mean to jump ahead of where you would go, Henry, in your own
Subcommittee, but we have an opportunity here.
Dr. Greenberg. Well, Mr. Chairman, one of the things I would like to
do, and I say this as a tribute to Mr. Moreland, is sit down with
Mr. Moreland and map out what a charge would be. I think the
first -- the obvious thing we need to do is clone Mr. Moreland,
because he clearly needs to be in two places at the same time.
The Chairman. Can you also include a time line of expectency in your
accounts you are about to give? I think it will sort of helpful to
us and whatever overlay there will be with regard to actions also
taken with Louisiana.
Dr. Greenberg. To me the principal issue is that we identified
opportunities for sharing, and the good news on that was that there
was agreement on both sides clinically about what the things -- what
services -- are the targets for sharing.
But beyond doing that, in doing some costing of construction, we
really haven't gotten in at all to the operational issues. And so
what I think we would need to focus on, just as categorically, would
be looking at moving towards implementation.
How would you actually operate this, not just build the shared
facility, but on a day-to-day service of these, of the clinical
service involved, how would they be operated?
To the best of my knowledge, the working group on clinical
integration really just scratched the surface. They made
considerable progress by identifying the category of services that
might be shared, but not how they would actually be operated. And to
me that really is the fundamental question.
I think six months is a reasonable period of time to do that. You
always seem to have a faster time track than I do, and that probably
is good, because it keeps us accountable and as productive as we can
be when you set time frames for us. But I think that these are
moving to fairly complicated questions about how things would operate
clinically and I think six months is probably a reasonable time frame
for that.
I would hope that in parallel with this, we get answers to the
questions about the security standards issue and some direction about
the magnitude of investment that is reasonable for us to be thinking
about so that it directs us towards an appropriate model. It will
clearly be a model of sharing, but as of yet, we don't really know
exactly how much should be shared. And so I don't want for us to
work in isolation of the thought process about what is a reasonable
fiscal investment to be made.
The Chairman. Mr. Moreland.
Mr. Moreland. I was thinking about the traditional way a project is
developed to get into the process of from concept to design to
construction. And, you know, what I think we provided is a basic
concept. Really the next step is design and generally one looks at
the estimated construction cost and then assets. That is a number of
about 10 percent. And then estimated project as to what it would
cost to then go into the next phase which is called design.
And in that design process, I recently participated with an architect
that has done some really interesting work called the FATHOM, and I
don't remember what all that acronym means, but essentially it is
sitting people in a room together and designing what that work space
should be like in the future, not the way we have done work in the past.
And I hear what Dr. Greenberg describing really is that kind of
process, and that generally is accomplished in the design process. So
what I am suggesting is opposed to having a work group, one might think
about moving it to that next step, which is more of an official step
which is the design process. That is just explaining the natural
progression of construction projects.
The Chairman. Can this be, if we were to say instead of doing the
demo actually, Dr. Greenberg, what Mr. Moreland has just said trumps
you big time, because what he just said has just advanced this so far
you ought to just hug him right now.
Dr. Greenberg. That is why I like him so much.
The Chairman. If we were to say, if we were to scrap your idea on a
demo, and actually go to plan and design -- let me just ask this,
though -- in a planning phase, we would need to put in some language,
I would think, we would need to put in some exact language, helping
to define what that Phase 2 is, because what we want to be able to do
here is replicate.
So if we are going to make this investment to examine all these
clinical areas, with integration for a successful operation, you want
to be able to say, okay, we have made an investment. We are
proceeding to do this in Charleston, but guess what? I am able to
use our investment with what I am about to do in New Orleans too,
right, because -- help me out here. I am not --
Dr. Greenberg. I think you are headed in a direction that I hope
the conversation would move in, which is I think it is a mistake to
look at the situation in New Orleans and the situation in Charleston
as being in conflict with each other.
The Chairman. I don't see them in conflict. We just have two
different time lines.
Dr. Greenberg. Right. I suspect much of the work that would be
involved in the design phase would have utility in both New Orleans
and Charleston. There are some things that would be specific to a
particular geographic configuration. But many of the operating
principles would be largely the same.
Now it gets even more complicated if you got three parties at the
table, but I just think it is an opportunity for us to think about
taking this to the next level, especially if it involves a
significant investment as Mr. Moreland has suggested.
In thinking about those principles that span not just these two
facilities, but hopefully would inform us in Las Vegas and Orlando
and other places that one might be considering the same kind of
thing. We don't have to reinvent the wheel uniquely in every
geographic location. We should look at a model to the extent
possible that can be replicated in each of these settings with the
understanding that there is always going to be some element of
difference between the individual settings, but the more that we can
make that can be transported from one setting to another, the more
efficient the whole process will be.
The Chairman. I concur. Consider the exporting of this model, let
us take Ms. Berkley's district for a second in Las Vegas. She has
tremendous challenges because this is a population growth unlike
anyplace in the country. And so what is plan and design today, by
the time you get it built may even be obsolete. I mean her
challenges are remarkable.
So she has an immediate need while at the same time, you have got
this desire of a chancellor to build a medical university, but guess
what? It will be on a different time line, too, right, because there
is a tremendous amount of funding required to pull something like
that off.
But if we know what the model is as they construct it, something can
be partnered for it at some point in time. And that is what we also
want to be able to be receptive to with Orlando. If Orlando or the
State of Florida has an interest in putting the medical university
there, then we want to be able to build a facility that is receptive
to that.
So, different than LSU, you have the property, right, and as I
understand, you want to be able to say to the VA, we have property.
We are interested in the collaboration, and we want to be able to
build this together, and work it out together, right?
Mr. Smithburg. We have some of the property.
The Chairman. So -- pardon?
Mr. Smithburg. We have some of the property and designs on the rest.
The Chairman. Okay. All right. So it is called the most flexible
model ever? You know what? The Charleston Model is appropriate,
because Charleston is that the, you know, a pretty loving city, a
caring city. We are exporting your love.
Chairman Brown, we will allow you to close.
Mr. Brown of South Carolina. Mr. Chairman, I just would like to
thank you for your interest and innovation and energy that you have
put on this project, and Mr. Moreland, Dr. Greenberg, Mr. Smithburg,
we are grateful for your energy that has been expressed today, and
our whole commitment is to provide better healthcare for our veterans
and our population as a whole and I think this is a win/win.
And certainly I am like Dr. Greenberg. I don't see a conflict
between Charleston and New Orleans. I think it is certainly a
complement to each other, and I think by moving them both the same
time, but certainly I think would have some numerical economic
savings, too. So I thank you all three for being here and being part
of this discussion. And thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Chairman. We as a Committee, want to
remain sensitive right now with regard to construction time lines
across the country, because they all have their own time lines, and
they all get really sensitive. Oh, my gosh, you got money for this
one. Are we less a priority, and that type of thing. We just want
to get these things built. We want these hospitals built.
We are going to embrace the suggestion from both of you. A
demonstration project, or do we really go to plan and design, or a
hybrid thereof? And so we will take that to the next step. We will
work with each other on how to define this properly and so when we put
together our construction budget, I think that will probably be the best
way to handle it. Do you agree?
Okay. Thank you very much for coming to town and really congratulations
to you. This hearing is now concluded.
[Whereupon, at 5:50 p.m., the Committee was adjourned.]
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