<DOC>
[108 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:96474.wais]
S. Hrg. 108-663
VA CAPITAL ASSET REALIGNMENT FOR ENHANCED SERVICES INITIATIVE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 11, 2003
__________
Printed for the use of the Committee on Veterans' Affairs
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senate
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COMMITTEE ON VETERANS' AFFAIRS
ARLEN SPECTER, Pennsylvania, Chairman
BEN NIGHTHORSE CAMPBELL, Colorado BOB GRAHAM, Florida
LARRY E. CRAIG, Idaho JOHN D. ROCKEFELLER IV, West
KAY BAILEY HUTCHISON, Texas Virginia
JIM BUNNING, Kentucky JAMES M. JEFFORDS, (I) Vermont
JOHN ENSIGN, Nevada DANIEL K. AKAKA, Hawaii
LINDSEY O. GRAHAM, South Carolina PATTY MURRAY, Washington
LISA MURKOWSKI, Alaska ZELL MILLER, Georgia
E. BENJAMIN NELSON, Nebraska
William F. Tuerk, Staff Director and Chief Counsel
Bryant Hall, Minority Staff Director and Chief Counsel
C O N T E N T S
----------
September 11, 2003
SENATORS
Page
Specter, Hon. Arlen, U.S. Senator from Pennsylvania.............. 1
Nelson, Hon. E. Benjamin, U.S. Senator from Nebraska............. 2
Prepared statement........................................... 4
Hutchison, Hon. Kay Bailey, U.S. Senator from Texas.............. 5
Miller, Hon. Zell, U.S. Senator from Georgia..................... 6
Nelson, Hon. Bill, U.S. Senator from Florida..................... 19
WITNESSES
Principi, Hon. Anthony J., Secretary, U.S. Department of Veterans
Affairs........................................................ 8
Prepared statement........................................... 10
Response to written questions submitted by Hon. Bob Graham to
the Department of Veterans Affairs......................... 14
Response to written questions submitted by Hon. Patty Murray
to the Department of Veterans Affairs...................... 15
Response to written questions submitted by Hon. Jim Bunning
to the Department of Veterans Affairs...................... 16
Alvarez, Everett, Jr., Chairman, Capital Asset Realignment For
Enhanced Services (CARES) Commission, U.S. Department of
Veterans Affairs............................................... 25
Prepared statement........................................... 26
APPENDIX
Murray, Hon. Patty, U.S. Senator from Washington State, prepared
statement...................................................... 35
Bunning, Hon. Jim, U.S. Senator from Kentucky, prepared statement 36
Roswell, Hon. Robert H., M.D., Under Secretary for Health,
Department of Veterans Affairs, prepared statement............. 37
VA CAPITAL ASSET REALIGNMENT FOR ENHANCED SERVICES INITIATIVE
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THURSDAY, SEPTEMBER 11, 2003
U.S Senate,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to notice, at 2:18 p.m., in
room SR-418, Russell Senate Office Building, Hon. Arlen Specter
(chairman of the committee) presiding.
Present: Senators Specter, Hutchison, Miller, and Nelson.
OPENING STATEMENT OF HON. ARLEN SPECTER,
U.S. SENATOR FROM PENNSYLVANIA
Chairman Specter. Good afternoon, ladies and gentlemen. The
hearing of the Senate Veterans' Affairs Committee will now
commence.
Our hearing today is on the Veterans Administration's
Capital Assets Realignment for Enhanced Service plan. This is a
major undertaking by the Department of Veterans Affairs to
analyze existing health care facilities and make a
determination what new facilities are necessary; what existing
facilities are obsolete; and how better care can be delivered
to our nation's veterans.
We approach this issue with a good deal of skepticism in
the veterans' community. I believe that is something that we
have to face very, very candidly. The budget constraints have
been restrictive. We have not been able to take care of the
influx of veterans, as we have an aging World War II
population; an aging Korean population; the Vietnam War; the
Gulf War; and now, most recently, the war in Iraq, so that
there have been very, very heavy demands placed upon the
Veterans Administration.
My own experience with the VA goes back to my childhood,
where my father, Harry Specter, a veteran of World War I, was
treated at the veterans' hospital in Wichita, Kansas. My dad
was an immigrant. He came from Ukraine; walked across Europe
with barely a ruble in his pocket to the United States; did not
know that he had a round-trip ticket to France, not to Paris
and the Follies Bergiere but to the Argonne Forest, where he
was wounded in action; carried shrapnel in his legs until the
day he died. And in the late thirties, with the tremendous
economic problems of the Depression, the veterans' hospital was
a godsend for my father.
I visited it not too long ago. It is now inside the city.
When he was there, I had a long bicycle ride out. But it was
worth the ride, because there was a free pinball machine there
when I got to the end of the road.
But my own experience has shown me, including my extensive
travels as chairman of this committee and, before that, as a
member of this committee; and earlier this week, I was in
Pittsburgh, where there is a proposal to close down a large
facility known as Highland Drive, which is a mental institution
for 1,000 people. I saw the empty spaces there. Just about 150
people are there, and there is a plan to buildup a fairly close
facility on University Drive. But there are very grave concerns
as to whether the other facility will be completed before the
first facility is closed down. That is understandable. And that
is something we have to address.
The veterans ask questions about will the appropriations be
there? Last Monday was the day after the President had
addressed the nation, seeking $87 billion for Iraq. I said to
the veterans even the President does not know if he is going to
get the appropriation. But I assured them that I thought that
our chances of getting that done were good.
There are many, many facilities. I know the Senator from
Texas has concerns about Waco. These are matters which we will
have to take up in some detail, but this committee intends to
pursue with diligence an analysis as to what this plan is and
to work with the Veterans Administration. We know you are
operating with good intentions to try to do the best we can for
the veterans.
In the absence of the ranking member, let me turn, on the
early bird rule, to the Senator from Nebraska, Senator Nelson.
OPENING STATEMENT OF HON. E. BENJAMIN NELSON,
U.S. SENATOR FROM NEBRASKA
Senator Nelson. Thank you very much, Mr. Chairman.
I know that you hail from Kansas, the State just south of
Nebraska, but you are probably a Penn State fan, and Nebraska
will wrestle with Penn State Saturday night. So I thought I
should remind you of that.
[Laughter].
Senator Nelson. But I do want to thank, first of all----
Chairman Specter. You did not have to remind me, Senator
Nelson.
[Laughter].
Chairman Specter. The only part that surprised me was that
you did not propose a wager.
[Laughter].
Senator Nelson. I was very good at wagers until we had a
seven and seven season, so I----
[Laughter].
Senator Nelson. When you learn humility the hard way, the
lesson is well-remembered.
However, first of all, I want to thank our panelists and
the witnesses for being here today. The veterans' issues are
issues that are on everyone's minds these days, and trying to
come to terms with the way to match the resources with the
needs has been part of what our witnesses have been involved
with for a long period, and I want to commend my good friend,
Secretary Principi. It is always good to see you, and I know
how difficult it must be for you at times or for all times to
hear that people have concerns, some skepticism about the best
plans that you are proposing, and you are here today to hear it
again.
But I do know that you are committed to doing what you
think will be best for our nation's veterans, both our current
veterans and, unfortunately, the veterans we are generating
every day in new engagements. So thank you for being here and
for the opportunity.
After the merger of VISN 13 and 14 was announced to form
VISN 23, you very graciously and honorably came to Nebraska to
discuss the impact it would have on our veterans, and I know
everyone there has appreciated that. The merger process was a
good example of the importance of including the concerns of
those directly impacted by these decisions, and I appreciate
the efforts of the VA to incorporate concerns from stakeholders
such as the veterans service organizations and Network
Leadership, the VA employees, VA affiliates and collaborators
under the CARES process.
I have reviewed both VISN 23 recommendations for enhanced
care as well as the draft national plan, and I would like to
take a moment to express some of those concerns that I
mentioned regarding the community-based outpatient clinics, the
CBOC's, to the realignment of some small facilities and, three,
of course, the issue of long-term care needs, which are
changing daily with the creation of new veterans' needs at the
present time.
Currently, only 51 percent of our Nebraska veteran
enrollees are within the VA driving guidelines for primary
care, the guidelines being 30 minutes for urban and rural areas
and 60 minutes for highly rural areas. As you are aware, VISN
23 is the most rural VISN, as we understand it. In order to
resolve the gap in access to outpatient care, VISN 23
established a planning initiative to develop CBOC's in
Bellevue, Nebraska; Holdridge, Nebraska; O'Neill, Nebraska; and
Shenandoah, Iowa; and to increase the capacity at the existing
CBOC in Norfork, Nebraska.
According to the CARES planning initiatives and market
plans, the rationale for selection of these sites, the
rationale was based on the population of enrollees that lack
access in these areas. By establishing the CBOC's, it would
increase the access level to 64 percent of enrollees by 2112
and up to 67 percent by 2022, with the ultimate target being 70
percent.
During the network review process, there was wide support
exemplified, with 80 percent of stakeholder comments agreeing
and supporting this proposal. So not all is as from the dark
side as we might have initially been concerned or thought with
the concerns being taken into consideration.
Chairman Specter. Senator Nelson, you are past the 5-minute
mark. Do you intend to be longer?
Senator Nelson. No, no. I will submit the rest of the
written statement. But what I wanted to do was indicate that
there are efforts underway to work with the stakeholders. We
appreciate that. But we have got such a long direction to go
with the new veterans and the changing in the demographics as
time goes by that we need to continue to work together. I will
submit the rest of my statement, Mr. Chairman, for the record,
but thank you very much for this opportunity.
Prepared Statement of Hon. E. Benjamin Nelson, U.S. Senator
From Nebraska
Good Afternoon. I would like to thank all of the witnesses for
appearing here today to discuss the services our veterans have earned
and received. Secretary Principi it is always good to see you again.
After the merger of VISN 13 and 14 was announced to form VISN 23, you
came to Nebraska to discuss the impact it would have on our veterans
that was greatly appreciated. The merger process was a good example of
the importance of including the concerns of those directly impacted by
these decisions. I appreciate the efforts of the VA to incorporate
concerns from stakeholders, such as, Veteran Service Organizations,
Network Leadership, VA Employees, VA Affiliates and Collaborators into
the CARES process.
I have reviewed both VISN 23 recommendations for enhanced care as
well as the draft national plan, and I would like to take a moment to
express some concerns regarding: (1) Community Based Outpatient
Clinic's (CBOC's), (2) Realignment of Small Facilities, and (3) the
issue of Long-Term Care needs.
Currently, only 51 percent of Nebraska Veteran enrollees are within
the VA driving guidelines for Primary Care, the guidelines being 30
minutes for urban and rural areas and 60 minutes for highly rural
areas. In order to resolve the gap in access to outpatient care, VISN
23 established a planning initiative to develop Community Based
Outpatient Clinics (CBOC) in (1) DOD/Bellevue, NE; (2) Holdrege, NE;
(3) O'Neill, NE; (4) Shenandoah, IA; and (5) increase the capacity at
the existing CBOC in Norfolk, NE. According to the CARES planning
initiatives and market plans, the rationale for selection of these
cites were based on the population enrollees that lack access in these
areas. By establishing these CBOC's it would increase the access level
to 64 percent of enrollees by 2012 and 67 percent by 2022 with the
target being 70 percent. During the network review process, there was
wide support exemplified with 80 percent of stakeholder comments
agreeing and supporting this proposal.
Therefore, I was concerned when the draft national plan classified
these CBOC initiatives in the priority 2 category. To qualify as
priority 1 a market must demonstrate a larger future outpatient
capacity gap, large access gaps and the number of enrolled who do not
meet access guidelines is greater than 7,000. According to 2001 VA
data, Nebraska has 52,022 enrollees and only 51 percent of these meet
the access guideline, leaving 49 percent or 27,696 total enrollees
outside of the driving guidelines.
I believe by placing all of these CBOC proposals effectively in the
priority 2 category that rural areas of Nebraska will not see
improvements in the near future and will be penalized in comparison to
more urban areas with a larger number of enrollees. Once again, 49
percent of Nebraska enrollees are outside of the driving guidelines;
meaning the Department of Veterans' Affairs is providing access to
Primary Care only half of the time for Nebraska's Veterans. I find this
statistic deeply troubling. Nebraska veterans, who sacrificed just like
other veterans, should not be penalized because they live in a densely
populated area. Therefore, I support the network proposal and advocate
that these 4 CBOC recommendations be included in the priority 1
category.
My second concern is in regards to the inclination to transition
some smaller facilities from Acute Care Hospitals to Critical Access
Hospitals. I am of the understanding that the VA is currently using the
Medicare definition of a CAH: (1) must have no more than 15 acute beds,
and (2) cannot have lengths of stay longer than 96 hours and (3)
maintain a strong link to their referral network. The national plan
proposed that the CAH model be implemented at the Cheyenne VA Medical
Center (VISN 19) and at the Hot Springs VA Medical Center (VISN 23).
921 Nebraska veterans utilize the Cheyenne Medical Center in
Cheyenne, Wyoming. In the past fiscal year these veterans were served
by 3,578 visits with an average length of stay for acute care at about
130 hours--above the 96 hours threshold for CAH model. The national
plan's focus for this facility is to maintain acute bed sections,
develop more restrictive parameters for types of in house surgery
procedure and close all ICU beds. The recommendation to convert this
facility to a CAH model however was not included in the network
proposal. Consequently, I have received a significant amount of
feedback from local veteran service officers, organizations, facility
employees and veterans concerned that this recommendation was suggested
late in the CARES process leaving little feedback time for shareholders
and many veterans feel they will see a continual decline in services at
the Cheyenne Medical Center.
2,590 Nebraskan veterans are registered at the Hot Springs Medical
with an average length of stay for acute care at about 72 hours--
conforming to the CAH model. The focus for this facility is to decrease
bed numbers and increase contracts and referrals. Many Nebraskan
veterans are concerned about downsizing this facility especially when
there is a clear need for continued inpatient services based on the
local domiciliary home and State veteran's home both located on the Hot
Springs Campus.
And the last concern I would like to address is in relation to Long
Term Care for our nation's veterans. The VA has acknowledged that
veteran's age 75 and older will increase from 4 million to 4.5 million
veterans by 2010. GAO has estimated that veterans 85 and older will
triple by 2012. Considering this increase, the VA will need all the
facilities they can build and maintain to plan for this increase.
Cutting facilities, as the draft CARES plan does, will not make this
problem go away and will only mean that another Administration is
forced to deal with it in the very near future. Thank you again for
appearing before the Committee to address our concerns.
Chairman Specter. Senator Hutchison.
OPENING STATEMENT OF HON. KAY BAILEY HUTCHISON,
U.S. SENATOR FROM TEXAS
Senator Hutchison. Thank you, Mr. Chairman.
I want to thank you for scheduling this hearing, because it
has reverberations throughout my State as well as throughout
the country, I am sure. All of us who serve on this committee
understand the need for the Veterans Administration to examine
all of the medical services provided to our veterans and to
realign the requirements, where necessary, to address the
greatest need. We also recognize the need for the Veterans
Administration to make the best possible use of our resources.
I am concerned, however, that the draft plan, as it impacts
my state, neither enhances services nor wisely allocates
resources. I recognize that we are only in the second step of a
four-step process and that neither the independent commission
nor Secretary Principi have reviewed these initial
recommendations. I am confident that the commission and
Secretary Principi will closely evaluate them.
The release of the draft plan caught many in Texas by
surprise. If the draft plan had been adopted as written, many
in Marlin, Big Spring and Waco, the communities most affected
by the proposal, fear they will lose access to veterans'
medical care. The plan would result in a drastic reduction in
current services. Prior to the release of the draft plan, our
veterans' organizations and local community leaders worked with
their respective service network regional directors in
developing plans to optimize use of their facilities.
But the draft plan that appeared in August bore almost no
resemblance to the original recommendations by the service
network directors in the field. For example, the Veterans
Integrated Service Network Market Plan recommended establishing
Waco as a regional psychiatric resource and spoke of an
enhanced mission for the Waco facility. Considering that the VA
has spent over $80 million over the past decade building state-
of-the-art psychiatric facilities in Waco and training
technicians and nurses in this specialized field, the original
recommendation to consolidate psychiatric services seemed to be
a good use of taxpayer funds. However, the recommendations were
disregarded, and closure was recommended.
Similarly, in Big Spring, and I would like to say that the
Mayor of Big Spring, Russ McEwen, and the Howard County
Commissioner, Bill Crooker, are in the audience, if you would
stand. They are so concerned about this. We appreciate your
being here.
Let me tell you the story of Big Spring. They serve a
veteran population spread over 74,000 square miles in an area
equal in size to New York, New Jersey, Connecticut, Rhode
Island, Massachusetts and Delaware combined. Big Spring VA
Hospital serves 63,000 veterans. It would be inconceivable to
imagine a recommendation to close a hospital in Delaware and
send veterans to be treated in Massachusetts, but that is
comparable to what is being done to Big Spring if that facility
is closed or severely downsized.
As was the case in Waco, the veterans' community in Big
Spring worked with the VISN to make a strong case about the
central location, and as I said this morning, even the mayors
of Midland and Odessa, where there would be a proposed new
facility, have written saying no, it should stay in Big Spring,
where it is more central. So I think that we can understand
that there was a shock for the report that came out after
working with the VISN.
I recognize the need for the independent evaluation.
Communities like Big Spring, Waco and Marlin need to have a
strong justification to keep their facilities in place. But I
am concerned that we are on such a fast track that maybe these
communities might not get the full time and have the ability to
fully prepare their defense. So I hope that we will not make
mistakes in closing facilities too quickly but that there will
be a good, solid timeframe for these communities to meet and
have business plans to say what the community would like to do
to upgrade the facility and make it more worthwhile.
The mayors of these cities with whom I have met: Waco and
Big Spring and Marlin, all say that they are willing to do
that. My final comment is for Mr. Alvarez. We want to say how
much we respect you and the record that you have. You have
undertaken a thankless task and one that really shows the
American spirit that you have already shown in your service
career that you would undertake it. I would just ask that you
look at the original recommendations in addition to the most
recent ones to see what the regional people brought forward,
because I think they shed a lot of light on this process.
Finally, Mr. Chairman, let me say: no secretaries or
assistant secretaries have been as open to discussion, as
forthcoming, as accessible as Secretary Principi and Secretary
Roswell. I have met with both of them. I have talked to them. I
know that their hearts are in the right place, but they could
not be more accessible, and I appreciate that. I just hope that
in the end, there will be an ability by the communities to
offer things that would be better for the veterans' hospital,
to make it better and also to look at these original proposals
that were made from the field where the service is really being
done.
With that, I thank you very much.
Chairman Specter. Thank you, Senator Hutchison.
Senator Miller.
OPENING STATEMENT OF HON. ZELL MILLER, U.S. SENATOR FROM
GEORGIA
Senator Miller. Thank you, Mr. Chairman. Thank you for
holding this hearing, and I would like to thank Secretary
Principi and Dr. Roswell and Mr. Alvarez for being here with us
and for the great job that they do every day.
I think it is very important and timely that the Veterans
Administration address health care and other concerns of the
soldiers, because military service should be a career of
distinction and honor. I know you believe that as strongly as I
do and that those who serve should be given the resources they
deserve.
With troops still facing danger and a new generation of
soldiers using VA health care, ensuring access to health care
services has become paramount. But I also want to say that just
as important as accessibility is ensuring that veterans receive
health care in a timely manner as well. We have all heard the
stories of veterans waiting 6 months to see a VA physician.
Those delays are too common across this country, and we have
got to address this problem.
I applaud the goal of the CARES commission, and I believe
the result of the commission's hard work will be more
comprehensive and more accessible health care for all of our
veterans. I am optimistic. I realize that there are going to be
changes that are not going to please everyone, but I also
understand that the Department of Veterans Affairs, just like
every other department and just like the Senate and Congress
should get as much bang out of the buck as we possibly can. It
is not Government money; it is taxpayers' money. We have got to
operate the most efficient system of veterans' health care
without compromising our mission.
We have the best military in the world, and our soldiers
put their lives on the line for this country every day. As you
well know, Georgia is home to 770,000 veterans, and it was
Georgia soldiers that made up the bulk of our troops deployed
to the Middle East. So it is critically important for the VA to
guarantee that they will have access to quality health care
facilities when they return home.
So as the CARES initiative progresses, it is vital for the
Veterans Administration to preserve its commitment to veterans.
I know you understand that. I also want you to know that I will
continue to work to make certain that the VA remains dedicated
to improving health care for veterans in Georgia and
nationwide, and it is my hope that Congress and the
administration can work together to find solutions to
adequately address VA's budget concerns while still providing
the quality health care that we all know our veterans deserve.
Thank you.
Chairman Specter. Thank you very much, Senator Miller.
We now turn to the distinguished Secretary of Veterans
Affairs Anthony J. Principi. Secretary Principi comes to this
job with superb qualifications I think never before matched, in
that he had previously served as Deputy Secretary of Veterans
Affairs under President George H.W. Bush. He had served as
chief counsel and staff director for the Senate Committee on
Veterans' Affairs, which is a tough job and a great learning
experience, and previous to that, he had been chief counsel for
the Committee on Armed Services. So he has quite a legislative
background and quite an executive background.
A graduate of the U.S. Naval Academy, he had been in the
private sector when President Bush brought him back to
government. He was confirmed on January 23, just 2 days after
inauguration day, and even though Secretary Principi has not
made judgments in the area, because the recommendations have
not yet come to him, it is he who started the process on his
determination, as he saw it, to give the veterans the best
possible care.
We customarily set the time limit at 5 minutes, and when I
start the proceedings with a time limit, I like to point out
that recently, on the memorial services for Ambassador
Annenberg, the time limit was set at 3 minutes for President
Ford and Secretary Powell and Arlen Specter and others. So it
should be noted that 5 minutes is a large allocation by some
standards.
[Laughter.]
Chairman Specter. Secretary Principi.
STATEMENT OF HON. ANTHONY J. PRINCIPI, SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS, WASHINGTON, D.C.
Secretary Principi. Thank you, Mr. Chairman. Thank you for
your time. Good afternoon, Mr. Chairman and members of this
Committee. I appreciate the opportunity to discuss the VA's
Capital Asset Realignment for Enhanced Services initiative,
usually referred to as CARES.
CARES is rooted in the answer to the question: how can VA
and the Congress best allocate the limited resources available
to support our vast infrastructure--well over 5,000 buildings;
well over 15,000 acres of land across the country--so as to
ensure that veterans receive the best possible care over the
decades to come in this new century? Many of our hospitals were
built, designed for medicine as it was practiced after World
War II and, in many cases, even after World War I, when we
inherited old Army forts from the military, and they became VA
hospitals in the late 1800's and early 1900's.
Then, lengthy inpatient admissions were the norm. Today, as
you well know, new procedures, advances in technology, new drug
therapies have moved most care to an ambulatory outpatient
arena and dramatically reduced the length of stay when
inpatient care is still required. Then, the mentally ill were
locked away for decades at a time behind closed doors. Today,
most can be treated in their communities with revolutionary new
drugs like atypical antipsychotics, where they can live at
home; they can go to work as long as they have the new drugs
and the community and non-institutional care support.
Telemedicine, digital radiology, allow physicians literally
hundreds if not thousands of miles away from physicians to
provide the latest diagnostic treatment and care with the
veteran in their community wherever that might be. Then, many
facilities were located with little regard to where veterans
live at the time, much less where they will be living in the
third decade of the 21st Century.
As you know, in 1999, GAO testified that maintaining
obsolete or duplicative structures diverts $1 million a day
every day, every year, away from the care of veterans. It is
for those reasons that the last administration initiated the
CARES process and why I believe it was important to carry it
forward. My goals are simple: provide our doctors and nurses
with the facilities they will need to provide 21st Century
veterans with 21st Century medical care; create a plan for
managing our capital assets over the next two decades that will
optimize the practice of modern medicine while acknowledging
the inevitable changes in veterans' demographics.
The parameters I set are clear. The plan must ensure that
VA's capacity to provide care, including our specialized
services such as mental health and spinal cord injury, is not
reduced. Nor do I want a plan that does not comply with the
statutory requirements for long-term care. As you know, we
initiated the process with a pilot in Network 12, basically
northern Illinois and Wisconsin. Implementation of the plan for
that network is underway. We learned a lot about our process in
that pilot project. It was very expensive. We paid contractors
and consultants millions to do what we could do for ourselves.
Veterans and other members of the community said that they did
not have a chance to provide input, and the process was very
slow.
We owe it to our veterans, to our health care providers, to
our communities as well as to the American people to get our
capital asset planning house in order quickly. Our
appropriations committees have made it clear that we must
produce a well-thought-out and comprehensive capital plan
before they will entrust us with significant construction
funding, even for patient safety and seismic protection
projects.
In real dollars, the past 5 years have seen construction
funding at one-tenth the rate we received in the 1980's. That
will not change until our project proposals reflect a plan for
21st Century medicine. I addressed this challenge by directing
the Undersecretary for Health to produce a plan based on
information developed with data on local facilities and
demographics and with input at the local level, from the
veterans we serve, our employees, our affiliates and our
communities. I further directed him to meld this input into a
comprehensive plan for an integrated national health care
system, but I also wanted a reality check.
To get that check, I commissioned an independent body, the
CARES Commission, to evaluate the Undersecretary's plan, to
independently obtain stakeholder input and to provide their
independent judgment to me on the plan prepared by the
Undersecretary. To lead the commission, I chose Mr. Everett
Alvarez, the gentleman to my right, a former VA deputy
administrator; a veteran whose courage and integrity were
forged as a naval aviator and tested as a POW for 8 years in
Hanoi and a man whose commitment to America's veterans is
absolutely unquestioned.
Under his leadership, the commission will make such
modifications as they deem appropriate and present their report
to me. I will then review this report very carefully; consult
with Members of Congress; and then accept the plan in its
entirety or reject it or ask the commission to go back and
answer further questions, but I will not pick, and I will not
choose among the recommendations and proposals.
When the process is completed, I expect that we will have a
road map for managing VA's capital assets for the next 20
years. I fully expect the plan to call for significant capital
expenditures. I do not delude myself that the plan will call
for leaving every VA facility intact as it exists today. I do
expect that implementation of the plan will mean better health
care for more veterans of this nation.
Thank you, Mr. Chairman for the opportunity to testify
before you today.
[The prepared statement of Secretary Principi follows:]
Prepared Statement of Hon. Anthony J. Principi, Secretary,
U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee:
I am pleased to appear before the Committee to describe the process
that produced VA's Draft National CARES Plan, which represents the most
comprehensive effort to develop a road map that will guide the
allocation of capital resources within the Veterans Health
Administration (VHA). With me today is Dr. Robert Roswell, VA's Under
Secretary for Health, who will discuss the contents of the draft
national plan itself.
CARES is a comprehensive, data-driven planning process that
projects the future demand for health care services in 2012 and 2022,
compares them against the current supply, and identifies the capital
requirements and the asset realignments VA needs to improve access,
quality, and the cost effectiveness of the VA health care system.
VA initiated CARES to create a strategic framework to upgrade the
health care delivery capital infrastructure and ensure that scarce
resources are placed in the types of facilities and locations that
would best serve the needs of an aging veteran population with
increased acute and outpatient care needs. The dramatic changes in the
delivery of VA health care services including the expansion of
outpatient services, an aging infrastructure with the average age of
buildings over 50 years, costs associated with the maintenance of
excess space, and the potential use of underutilized campuses to
provide revenues to enhance services were powerful factors that
coalesced into the need for CARES. GAO's 1999 reports, which were
critical of the management of vacant space within VHA, and
Congressional reluctance to provide capital without an overall
assessment of the current and future capital requirements to meet the
health care needs of veterans have reinforced the importance of a
comprehensive capital plan.
The CARES Process was designed to balance the need for a national
planning process with the recognition that health care delivery is
local. This was accomplished through the use of national data bases
that standardized the forecasts of enrollment and utilization, the
identification of national planning topics, and the use of standardized
tools in determining how to meet the projected needs. Forecasts of
enrollment and the need for outpatient and inpatient care were
developed through the year 2022 for each VISN and market area. Data
were integrated with Medicare to ensure forecasts reflected Medicare
utilization. All VHA space was assessed for functionality and safety.
Based upon these data, a national planning agenda was developed and
sent to the field for solutions. A standardized costing and decision
support system assisted in the planning. The agenda included the
development of cost effective solutions to meet the future space
requirements, the mission of small facilities, reduction in vacant
space, consolidations and realignments of services and campuses and
collaboration with DoD. Stakeholder input was required and occurred at
the national and field levels. Seventy-four market plans were submitted
as input to the development of the Draft National CARES Plan.
CARES was initiated in a Pilot in VISN 12 in 1999. The CARES
process focuses on markets--or distinct veteran population areas. The
Phase I pilot identified three market areas: the Chicago area,
Wisconsin and the Upper Peninsula of Michigan.
In this initial effort, the contractor assessed veterans' health
care needs in the test market and then formulated various solutions
that could meet those needs. Following a detailed review process a plan
to realign capital assets in the VISN 12 market areas was approved. The
results of CARES Phase I were announced in February 2002.
In preparing for CARES Phase II extension of the process to the
remaining 20 VISN's, I determined that VA personnel, rather than
contractor staff, would coordinate and carry out the planning process.
The conversion from a contracted study in one VISN, to a VA-operated
planning process extended to the entire system, went well beyond the
scope of the pilot. The use of VA staff was necessary to ensure that a
process was created that would be ongoing and become part of VA
strategic planning process rather than a one time study performed by
outside consultants.
In effect, CARES Phase II piloted a new process that will be
integrated into a redesigned strategic planning process. The challenge
of developing a national process while recognizing that health care is
delivered through local systems required a new approach that included
the following elements:
<bullet> use of national data bases and methodologies to determine
current and future needs;
<bullet> assessment of all space in VHA for its safety and
functionality;
<bullet> national definition of the planning initiatives to be
addressed by VISN's. VISN development of plans that address the
planning initiatives;
<bullet> standardized planning support systems and data for plan
development and costing to ensure consistent results;
<bullet> policy and tools that supported local and national
stakeholder involvement;
<bullet> onsite technical support to the VISN's for plan
development; and
<bullet> detailed national review process to create a national plan
from the VISN plans.
A major enhancement in the Phase II model was increased commitment
to the aggressive, systematic inclusion of stakeholders. The
requirement for in-depth communications with a vitally interested
public at national, regional, and local levels was integral to the
process. Multiple modalities and media were designed and used to inform
stakeholders about CARES in general and to solicit their comments on
potential changes in respective markets in particular.
NINE-STEP PLANNING MODEL
The enhanced CARES model comprised a nine-step process designed to
ensure consistency in the development of CARES Market Plans within each
VISN.
STEP 1: IDENTIFY MARKET AREAS AS THE PLANNING UNIT FOR ANALYSIS
OF VETERAN NEEDS
The VISN's identified 74 market areas based on standardized data
for veteran population, enrollment, and market share provided by HQ.
Each network also used local knowledge of their unique transportation
networks, natural barriers, existing referral patterns, and other
considerations to help select their market areas.
STEP 2: CONDUCT MARKET ANALYSIS OF VETERAN HEALTH CARE NEEDS
A national actuarial firm--referred to hereinafter as CACI/
Milliman--that had developed enrollment, workload, and budget
projections for VA budget development, under VA direction modified the
model to develop standardized forecasts of future enrollees and their
utilization of resources from 2002 through 2022 for each market area in
all VISN's. Translation of the data into the VHA CARES Categories
listed below facilitated the identification of ``gaps'' between current
VHA services and the level or location of services that will be needed
in the future. These were ``high level'' macro categories that would
enable planning to occur at a level of detail adequate for capital
needs rather than detailed service-level planning: Inpatient Medicine;
Outpatient Primary Care; Inpatient Surgery; Outpatient Mental Health;
Inpatient Psychiatry; Outpatient Specialty Care; Outpatient Ancillary
and Diagnostic Care.
The model also projected workload demand in the following
categories, which were not used to identify gaps because private sector
benchmark utilization rates were not available to validate results:
Residential Rehabilitation; Intermediate/Nursing Home Care;
Domiciliary; Blind Rehabilitation.
Spinal Cord Injury
Since the statistical model's data validation on these non-private
sector services was not adequate for objective planning, these
categories were either removed from the Phase 1/ cycle (Le., held
constant) or, as in the case of Blind Rehabilitation and Spinal Cord
Injury, alternative forecasting models were developed by teams of VA
planners and VHA experts from the concerned special disability
programs, who collaborated to produce these unique projections.
Data on the current supply and location of VHA health care services
were collected for all facilities, markets, and VISN's. In most
instances, fiscal year 2001 was used as the source year for baseline
data. A profile was created for each VISN and made accessible to VHA
staff on a web site established as the repository for all CARES data.
Baseline data included:
<bullet> Space (condition, capacity and current vacant space)
<bullet> Workload (fiscal year 2001 bed days of care and clinic
stops)
<bullet> Unit Costs (facility specific in-house and contract unit
costs)
<bullet> Special Disability Population Data
<bullet> Access Data
<bullet> Facility List
<bullet> Research Expenditures and Academic Affiliations
<bullet> Clinical Inventory
<bullet> Potential DoD, VBA and NCA Collaborations
<bullet> Enhanced Use Lease Valuations
<bullet> Summary of VISN fiscal year 2003/fiscal year 2007
Strategic Plans
STEP 3: IDENTIFY PLANNING INITIATIVES FOR EACH MARKET AREA
Data collected in Step 2 made it possible to directly compare
current access and capacity, with quantitative projections of future
demand. ``Gaps'' were indicated in any market where actual utilization
in fiscal year 2001 was significantly less than utilization projected
for fiscal year 2012 and fiscal year 2022. Such gaps in various market
areas formed the basis for the development of ``planning
initiatives''--essentially a description of the potential future
disparity between capacity and need.
Planning Initiative Selection Teams were formed and selected
planning initiatives for each VISN and Market Area based on established
criteria for planning remedial action. Planning Initiatives were
identified in the following areas:
<bullet> Access to Health Care Services
<bullet> Outpatient Capacity (Primary Care, Specialty Care, Mental
Health). Inpatient Capacity (Medicine, Surgery, Psychiatry)
<bullet> Special Disabilities (Blind Rehabilitation, Spinal Cord
Injuries and Disorders)
<bullet> Small Facilities
<bullet> Consolidations and Realignments (Proximity)
<bullet> Vacant Space
<bullet> Collaborative Opportunities (DoD, VBA, NCA)
In addition to the Planning Initiatives, all workload changes that
resulted in gaps between predicted demand and current supply had to be
planned for, including in-house provision of services or by
contracting, sharing, or other arrangements. The requirement to manage
all projected workload was a significant addition to the planning
process; it was included in order to assure that all space needs were
addressed in the National CARES Plan. The Planning Initiatives and
their data were transmitted to the field in November 2002 to begin the
market planning process.
STEP 4: DEVELOP MARKET PLANS TO ADDRESS PLANNING INITIATIVES
AND ALL SPACE REQUIREMENTS
The selected planning initiatives formed the key elements of the
VISN CARES Market Plans. All VISN's developed market plans, which
included a description of the preferred solution selected by the VISN
for all planning initiatives identified in every market as well as
potential solutions considered to address each planning initiative.
VISN planning teams were expected to identify alternative solutions
for their plan development process. In proposing these various
alternative solutions, VISN planners were required to assemble specific
supportive data, which were entered into the IBM-developed market-
planning tool. The standardized algorithms in the market planning tool
assured a consistent methodology for analyzing each solution's impact
on workload, space and cost, as well as other CARES criteria such as
quality, access, community impact, staffing, and others.
Thus, all VISN's used the same criteria and planning tool (using
local operating and capital costs) to determine the relative merits of
meeting future demand via contract, renovation of available space, new
construction, sharing/joint ventures/enhanced use or acquiring new
sites of care. VISN's briefed stakeholders on their planning
initiatives, and presented their proposed solutions. Comments and other
feedback from stakeholders were duly noted for incorporation into the
planning process. VISN market plans were submitted to VHA Headquarters
on April 15, 2003.
STEP 5: VACO REVIEW AND EVALUATION: DEVELOPING THE DRAFT
NATIONAL CARES PLAN
The VISN plans served as input to the development of the Draft
National CARES Plan. The Draft National CARES Plan is not a compilation
of individual VISN plans. It represents a comprehensive series of
national decisions made after reviewing the individual VISN Market
Plans. Each VISN CARES Market Plan was subjected to an extensive tri-
partite review before ultimately being considered by the Under
Secretary for Health for inclusion in the Draft National CARES Plan.
The groups conducting the reviews were field and headquarters review
teams organized by the National CARES Program Office, the Clinical
CARES Advisory Group (CCAG), and the CARES Strategic Resource Group
(also known as the ``One VA Committee''). The clinical experts (CCAG)
provided the most rigorous review and comments on issues with medical
and other direct care (including mission-related) implications, while
the Strategic Resource Group took a more generalized management
approach, looking especially closely at matters concerning
collaboration with other departments or administrations.
The National CARES Program Office performed a comprehensive and
intensive review, assembling review groups to look at similar types of
planning initiatives from all VISN's, assuring a structured assessment
that was consistent across the VA system as well as an overall
assessment of whether the individual solutions within a market added up
to a sensible market plan.
The final review was by the Under Secretary for Health, who
reviewed the key issues and the comments from the diverse review groups
and stakeholders. As a result of the Under Secretary for Health's
review of the adequacy of the market plans, selected VISN's were
required to review the potential realignment of specific facilities/
campuses and to consider the feasibility of conversion from a 24-hour/
7day-per-week operations to an 8-hour-per-day/40-hour-per-week type of
operation. The rationale for the requested review was to fully assess
the potential to consolidate space and improve the cost effectiveness
and quality of VA's health care delivery. The guidance included the
continuation of all services to veterans as part of the realignment
review. The results of this initiative were completed in July 2003 and
incorporated into the draft National CARES Plan.
The product of the Under Secretary's review process and policy
decisions formed the draft National CARES Plan that I transmitted to
the CARES Commission on August 4, 2003.
STEP 6: INDEPENDENT COMMISSION REVIEW
I established the CARES Commission in December 2002 to provide an
objective and external perspective to the CARES process. It is not
expected to provide a `de novo' review of the VA medical system.
Rather, the Commission is charged with reviewing the Under Secretary's
Draft National CARES Plan so that it can make specific recommendations
to me regarding the realignment and allocation of capital assets needed
to meet the demand for veterans' health care over the next 20 years.
At the first of its monthly meetings, in February, I asked the
Commission to examine the Draft Plan with a critical and independent
eye; I also asked the Commission to report to me on the validity of the
opportunities identified in the Plan for improving our ability to
provide quality healthcare for veterans by effective deployment of
physical resources.
The Commission is made up of 16 individuals from all walks of life:
doctors and nurses, medical and nursing school professors and deans,
health care professionals, members of veterans' service organizations,
former VA officials, business managers and leaders in their
communities. Each member brings his or her special qualifications and
experiences to the Commission, as well as sensitivity to the
Commission's unique mission. Chairing the Commission is the Honorable
Everett Alvarez, Jr., who is best known as the first American aviator
shot down over North Vietnam and who was a prisoner of war for 8\1/2\
years. Among his other accomplishments, Chairman Alvarez served as
Deputy Director of the Peace Corps, and as Deputy Administrator of the
Veterans Administration for 4 years.
The Commission may accept, modify or reject the recommendations in
the Draft National CARES Plan. In making its recommendations, the
Commission will consider information gained through nation-wide site
visits, written comments from interested parties and formal public
hearings. The Commission completed 59 of its 65 site visits in July,
with some scheduled into this month. These informal tours through VA
facilities and the geographic areas they serve have included meetings
and conversations with many veterans, individuals inside the VA family,
and local community leaders. The Commission has completed over half of
its 36 formal public hearings, with the last one scheduled for October
3.
STEP 7: SECRETARY OF VETERANS AFFAIRS DECISION
I anticipate that the Commission will provide me their
recommendations and supporting comments regarding the Draft National
CARES Plan by December 2003. After reviewing their recommendations, I
will make a determination to accept, reject, or refer back to the
Commission for additional review or information prior to making a final
decision.
STEP 8: IMPLEMENTATION
VISN's will prepare detailed implementation plans for their CARES
Market Plans, which will be submitted to the Under Secretary for Health
for approval. Approved market plans will be used by VISN's to develop
capital proposals that will be selected for funding through a capital
prioritization process that is linked to the CARES process and to
subsequent strategic planning cycles.
STEP 9: INTEGRATION INTO STRATEGIC PLANNING PROCESS
As VISN's proceed with the implementation of their CARES Market
Plans, the planning initiatives and proposed solutions will be refined
and incorporated into the annual VHA strategic planning cycle. The
integration of capital assets and strategic planning will ensure that
programmatic and capital implementation proposals are integrated into
current VHA strategic planning and resource allocation. The alignment
of policy assumptions and strategic objectives will thus form an
integrated planning process.
Mr. Chairman, in a recent article in the Washington Post, Dr. David
Brown commented on VA by indicating that ``VA is the most safety
conscious, self aware, and in many ways the best run medical system in
the country.'' This is high praise indeed from a well-respected
physician, and it is my goal that the VA strategic planning process
will in every way possible reflect the standards and performance
implicitly expressed in Dr. Brown's statement. The CARES initiative is
an important step in that direction. This completes my testimony. I
will now be happy to answer any questions that you or other Members of
the Committee might have.
__________
Response to Written Questions Submitted by Hon. Bob Graham to the
Department of Veterans Affairs
Question 1. In the market plan submitted to the Under Secretary for
Health by VISN 1, officials stated they had considered ``alternatives
to consolidate Long Term Care (LTC) (including the Alzheimer's and SCI
Units) and Psychiatry inpatient beds from the Bedford to Brockton
facilities'' yet, ``as final projections are not available for LTC
inpatient beds and earlier projections indicated a substantial increase
in LTC beds, it was determined to utilize current capacities.'' Despite
these assessments to the contrary--made by those with firsthand
knowledge of the situation--VA's draft National CARES Plan proposes
that Bedford instead convert these facilities into outpatient
operations only. (a) How do you justify this disconnect? (b) If the
conversion does take place, what will happen to those patients who rely
on the Bedford VAMC's 100-bed specialized care unit for veterans with
Alzheimer's disease? Please explain how VA will ensure that these
veterans continue to get the long-term care services they so
desperately need.
Response. VA's complete response to both questions follows question
2 below.
Question 2. In addition to its specialized care unit for veterans
with Alzheimer's disease, the Bedford VAMC houses a Geriatric Research,
Education, & Clinical Center (GRECC), which is widely respected for its
innovative and practical clinical research on dementia care. The GRECC
is also a recognized leader in providing palliative care to veterans
with advanced progressive dementia. (a) How will a conversion of the
Bedford facility impact the ongoing dementia research that is presently
taking place at the Bedford GRECC? (b) Along similar lines, how does VA
plan to continue providing palliative care services to the veterans who
depend on the Center?
Response. The following response is intended to address all parts
of both questions.
The realignment proposal for the Bedford campus contained in the
draft National Plan provides that outpatient services will be
maintained at the Bedford campus. Current services in inpatient
psychiatry, Alzheimer's disease, domiciliary care, nursing home care,
and other workload from the Bedford campus will be transferred to other
VISN 1 facilities. The realignment process will also maintain special
programs such as Alzheimer units, GRECC's (including dementia
research), and palliative care, though not necessarily at the Bedford
campus. The preliminary proposal included the possibility of realigning
these programs to the Brockton campus. The remainder of the Bedford
campus will be evaluated for alternative uses such as enhanced use
leasing for an assisted living facility that would be available to
veterans. Any revenues or in kind services will remain in the VISN to
invest in services for veterans.
The realignment proposal is currently being refined and will
specifically address the needs of all programs, including the special
programs mentioned above, to ensure that patient care needs are met and
will be part of the proposal that is reviewed by the CARES Commission
and the Secretary. In addition, research associated with these programs
will be considered in the revised realignment proposal.
The LTC planning model that is currently available does not
adequately account for changes in the delivery of long-term care
services and changes in disability among the elderly population. It
overstates the future demand for Nursing Home beds. This model is
currently under revision. As a result, in this stage of the planning
process, the realignment analysis uses current nursing home capacity
rather than plan for what may be an excessive number of beds. However,
if the Secretary approves the recommendation, the results of the
improved forecasting model will be available and used to finalize the
proposal prior to implementation planning. This will ensure that future
nursing home needs are accurately assessed both for Bedford and
throughout the VA health care system.
Implementation plans to effect the transfer of programs and
services are not yet developed. However, the transition would take
place over time and in a manner that is least disruptive to patients
and their families. The final determination of the future of the
Bedford VAMC is being made in successive steps to ensure that patient
care services are maintained for veterans. Both the CARES Commission
and the Secretary will review the realignment recommendation before the
Secretary makes a final decision on the draft National CARES Plan
proposal. It is the Secretary's policy that no services will be closed
without alternative locations to provide these services to veterans.
______
Response to Written Questions Submitted by Hon. Patty Murray to the
Department of Veterans Affairs
Question 1a. My understanding is that the VISN 20 regional VA
leaders complied with all the requirements for the CARES market plan. I
fail to understand why, at the very last minute--before the plans were
sent on to the Commission--more than two dozen facilities, including
three in Washington State, were told to re-do their plans. It looks to
me that after months of reviewing VISN submissions, the VA has decided
to rewrite the rules to get the response it seeks. This undercut months
of work and more importantly it seems like a particularly disingenuous
thing to do to our veterans groups--in Washington State and in the
dozens of communities which were affected. Why was the decision made to
undercut the CARES process at the 11th hour?
Response. The Under Secretary for Health requested changes to the
market plans as a result of reviews conducted during preparation of the
draft National CARES Plan. This review was an integral part of the
design of the CARES process to ensure that the plan was truly national
in scope and not simply a compilation of the individual VISN market
plans. Rather than undercutting the CARES process, this review and the
proposed changes to the market plans were an effort to ensure that
national, system-wide issues are adequately addressed. The VISN's'
market plans contain the results of thousands of decisions regarding
how outpatient and inpatient demand will be managed, i.e., whether
space will be leased, renovated, or constructed, or whether community
contracts and 000 sharing will be utilized. Almost all of these
decisions are included as recommended in the market plans.
When the Under Secretary reviewed the results of the market plans,
he concluded that there were opportunities to realign campuses to
improve the quality, access, and resource use by examining
opportunities to move these campuses from inpatient to outpatient
operations, i.e. by converting from 24-hours, 7-days/week to an 8-
hours, 5-days/week operations. He asked the VISN's to determine how
this could be accomplished at selected sites with the provision that
there would be no loss of services to veterans. He specified that
inpatient services must be provided either at other VAMC's through
sharing agreements or in the local community through contracts. He also
stipulated that outpatient services were to be maintained on the VAMC
campus or in the local community through leasing of sites or
contracting for care.
The realignments focused on moving long-term care sites to
locations with an acute care presence because this would also improve
access to diagnostic and therapeutic services for the long-term care
population. In addition, the current physical environment in many
sites, such as Walla Walla and White City, would require significant
capital investment in older buildings. It would be more expensive to
renovate such buildings than it would be to build a new nursing home,
for example. Many patients served by long-term care facilities are
often more dispersed geographically than those served by acute care
facilities, and where contracting is combined with relocation of beds
to other VAMC's, access is likely to be improved.
With respect to the Vancouver campus, we believe we have an
opportunity to put the campus to better use. It appears to be
underutilized for inpatient care services, and we are exploring
opportunities to improve access to outpatient services at another
location.
All of the draft National CARES Plan realignments are proposals
that are being further reviewed. Additional cost benefit information
will be available to the CARES Commission and the Secretary prior to
the final decision on the National CARES Plan. Should the proposals be
approved, detailed planning would occur as part of implementation
planning.
Question 1b. Can you explain to me why headquarters desired a
significantly redrawn market plan for Washington State and VISN 20?
Response. The only changes in the VISN 20 market plan involved the
three facilities indicated in the realignment analysis mentioned above
in our response to Part A of your question.
Question 2. The stated CARES mission is to ``realign and enhance VA
health care to meet veterans' needs now and into the future.'' What I
keep hearing from the VA is a need to close existing facilities to
provide better care to our veterans; a promise to use any savings from
CARES efficiencies to enhance VA healthcare in areas with a growing
veterans population and expand coverage into currently underserved
areas. Unfortunately, veterans in my State have no recourse if any
expected cost savings don't materialize, or are directed for another
purpose. What assurances do we have that the Administration will
request enough funding to cover the costs of expanding the coverage and
enhancing care?
Response. While there are always budget constraints, the final
CARES Plan will provide a systematic data-driven assessment of the
capital requirements to meet the current and future needs of veterans.
I am committed to developing capital funding requests that will provide
the improvements and expansion of our infrastructure through the 5-year
capital planning process. In many, perhaps most, cases the savings
generated by CARES will require front end capital investments whose
savings and revenues will not be realized until all the components of
the realignment are in place and will occur over an extended timeframe.
In addition, the capital requirements associated with realignments will
receive the highest priority in developing these budget requests.
In this regard, we also note that S. 1156, marked up by the Senate
Committee on Veterans' Affairs on September 30, contains a provision
(section 402) that would authorize VA to plan and carry out major
construction as outlined in the final National CARES Plan. It would
also authorize up to 5-year contracts for these CARES projects and the
use of any combination of funds appropriated for CARES.
Question 3a. We know the final CARES plan may include the closure
of nearly 6,000 beds--hundreds in Washington State. It is my
understanding that the VA's intention is to reopen these beds in other
VA facilities or to contract out for the beds. But, I find virtually no
mention of how this will be accomplished. Are you comfortable telling
our veterans that their hospitals will be closed but hopefully beds
will be found later?
Response. The draft National CARES Plan identifies the need for
approximately 600 fewer acute care beds by 2022. These beds are spread
among 20 VISN's and do not significantly impact the future of any acute
care facilities. The number of beds affected by proposed realignments
total approximately 3,144. These are primarily Nursing Home,
Domiciliary, and Long-Term Psychiatry beds. These beds will continue to
be available either in other VAMC's or through local contracts. If the
proposed realignments are approved for the final National Plan, further
study will be required to finalize the exact distribution; however, the
majority of these beds are currently proposed for transfer to other
VAMC's.
Question 3b. How can the VA make the decision to close more than a
hundred nursing home and psychiatric beds in Washington State without
having examined the potential demand for such care?
Response. The proposed realignment maintains services to veterans
and does not eliminate the nursing home and psychiatric beds to
veterans. However, the forecasting models for Nursing Home,
Domiciliary, and long term psychiatry that were available for the VISN
market planning and the draft National CARES Plan required improvement
to accurately represent the future needs of veterans. As a result, the
demand for these beds was maintained at current capacity. This enabled
the planning process to move forward while recognizing that final
detailed planning would require projections of future demand. The
planning models that will provide this information are under revision.
If the proposals are approved, the revised planning models will be
available to ensure that final implementation planning is based on the
most accurate estimates of the expected needs of veterans.
______
Response to Written Questions Submitted by Hon. Jim Bunning to the
Department of Veterans Affairs
Question 1. Dr. Roswell, would you please give me your reasons for
proposing to close the Leestown Road Medical Center in Lexington? I
particularly want to hear what benefits you expect to come from that
and what you plan to do to offset any losses there.
Response. The CARES Commission recommended that the Lexington-
Leestown campus remain open, and that plans be developed to make the
footprint of the Leestown campus smaller, making most of the campus
available for disposition and/or enhanced use leasing. The benefits of
remaining, on the Lexington Campus, but in modernized facilities, will
alleviate any additional burden on Cooper Drive. While the mission of
the Leestown Campus will remain unchanged VA will develop a master plan
to provide for an appropriate sized footprint and consider enhanced use
lease partnerships. At the same time, the master plan will provide an
improved environment for care and maximize reuse potential of
Lexington. As you know, these actions are consistent with the
Secretary's May 7, 2004, decision for Lexington-Leestown to pursue
opportunities to reduce the footprint of the Leestown campus.
Question 2. Dr. Roswell, the current VA hospital in Louisville is
very old and the design is not suited to modern health care delivery.
What other factors made you decide to study moving the hospital and
what benefits do you expect to gain by a new partnership with the
University?
Response. Due to the poor environment of care and overcrowding at
the current Louisville VA Medical Center (VAMC), the CARES Commission
recommended that VA study the feasibility of building a replacement
VAMC for Louisville in proximity to the University of Louisville,
including the possibility of a shared infrastructure with the medical
school and the VA Regional Office (VARO). In his May 7 CARES decision,
the Secretary decided to study the need for a replacement hospital for
the Louisville VAMC, focusing on access to and quality of care as well
as referral patterns with other regional medical centers, the potential
for collaboration with the University of Louisville, and the
collocation with the VARO. The study is expected to be completed in
November 2005.
Question 3. Mr. Alvarez, what information are you looking for to
decide whether to retain the existing Louisville facility or to build a
new facility in cooperation with the University of Louisville?
Response. Due to the poor environment of care and overcrowding of
the current medical center, the CARES Commission concurred with the
Draft National CARES Plan proposal to study the feasibility of building
a replacement medical center for the Louisville VAMC in proximity to
the University of Louisville, including the possibility of shared
infrastructure with the medical school and the VBA office. As you know,
on May 7, 2004, the Secretary announced his acceptance of the
Commission's recommendation and VA will undertake a comprehensive study
of the feasibility, cost effectiveness and impact of replacing the
Louisville VA Medical Center with a state-of-the-art medical center
with a focus on access to and quality of care. Further, this
comprehensive study will consider referral patterns from other regional
medical centers, the potential for collaboration with the University of
Louisville, and collocation with the Veterans Benefits Administration.
Question 4. Mr. Secretary, I am glad that the draft proposal
recommends more clinics in Kentucky like we talked about earlier this
year. I am not sure the final cares plan can predict all locations
where clinics will be needed in the future. If the need is shown are
you willing to consider and support building more clinics even if they
are not in the final cares plan?
Response. The CARES Commission recommended that VA prioritize
community-based outpatient clinics (CBOC's) under a national framework
and continue to enhance access to care. In my May 7 CARES decision, I
prioritized 156 of the CBOC's proposed in CARES for implementation by
2012 pending availability of resources and validation with the most
current data available. This list reflects VA's priorities for planning
based upon the most current information. As VA proceeds in implementing
CARES and engages in future planning, the locations of these CBOC's may
change, but the priorities will remain constant.
For example, VA currently has 11 CBOC's in Kentucky located in
Prestonburg, Whitesburg, Somerset, Morehead, Fort Knox, Dupont,
Shively, Staniford, Bowling Green, Paducah, and Fort Campbell. Under
the CARES plan, an additional 9 CBOC's will be implemented by 2012:
Berea, Hopkins County, Perry County, London, Glasgow, Grayson County,
Graves County, Davies County, and Carroll County. An additional CBOC in
Morehead that was previously congressionally approved, but never
implemented will be opened in 2005.
VA will enhance access to care in underserved areas with large
numbers of veterans, enable overcrowded facilities to better serve
veterans, and continues to support sharing with DOD. These principles
will remain priorities even if management strategies to meet them
evolve as new data and information become available.
Chairman Specter. Thank you very much, Mr. Secretary.
We will now proceed with a round for 5 minutes for each
member.
Mr. Secretary, there has been considerable concern about
the exclusion of Category 8, which would be veterans with non-
service disabled or veterans who have income generally of less
than $23,000 a year. Do you foresee a relaxation there so that
veterans who earn more then $23,000 a year or some other
combination of non-service connected disability would allow
others to get the service? $23,000 a year does not signify that
a person could afford medical care.
Secretary Principi. Indeed, it does not, Mr. Chairman.
The answer to the question really depends upon the level of
resources that the Department receives to provide care to,
first and foremost, our core constituency, the men and women
disabled in service; the poorest of the poor, who have few
other options for health care; and third, those in need of
specialized services like spinal cord injury and blind
rehabilitation.
It is certainly my hope that, whether it be next year or
the year after, we will be able to once again reopen enrollment
to Priority 8 veterans, but our focus has been over the past
year to ensure that those men and women, both in the past and
returning from Iraq and Afghanistan today who are disabled in
combat or in training accidents are able to access the VA
health care system as well as the very, very poor, the
pensioners, the people at the poverty line. I am sure that once
we are able to do that, we are able to reduce our waiting list
to zero, then we will certainly--I certainly will consider
reopening it up to Priority 8s.
Chairman Specter. Mr. Secretary, what factors or what
events--what do you think would have to occur before you would
reopen Category 8 or at least make a modification to include
more veterans?
Secretary Principi. Well, certainly, I think it depends
directly on the level of appropriations that we receive from,
you know, requested by the President and appropriated by the
Congress and a recommendation from my undersecretary that we
can reopen the doors to Category 8s, because we are able to
meet the demands that are being placed upon the VA.
But I might say, Mr. Chairman, members of the committee,
the demands are unprecedented. Categories 1 through 7 continue
to grow dramatically in many parts of the country. More and
more veterans are coming to us for care. A significant number
are coming to us for prescription drugs, because they simply
cannot get it, as we all know, in the private sector.
They have Medicare physicians. They are getting medical
care, but they cannot get the prescription drugs, and they are
coming to the VA in record numbers.
Chairman Specter. Mr. Secretary, there had been a
preliminary staff review, which suggests that the real focus
here is on psychiatric institutions like the one at Highland
Drive in Pittsburgh, which is a facility for 1,000 people and
is largely vacant, has only about 150 people, and some of those
are homeless.
The treatment for psychiatric patients has now changed
dramatically with drugs, with integration into the community.
Is a major thrust of the CARES project here the re-evaluation
plan being directed toward psychiatric hospitals?
Secretary Principi. Acute psychiatric care is clearly
considered in our plan. What we are doing in the VA is we are
developing a new, long-term care psychiatric model to address
the long-term psychiatric care, institutional care needs of our
nation's veterans. But as you said, the focus in our Nation has
been on community reintegration of the mentally ill back into
the community, and we are able to do that because of
revolutionary new drugs, but we also have to have the non-
institutional care programs and the community support services
available to care for these veterans and, you know, all
Americans who are moved from mental institutions.
I believe that mental health is a very important core
mission of the VA. It may not be as glamorous as some of the
other things that are being done, but it is very, very core;
very important: PTSD, substance abuse, chronic mental illness--
--
Chairman Specter. Mr. Secretary, let me interrupt you. I
have got 16 seconds left.
Secretary Principi. Sure.
Chairman Specter. I want to ask one more question, and I am
going to observe the red light.
You say you will accept the plan only in its entirety. Do
you think that the law constrains you to take it all or none?
Secretary Principi. No, sir.
Chairman Specter. Or why would you not exercise some
discretion?
Secretary Principi. I will exercise----
Chairman Specter. I will note the red light went on with
the conclusion of the word discretion.
Secretary Principi. The law does not constrain me. I just
did not want to be in a position to politicize this report by
picking and choosing. I wanted to work closely after the
commission submitted their report to me to address concerns
that I might have, questions I might have, with regard to some
of their recommendations and ask them to go back and to
reassess it.
But I felt that politicizing this report would destroy its
integrity and perhaps doom our entire effort. But I am not
constrained by law.
Chairman Specter. Senator Nelson.
OPENING STATEMENT OF HON. BILL NELSON, U.S. SENATOR FROM
FLORIDA
Senator Nelson. Thank you, Mr. Chairman.
Mr. Secretary, as I described, in rural markets, we are
having problems with veterans who have to drive long distances.
Do you feel like we are serving our veterans in this area by
placing the CBOC proposals in the Priority 2 category? It seems
to me that that is a significant question, and I would be
interested in what you think about that.
Secretary Principi. Well, as you know, Senator, over the
past several years, the VA has moved very dramatically into
outpatient care. Prior to the mid-1990's, if I am correct, Dr.
Roswell, the VA had no freestanding community-based outpatient
clinics, and it has been a dramatic change that today, we have
close to 700 community-based outpatient clinics; thereby,
veterans in rural areas do not have to drive 4, 6 hours to a VA
medical center to get care. They can access it much closer to
their homes.
So we have literally gone from 0 to almost 700. This plan--
and Dr. Roswell can comment--it calls for, I believe, another
48 community-based outpatient clinics. But we have to maintain
balance. We have to preserve our inpatient care capability and
our outpatient care. We cannot afford to go too far in one
direction, because at some point in time, those veterans are
going to need to get into inpatient care. That is why we have--
Dr. Roswell, you may want to comment.
Dr. Roswell. Yes. Let me just add, Senator Nelson, that the
Priority 1 CBOC's recommended in the national plan were those
CBOC's where 7,000 or more veterans failed to meet the access
criteria established in the plan. Unfortunately, the CBOC's
proposed for your State did not meet those criteria. There were
fewer than 7,000 veterans in those locations who would be
served by a new CBOC. That is not to say, though, that they are
taken out of the plan. A very important construct of the
national plan that I forwarded to the CARES Commission was that
the recommendations in the national plan augment what is in the
existing plan. We still recognize all 262 CBOC's proposed in
each of the VISN market plans as bona fide requests, and
certainly, the ones from your State are included in that list
of 262. But the national plan, of necessity, had to identify
our highest priority, hence, those 48 included only those
CBOC's where 7,000 or more veterans would now meet access
standards.
Senator Nelson. Chairman Alvarez, is the CARES Commission
considering at the present time changing the priority grouping
for these CBOC proposals, or are you going with the initial
recommendations, if you know?
Mr. Alvarez. At this time, we are not going along with
anything. We are not sticking with any or making any changes.
We are in the process of gathering information, and we are
holding hearings around the country at this time. When we
finish that, we will take all of the information that we have.
I must add that we continually, as we go through the hearing
and the data gathering process, continue to ask for more
information.
But I can assure you that this is one area that we have a
special interest in also. We have noted the large number of
veterans who have to travel long distances for access to
primary care, and of course, that is one of the charges I have
given the members is to take a good look at that, understanding
the Priority 1, Priority 2 categories, but look at everything
very closely, so no, we are not following any special standard.
Senator Nelson. Mr. Secretary, as we were speaking about
the creation of new veterans every day, are there any studies
underway right now with respect to the wounded in terms of
location as to where their future needs may be and how those
special needs might be met as well as the current needs and the
changing needs of areas? Perhaps Dr. Roswell would want to
address that.
Dr. Roswell. Certainly, with the Secretary's leadership, we
are working in an unprecedented manner with the Department of
Defense to identify casualties coming out of Operation Iraqi
Freedom. To date, there have been 6,000 men and women who have
been evacuated from that theater of operations. We are working
very closely with DOD to track all of those.
Fortunately, the vast majority of them have non-life-
threatening illnesses, and in fact, many of them may return to
active duty. But where there are serious illnesses, it will
certainly lead to future health care needs through the
Department of Veterans Affairs and disability compensation
benefits. We have established a very comprehensive program to
identify those veterans and make sure they get their disability
benefits, the services through the Department as well as the
health care that is needed.
Secretary Principi. We have full-time employees up at
Walter Reed, at Bethesda, participating in the discharge
planning process, so that we know when they leave Bethesda,
Walter Reed, and go back to Omaha, wherever, that they do not
fall through the cracks; that they are enrolled, and when they
get to the VA, their name is in the computer. I think that is a
very important step.
Senator Nelson. Thank you.
Thank you, Mr. Chairman.
Chairman Specter. Thank you very much, Senator Nelson.
Senator Hutchison.
Senator Hutchison. Thank you, Mr. Chairman.
Mr. Secretary, I think the most shocking thing that you
have said here today is what the Chairman picked up on, and I
did as well, that you do not intend to pick and choose among
the recommendations. What I am concerned about is that while
the committee will be charged with looking at the very best way
to give the best service to veterans, it will be only the
Secretary and the Department that could put the efficiencies
and the budgetary issues and also the issues of where different
services are given together to make a final decision.
So my question is: how are you going to put the overview on
the commission findings so that you would be the one who could
say certain areas could be addressed that perhaps the
commission would not have the information to even put into the
system?
Secretary Principi. Once I receive a report and study it
very, very carefully, it would be my intention to work closely
with the members of the commission, the chairman of the
commission, to address any issues that I believe need further
refinement or perhaps need to be changed; that I have a
question about or a concern about, and I will not approve the
report until such time as I am convinced, in my own mind, that
from both a local and a national perspective, it is correct.
I just did not believe it would be appropriate, once I had
all of those questions asked and answered and my concerns
addressed to start, you know, picking and choosing. I wanted to
adopt this plan in its entirety to ensure that, from a national
perspective, looking at all of the different markets, all of
the different networks, that this plan promotes the delivery of
health care, access and quality of health care across the
nation. But I can assure you, Senator, that I will work very,
very closely with the Chairman of the Committee to ensure that
all the issues are addressed.
Senator Hutchison. Well, I am going to take it from that
that you will provide the overview within the process before
there is a final----
Secretary Principi. Most assuredly.
Senator Hutchison [continuing]. Plan adopted.
Secretary Principi. Most assuredly, Senator.
Senator Hutchison. Second, let me ask you, because I know
two of my communities have asked this question, and I would
assume it would probably be throughout the country, but my two
communities would like to have some ability to offer help to
make a hospital more effective. What would be the process for
them to be able to do that? They have the hearings, but if they
do not know exactly where you and your overview are going, they
might not know what they could offer that would be helpful. So
how are you going to accommodate that before the final, final
decision to actually close a facility?
Secretary Principi. Well, I would certainly hope that
communities would make those views known to the members of the
commission when they testify; certainly submit proposals to the
commission or to the undersecretary for any collaboration that
might assist one way or the other in the disposition of what is
going to happen at that facility and then certainly after the
report is submitted can submit that to me.
So I would believe that right now, the commission is in the
phase of holding hearings, gathering data and input from the
communities, and community involvement and community impact is
an important consideration for the commission. So I would
suggest, Senator, that they make those views known to the
commission, the commission staff here in Washington, and if
there is any difficulty in getting that information to us, I
would be more than happy to assist.
Senator Hutchison. Well, let me just ask----
Mr. Alvarez. May I?
Senator Hutchison. Yes.
Mr. Alvarez. In addition to what the Secretary just stated,
what we are finding out is that there are a number of proposals
that have come forth from the community affecting the plans.
What we have found is that these people in the communities have
already worked with the local VA people through the VISN
director's office and have establishing relationships and are
working on their portions. So I would offer that as another
opportunity, because as a reviewing committee, we became aware
of it and keep an eye out for it when it comes up.
But I think the bulk of the work can be initiated through
the undersecretary.
Senator Hutchison. OK; thank you. I see my time is up. But
there will be a second round?
Chairman Specter. No, we are going to have to move on,
Senator Hutchison. Would you care to ask an additional question
or two now?
Senator Hutchison. Well, yes. Let me just ask Mr. Alvarez:
would you have in your purview also looking at the VISN
recommendations that did not make it to the final draft plan?
Mr. Alvarez. Yes, Senator, we have access to all of that
information.
Senator Hutchison. And will you look at those----
Mr. Alvarez. We will look at that plan.
Senator Hutchison [continuing]. As part of your
decisionmaking?
Mr. Alvarez. We are asking questions not only about the
national plan but also about the market plans that were
submitted. So that is part of the----
Chairman Specter. Senator, there will be an additional
round as to the other witnesses.
Senator Hutchison. Oh.
Chairman Specter. I was really referencing that as to
Secretary Principi.
Senator Hutchison. Are the other witnesses going to speak
and then have questions?
Chairman Specter. Secretary Roswell is not going to be
offering an opening statement and is prepared to submit to
questions.
Senator Hutchison. But Mr. Alvarez will?
Chairman Specter. Will, too. Mr. Alvarez will, too, so
there will be another round.
Senator Hutchison. OK; well, let me just finish, then, with
Mr. Principi one other question, and that is the one concern I
have about a community coming forward with some suggestions is
that you might have, in the back of your mind, a different use
for the facility that the community could then say we will be
able to provide, say, a private developer for an extra building
with a leaseback or something that they might not know is in
your mind. So will there be some process by which you could say
we are looking for an opportunity to see what you could put
forward in this realm, if it is different from what they are
doing now?
Secretary Principi. Absolutely. Senator, this is a planning
process that will result in a series of recommendations and
from that point becomes a very critical stage of looking toward
the implementation of this plan. I would highlight here that
this is a 20-year plan and that some of the changes would take
place in the first few years, but this is scheduled to be
phased in over a 20-year period as the demographics of the
veteran population change. So it is not going to happen all in
year one or year two.
The second important point to mention for all members of
the Committee is that it certainly is my intent not to sell
this VA property, to excess it, to board it up. It is my intent
and my hope that through the enhanced lease use authority that
you have given us by statute that we can convert some of these
properties that are underutilized into projects such as
assisted living to meet the long-term care needs, the assisted
living needs, of our nation's veterans or for other purposes
that provide services to veterans.
So I expect that we will be maintaining this property, but
we will be transforming it in many different ways. Of course,
the community would play a major role in whatever decision is
ultimately made.
Senator Hutchison. Thank you very much.
Thank you, Mr. Chairman.
Chairman Specter. Thank you, Senator Hutchison.
Senator Miller.
Senator Miller. Mr. Secretary, have you received the input
and participation, are you getting it that you hoped to get
from the veterans' organizations?
Secretary Principi. Yes, we have, and we have really----
Senator Miller. You have probably gotten more than you
wanted?
Secretary Principi. Well, we have certainly tried to make
that an important part of this process, and I think one of the
criticisms early on, when that first phase was started, was
that there was little input. When I changed this process
around, I wanted to ensure, to the degree that we could, that
the stakeholders had an input. Of course, a lot of that
information and preliminary plans had to come to Washington for
a national perspective, and some changes were made by the Under
Secretary, and he can address those. But clearly, that was an
important part.
Senator Miller. I agree.
This is a question probably for Dr. Roswell. Explain to me
how the medical facilities on the military installations, how
are they worked into this process exactly.
Dr. Roswell. In the formulation of the national plan, we
had three representatives from the Department of Defense who
worked very directly with us and considered a large number of
potential collaborations. In fact, upwards of 70 different
potential collaborations between VA and DOD were considered.
Twenty-one were identified as high priority in the national
plan and went forward as projects to be pursued in
collaboration with the Department of Defense.
Senator Miller. I cannot help but wonder, though, what
would happen if BRAC comes along and closes those that you have
worked into that.
Dr. Roswell. Well, certainly, that is a concern that we
have addressed. That is why we have asked for DOD input.
Obviously, no one can foretell what the next round of BRAC will
bring. But I think the collaboration and the highest and best
use of Government facilities, be they VA or DOD, to better
serve all Americans, certainly, is a laudable use of Government
resources that would surely be considered by a BRAC process in
the future.
Secretary Principi. I think there is a growing realization,
Senator, that the military and the VA need each other. You
know, we are two very large health care systems in this
country, the largest direct health care providers in America,
and we are both national resources, in my opinion, to the
American people. By working together, we can provide more care
to more people in a more cost-effective manner. That is why
sharing makes a great deal of sense. We are doing that at
Kirkland in Albuquerque. We are doing it in Nevada. We are
doing it in Alaska. We are doing it out at Tripler in Hawaii.
Across the country, we are finding the military and the VA are
working closer together than ever before. I think that is good
news for military people, for veterans and for the American
people.
Senator Miller. I share that belief.
Thank you.
Chairman Specter. Thank you, Senator Miller.
Chairman Specter. We are now going to have another round
with Chairman Alvarez and Secretary Roswell. We had intended
the first round to be on Secretary Principi, but we are
flexible, and when the questions have gone to the other
witnesses, that is fine.
Dr. Roswell is the deputy undersecretary and, in that
capacity, heads the Veterans Health Administration. He has an
excellent background, having directed VA's health care networks
for Florida and Puerto Rico. He had served in Birmingham,
Alabama and Oklahoma City. He is a 1975 graduate of the
University of Oklahoma School of Medicine. I would like to say,
on a parenthetical personal note, I went to the University of
Oklahoma for a year myself at the start of my college career. I
notice that Senator Nelson is not going to touch Oklahoma and
Nebraska, at least at this point.
[Laughter.]
Chairman Specter. Chairman Alvarez is a member of the Bar
of the District of Columbia. He served as deputy administrator
of the Veterans Administration from 1982 to 1986 and deputy
director of the Peace Corps from 1981 to 1982. But I think his
most remarkable public service occurred on August 5, 1964,
when, as a young lieutenant, junior grade, he was the first
American pilot shot down over North Vietnam; 8\1/2\ years in a
prisoner of war camp in North Vietnam, as described in his
book, Chained Eagle, the circumstances relating to that. For
those who have read the book, it is very inspirational. So we
thank you for your great service, Chairman Alvarez, taking on
this job. We will start a second round of questions as to both
Dr. Roswell and Chairman Alvarez.
Dr. Roswell, as I stated, is only responding to questions;
does not have an opening statement. If you would care to make
an opening statement, Chairman Alvarez, we would be pleased to
hear it.
STATEMENT OF EVERETT ALVAREZ, JR., CHAIRMAN, CAPITAL ASSET
REALIGNMENT FOR ENHANCED SERVICES (CARES) COMMISSION, U.S.
DEPARTMENT OF VETERANS AFFAIRS, WASHINGTON, D.C.
Mr. Alvarez. Thank you, Mr. Chairman. I have submitted a
statement for the record, and if it is all right with you, I
will just summarize it.
Chairman Specter. Fine. The full statement will be made a
part of the record, and we will welcome your summary.
Mr. Alvarez. Thank you.
As stated in the CARES Commission charter, Secretary
Principi established our commission in December of 2002 to
bring an objective and external perspective to the CARES
process. The parameters set for the 16-member commission that
we have are straightforward. First, we are to review the
proposed realignment and allocation of capital assets described
in the undersecretary's draft national CARES plan in order to
determine whether the proposals reasonably assess and meet the
demand for veteran health care over the next 20 years, with the
understanding that the goal is to enhance VA's health care
services. Then, we will make specific recommendations to the
Secretary.
I want to state that our mission is not to provide a `de
novo' review of the VA medical system or to rebuild the
proposed plan. In accordance with our charter, we may accept,
modify or reject the recommendations in the draft national
CARES plan. We will provide our rationale for any positions
that we take. Further, in making these recommendations, we will
consider information that we are gaining from involved parties
that speak at our meetings and through our nationwide site
visits; written comments from interested parties and formal
public hearings that we currently are holding.
By dividing into groups, our commission was able to visit
59 VA facilities in July, and we will have visited nine more by
the end of this month for a total of 68 site visits. These
informal tours through VA facilities and the geographic areas
they serve have included meetings and conversations with many
veterans, individuals inside the VA family and local community
leaders. In addition, currently, we have completed over half of
our 36 formal public hearings, with the last one scheduled for
October 3. The selection of the sites for all of the public
hearings was made with careful consideration of many factors,
and this deliberative process included coordination with many
of the VISN staffs and their directors, reviewing market plans
and taking into account the public access to the hearings.
The locations were selected to provide access to concerned
individuals from all markets covered at each hearing. Where
appropriate and available, we are also providing video feeds
from the hearings to medical centers in some locations to
ensure easier access for attendees who might otherwise not be
able to personally view the proceedings.
Thousands of individuals have attended these public
hearings so far, and we have heard from the local population
mostly impacted by the draft plan. Oral testimony has usually
been sought from local veteran service organizations, employee
organizations, academic affiliates, organizations with
collaborative relationships and involved local elected
officials. We have also welcomed Members of Congress who have
either submitted their views personally or through written
statements, and we have also received, as of this week,
comments from over 11,500 individuals.
Let me conclude by thanking you for the opportunity to
advise you of the work of our commission. I believe it is a
deep honor and a responsibility I take very seriously to serve
as the chairman of the CARES Commission, and I hope that our
counsel will assist Secretary Principi and the Department of
Veterans Affairs in its goal to effectively realign and
allocate VA's capital assets to meet the demand for health care
services for our well-deserving veterans over the next 20 years
and beyond.
Thank you very much.
[The prepared statement of Mr. Alvarez follows:]
Prepared Statement of Everett Alvarez, Jr., Chairman, Capital Asset
Realignment for Enhanced Services (Cares) Commission, U.S. Department
of Veterans Affairs
As you know, and as stated in the CARES Commission Charter,
Secretary Principi established the CARES Commission in December 2002 to
bring an objective and external perspective to the CARES process. The
parameters set for the 16-member Commission are straightforward: the
Commission is, first, to review the proposed realignment and allocation
of capital assets described in the Under Secretary's Draft National
CARES Plan in order to determine whether the proposals reasonably
assess and meet the demand for veterans' health care over the next 20
years, with the understanding that the goal is to enhance VA's health
care services. We will then make specific recommendations to the
Secretary.
At the first of our monthly meetings, in February, the Secretary
asked the Commission to examine the Draft Plan with a critical and
independent eye. He also asked us to report to him on the validity of
the opportunities identified in the Plan for improving VA's ability to
provide quality healthcare for veterans by effective deployment of
physical resources. We intend to fulfill this responsibility.
Our mission is not to provide a `de novo' review of the VA medical
system or to rebuild the proposed Plan. In accordance with the
Commission Charter, the Commission may accept, modify or reject the
recommendations in the Draft National CARES Plan. We will provide our
rationale for any positions we will take. Further, in making these
recommendations, we will consider information gained from involved
parties speaking at our meetings and through nationwide site visits,
written comments from interested parties and formal public hearings.
We will also rely on our own experiences. Over time, and in
conversations with my colleagues, we have recognized and agreed that,
in appointing the Commissioners, the Secretary identified and appointed
individuals whose qualifications, taken together, supply a sound basis
for fulfilling this mission. The commissioners come from all walks of
life--doctors and nurses, medical and nursing school professors and
deans, health care professionals, members of veterans service
organizations, former VA officials, business managers and leaders in
their communities. We also have learned to recognize and depend upon
the special backgrounds and experiences each of us brings to the
Commission, and have noted each other's deep sense of commitment to the
Commission's unique mission to benefit America's veterans.
Before we can make our recommendations to the Secretary, as I
stated earlier, we will consider information gained through our
meetings, nation-wide site visits, written comments from interested
parties and formal public hearings.
At our monthly meetings, we have heard from and questioned
representatives from the CARES office and the contractors who developed
the underlying model to the Draft Plan. We also have heard from others,
from within and outside VA, such as representatives from Veterans
Service Organizations, employee organizations, medical affiliates,
experts in modeling, enhanced use opportunities, and Federal property
management and from the GAO.
By dividing into groups, the Commission was able to visit VA
facilities in 59 locations in July and will have visited 9 more by the
end of this month, for a total of 68 site visits. These informal tours
through VA facilities and the geographic areas they serve have included
meetings and conversations with many veterans, individuals inside the
VA family and local community leaders.
In addition, we have completed over half of our 36 formal public
hearings, with the last one scheduled for October 3. The selection of
the sites for all of the public hearings was made with careful
consideration of many factors. This deliberative process included
coordinating with the many Veterans Integrated Service Networks, or
VISN's, reviewing market plans, and taking into account public access.
The locations were selected to provide access to concerned individuals
from all markets covered at each hearing. Where appropriate and
available, we also are providing video feeds from the hearings to
medical centers in some locations to ensure easier access for attendees
who might otherwise not be able to view the proceedings.
The CARES Commission's public hearings are formal proceedings where
invited witnesses submit written testimony and answer the
Commissioners' questions. Thousands of individuals have attended these
public hearings, where we heard from the local population most impacted
by the Draft Plan. Oral testimony has been sought from local Veterans
Service Organizations, employee organizations, academic affiliates,
organizations with collaborative relationships and involved local
elected officials. We have also welcomed Members of Congress, who have
either submitted their views personally or through written statements.
We also have received, as of the beginning of this week, comments from
11,500 individuals.
Before we begin our deliberations, however, we will hold, in this
very room, our first National Meeting since the Draft National CARES
Plan was issued where we will hear from parties outside of the
Department of Veterans Affairs. This meeting is scheduled for Tuesday,
October 7. We are inviting, from both the Senate and House of
Representatives, the Chairmen and Ranking Members from the Veterans
Affairs Committees and Appropriations VA, HUD and Independent Agencies
subcommittees. We also are inviting leadership from Veterans Service
Organizations, the Department of Defense, national Veterans Affairs
employee organizations and national medical and nursing affiliate's
organizations. As a final step in the Commission's information
gathering process, and as we prepare to begin formal deliberations, we
have asked these leaders to provide a national perspective on the CARES
process and the Draft National CARES Plan to the entire Commission. We
believe hearing their opinions provides an essential and valuable
contribution to the Commission. The meeting is scheduled to begin at
8:30 a.m.
Let me conclude by thanking you for this opportunity to advise you
of the work of the Commission. I believe it is a deep honor, and a
responsibility I take very seriously, to serve as the CARES Commission
Chairman. I hope our counsel will assist Secretary Principi and the
Department of Veterans Affairs in its goal to effectively realign and
allocate VA's capital assets to meet the demand for health care
services for our well-deserving veterans over the next 20 years. Thank
you.
Chairman Specter. We will now proceed to 5-minute rounds
for each of the members.
Dr. Roswell, are you in a position to give categorical
assurance to the veterans in the Pittsburgh vicinity that
before the Highland Drive facility is closed that there will be
a replacement facility opened.
Dr. Roswell. I cannot give a categorical assurance,
because----
Chairman Specter. How about a plain assurance.
Dr. Roswell. Well, obviously, the University Drive
division, where those patients are planned to be relocated,
will require some structural renovations that will be dependent
upon construction appropriations being available to the
Department, but I can give you an absolute assurance that we
will not separate any veteran from care that is currently being
received unnecessarily.
Chairman Specter. Not separate them unnecessarily, you say?
Dr. Roswell. In other words, we will not----
Chairman Specter. In what context did you use the word
unnecessarily?
Dr. Roswell. We will be sure that all care provided to
veterans is continued throughout this process.
Chairman Specter. Well, you do not know about the
appropriations for the other facilities; OK, you do know, you
do have the power to control not closing down Highland Drive
until the replacements are there.
Dr. Roswell. That is correct, and that would be the intent.
The Secretary spoke of VISN 12. We have had a situation where
patients could be relocated to an existing facility without the
need for new construction, although new construction was
planned as a further enhancement of that campus. In those
situations, patients were moved.
Chairman Specter. Well, OK, but what you are saying is that
Highland Drive is not going to be closed until you can
accommodate the veterans in the area at the new facility.
Dr. Roswell. That is correct.
Chairman Specter. OK. Moving on to Butler and Erie and
Altoona, Pennsylvania is a fairly popular State on the hit
list. Does that have anything to do with my being Chairman?
Dr. Roswell. No, sir, it does not.
Chairman Specter. OK; I am advised that the network
director did not recommend the changes as to Butler, Erie or
Altoona, and I am also advised that it is OK for me to say
that, not revealing any confidences in making that disclosure.
It is important to know things; it is also important--not
important; indispensable to maintain confidences, but we are
not disclosing any confidences.
Now, as to Butler, there seems to be a view that because it
is small, it ought to be closed. I hope you will not make that
distinction, because there are many facilities which are small.
I go back to my early days in the State of Kansas where
everything is small. It might even apply to Nebraska. What is
the thinking, Dr. Roswell, on closing someplace because it is
small?
Dr. Roswell. Well, our first priority is to make sure that
we provide world-class care to veterans and to do that to an
increasing number of veterans in the years ahead. Let me point
out that the CARES plan actually will enhance our ability to
provide services to----
Chairman Specter. Dr. Roswell, I have got two more
questions in a minute and 44 seconds.
Dr. Roswell. With regard to Butler, there are only a very
small number of acute beds, just 30 miles away from a world-
class facility at Pittsburgh. That is our recommendation, to
move that acute inpatient care there. But we would preserve the
nursing home care and the outpatient care that currently is
provided with very high quality at Butler.
Chairman Specter. Let me urge you not to make decisions on
the basis of size smallness, and let me urge you to travel
Route 8 from Butler to Pittsburgh before you make the final
decision.
As to Erie, the plan is to cease inpatient surgical
services, and my review and the information I have pretty
conclusively is that the inpatient surgical services are very
good, notwithstanding the contention that because they are
limited, they may lose their skills. What is your thinking on
Erie?
Dr. Roswell. Actually, our recommendation in the national
plan is to discontinue acute inpatient surgery but to maintain
a surgical observation unit and allow the staff to continue to
perform outpatient surgeries.
Chairman Specter. Why the limitation?
Dr. Roswell. Because the average daily census in 2002 at
Erie on the surgical service was three patients. We do not
believe that provides sufficient numbers of patients to justify
or to provide the high quality of care that is required of our
patients not only by the surgeon but by the entire
perioperative team.
Chairman Specter. Well, I hear those surgeons have access
to other work to keep their skills sharp.
My last question in the eight remaining seconds is as to
Altoona, you talk about a critical access hospital. What does
that mean?
Dr. Roswell. A critical access hospital is a hospital that
basically recognizes that small hospitals are needed, just as
you have said, Mr. Chairman, in certain locations. The inherent
danger with quality in a small hospital is if the staff are
tempted to provide care beyond their capability. In many cases,
we have part-time physicians who maintain their skills, but let
me point out that in situations such as Erie, the nursing
staff, the postoperative staff, are generally full-time VA
employees, and they need to maintain their skills as well to
assure that quality care is continued. We believe we can do
that on an outpatient basis, but on an inpatient basis, we have
to maintain the integrity of the entire staff.
A critical access hospital would not normally provide
surgical care other than limited outpatient care. It would be
designed to provide inpatient care for less-complicated
inpatient requirements that normally could be managed
definitively within a 96-hour period of admission. For patients
who require inpatient surgical care or more intensive inpatient
care, including ICU stays, the recommendation would be to
stabilize those patients and transfer them to a world-class
tertiary facility such as the one in Pittsburgh.
Chairman Specter. Senator Hutchison. Pardon me, Senator
Nelson.
Senator Nelson. Thank you, Mr. Chairman.
With respect to changing acute care hospitals to critical
access hospitals, it is my understanding that the VA uses the
Medicare definition generally. But in the case of the Cheyenne
Medical Center, that apparently is not the case, because the
average stay there is considerably longer than in the case of a
critical access hospital. But, yet, you want to switch it to
that.
It has a great impact on Nebraskans. One thousand
Nebraskans utilize that center. In the past fiscal year, there
were 3,578 visits by 1,000 Nebraskans for acute care at about
130 hours above the 96-hour threshold. Yet, you are in the
process of apparently recommending changing that category. Can
you explain to me why that is the case and, also, how that is
going to improve care for those Nebraskans and others who use
the hospital?
Dr. Roswell. Well, ultimately, Senator, we believe that the
veterans in western Nebraska are entitled to the same standard
of care as veterans are anywhere in the nation, and we want to
make sure that that care is high-quality care and accessible.
Sometimes, that is not possible because of the sparse
populations.
In the case of the Cheyenne, Wyoming facility, the level of
surgical care is somewhat limited, but the level of expertise,
the imaging support, the technology support for the hospital in
Cheyenne is less comprehensive than it is, for example, in
Denver. We still believe that that hospital serves a very----
Senator Nelson. It is a long way to Denver.
Dr. Roswell. It certainly is. There is no question about
that.
But we believe that we have to assure that patients who
receive care at that facility receive the very best possible
care we can provide. The recommendation to make it a critical
access-like hospital would be to limit complex surgical care
and to attempt to reduce stays on average to 96 hours.
Senator Nelson. Well, I applaud the effort at trying to get
quality care, because the last thing we want is a reduction in
quality care. But the access issue and the ability of people to
be able to get that access continues to be in doubt. Would you,
for example, be able to certify the hospital, which is not a VA
hospital but could become an approved hospital, in Scottsbluff,
which is a full-service hospital with regard to everything? I
mean, I think we have to have a plan other than saying go to
Denver, and I appreciate the fact that Mr. Alvarez is picking
up on where I am going, because I think it is not going to be
unique to Nebraska; obviously, it is going to have implications
for Texas. The whole VISN 23, a very rural area, is going to be
affected by very similar decisions.
Dr. Roswell. I certainly agree with the premise, and let me
point out that in the national CARES plan, reliance upon
contract hospitalization, access to tertiary services
contracted locally in the community, is a key feature, and it
is a current deviation from VA's existing policy. With me today
is the acting director of our national CARES program office,
Mr. Jay Halpern, and he may wish to address that further.
Mr. Halpern. Senator, we are absolutely committed to
maintaining services that are accessible. In areas where there
are those tertiary capabilities that meet those standards, we
would want to contract with them. In addition, we will be
developing our own critical access hospital policy. Ninety-six
hours right now is what Medicare uses. I do not know that we
are fixed to that length of stay. We have to develop our own
policy that makes sense for us. But certainly, that is the
intent.
Senator Nelson. Well, can you give me a categorical
assurance that before people are told in Western Nebraska that
they can no longer go to the Cheyenne Medical Center because of
the change you will have a contract in place with another
facility in closer proximity to those veterans? Because I think
that is the question, and that has to be the goal.
Dr. Roswell. It is unequivocally the goal, that we enhance
access to services, including outpatient care, inpatient care,
surgical care, and all types of care that veterans might need,
including those in Western Nebraska. We will do everything that
we possibly can. That is as close of an assurance as I can give
you.
Senator Nelson. It is not quite categorical, but it is
moving in that direction.
Dr. Roswell. Thank you.
Senator Nelson. Thank you.
Thank you, Mr. Chairman.
Chairman Specter. Thank you, Senator Nelson.
Senator Hutchison.
Senator Hutchison. Thank you, Mr. Chairman.
Let me just ask Dr. Roswell: the VA estimates that the
number of veterans most in need of long-term care, 85 years of
age and older, will more than double to about 1.3 million in
2012. Yet, I am told that the CARES planning process did not
take into account the long-term care and outpatient mental
health needs projections. So how are you going to care for
those people that you are projecting to have such an increase
in population?
Dr. Roswell. Well, actually, Senator, we believe that the
population over 85 will triple by 2012, so your point is
extremely well-taken. We are very concerned about providing
long-term care to older veterans, and we will have a
substantial burden. We have preserved the current long-term
care capacity in the national CARES plan. We believe, however,
we need to carefully examine our long-term care policies to
determine what mix between institutional and non-institutional
care will be required to meet the future demand.
We also have been criticized, and understandably so, for
proposing to close hospitals when we, in fact, might need those
facilities to provide nursing home care to older veterans if
institutional care becomes a requirement. We have learned,
through very painful experiences, that when you convert a 50-
year or older hospital which was designed for hospital care a
half-century ago to a nursing home, you wind up with a
substandard nursing home, and the cost of such conversion is
approximately twice the cost of new construction.
So we anticipate that, in fact, when we are able to further
determine the definitive long-term care policy, we may need
additional long-term care beds. But we believe veterans deserve
the best long-term care facilities, and that would be new
construction in lieu of converting a 50-year-old hospital to
inadequately meet the long-term care needs.
Senator Hutchison. Thank you, Mr. Chairman. I asked my
other question of Mr. Alvarez earlier, and I appreciate that
opportunity. Thank you.
Chairman Specter. Well, I will return to the questions that
I asked you that really could not be answered in the course of
the 8 seconds that we had left, and we will be submitting some
additional questions for the record. But when we are talking
about the medical center in Erie, and we are talking about
enough cases to have adequate competency, you cannot maintain
sharp surgical care if a surgeon does not have enough cases.
But it is my understanding that although the surgeons would
have only a few cases at the VA facility, they would have other
practices privately where they are maintaining their skills, so
that there is really no reason to close Erie because the
doctors do not have adequate surgical skills. Is that not
correct?
Dr. Roswell. The premise that you presented is a correct
premise, that the surgeons, in fact, may maintain their
surgical skills by practicing in venues other than the VA
facility. However, just as important if not more important is
the anesthesia staff, the post-anesthesia recovery staff, the
surgical nursing care that is provided within the first 24
hours postoperative and then the continuing surgical care that
is provided by the nursing staff.
In those professions, not physicians but still valuable
members of the health care team, nursing personnel need to
maintain their skills with regard to surgical care and
postoperative surgical management, and it becomes more
difficult to maintain that skill set in that population of
professionals.
Chairman Specter. Well, Dr. Roswell, have you analyzed
those collateral skills and come to the conclusion that they
are not sufficiently active to maintain those skills.
Dr. Roswell. We have looked at that both within the
Department; we have looked at that through our National
Surgical Quality Improvement Program. We have looked at the
results of the leapfrog group, which is----
Chairman Specter. How about at Erie?
Dr. Roswell. At Erie, I have not personally or specifically
looked at that.
Chairman Specter. Well, have your subordinates.
Dr. Roswell. Again, let me ask Mr. Halpern to address the
situation at Erie.
Chairman Specter. Mr. Halpern, we had not expected you to
testify, so we have not extolled your virtues. But let the
record show that you are the acting director of CARES; have
been that since December 2002; that you have 35 years in the
Federal Government in a variety of health care capacities, and
we will include your resume in the record. It is very
distinguished.
Mr. Halpern. That is very fine. Thank you, Senator.
Chairman Specter. Now, you may answer, now that you have
been accredited.
Mr. Halpern. What I would add to Dr. Roswell's comment is
that it is not just about today's practice of medicine and
practice of surgery. It is looking into the future. It is very
hard for a small facility to acquire the technology, the
diagnostic and interventional technologies that are
increasingly a part of modern-day surgery. So it is very
difficult for staff, in fact, to be skilled in those particular
areas, particularly support staff, the technical staff. We have
not specifically site-visited and assessed Erie.
Chairman Specter. Well, I would like you to take a look at
that, because the backup facilities identified by Dr. Roswell
have been functioning there for some time, and we can make a
determination as to whether they are able to maintain their
skill level. But I think before you can make a determination
for closing a facility, you really have to individualize your
analysis, just take a look at the specific facility, because we
will. This Committee will. So we are going to be asking you the
hard questions as to what the facts are upon which you base
your conclusion that there are insufficient skill levels. So I
would ask you to take a look at Erie.
Dr. Roswell. Mr. Chairman, I understand your concern. I
will share a----
Chairman Specter. It is not only a concern for Erie. I have
not had a chance to go to all of the other facilities that are
on the list, but all of these other Senators will.
Go ahead, sir.
Dr. Roswell. I just want to say that I have met with the
VISN director from VISN 4 and the facility directors. We have
discussed this in great detail. I sat across from the table,
much closer than you and I are, with the director of one of the
smaller facilities, and I said yes or no, if you had a serious
problem, would you want to get acute care in your hospital? And
the answer was no.
Chairman Specter. How is it that you can get yes or no
answers, and I cannot?
[Laughter.]
Chairman Specter. Well, let us go on to Altoona. In more
than 8 seconds, tell me what a critical access hospital is.
Dr. Roswell. First of all, let me point out that Altoona
has a fairly dynamic work load right now. The recommendation in
Altoona is, and the projections are, that by the year 2012 and
beyond, the demand for acute inpatient care at that location
will decline to the point where it really may not be feasible
any longer to maintain an acute tertiary inpatient----
Chairman Specter. You are projecting to when?
Dr. Roswell. 2012, so the recommendation in the national
CARES plan would actually maintain Altoona----
Chairman Specter. 2012? How do you project to 2012, Dr.
Roswell?
Dr. Roswell. We took the 2000----
Chairman Specter. I talked about that with Strom about 20
years ago when he could not do that.
Dr. Roswell. Well, it is difficult. There is no question
about it. But we are using the very best health care actuary in
the nation, in the world, for that matter, to help us project.
We are extrapolating the veteran population. We look at the
demand for care, the types of problems treated, and we actually
come up with what we believe are fairly accurate projections
that not only look into the future but have been validated by
back-testing. We believe that they are, in fact, as accurate as
we possibly can be.
As the Secretary pointed out, this is a 20-year plan that
looks at a comprehensive set of resources that must be in place
for veterans in the decades ahead, and it is imperative that we
act now to be able to address those needs in the future.
We may be wrong, though. In the case of Altoona, if we do
not see the decline in the acute inpatient work load, it will
not convert to a critical access hospital.
Chairman Specter. Well, we want to help you not be wrong,
especially as to Altoona. When you say Altoona is dynamic, it
is a growing area. It is an area on the move. I will take a
look at your projections and how you figure it out. But from
what I see on the ground, Altoona is growing. It is not
contracting.
Dr. Roswell. Well, again, this would be a recommendation to
monitor the actual inpatient census, but we anticipate that
sometime around 2010, 2012, the census would begin to decline,
which would then, at that time and only at that time, require
us to re-evaluate the mission of the Altoona VA Medical Center.
We will be happy to monitor it concurrently with you and
certainly will take no actions to reduce the scope of services
at Altoona unless we actually observe, realize that decline in
inpatient work load.
Chairman Specter. Well, all right; that is a good
assurance, if you are not going to alter the available services
at Altoona until you see that actual decline. That is not based
on a projection; that is based on hard facts at hand.
Dr. Roswell. Exactly.
Chairman Specter. I also want to thank you, gentlemen, for
coming in today. There is a lot of interest in this subject
matter across the country, and that is reflected by a lot of
interest on Capitol Hill. I know you men and the Veterans
Administration generally are committed to veterans' care, and I
conclude with the same admonition on skepticism that I began
with: wherever I travel extensively in my State and beyond,
veterans are concerned about the adequacy of the budget. So,
starting there and the budget constraints, there is just an
inevitable feeling that changes are being made with regard for
the continuation of service.
I think your testimony here is solid on those assurances,
and we are going to have to back it up, and it is important for
the veterans to know that there will be Congressional oversight
and Congressional analysis on what you are doing.
Thank you all very much, and that concludes our hearing.
[Whereupon, at 3:30 p.m., the committee adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Patty Murray, U.S. Senator
from Washington State
Chairman Specter, I want to thank you for convening the
Committee, and I want to welcome Secretary Principi and
Chairman Alvarez.
As we all know--under the CARES initiative--the Department
of Veterans Affairs asked its regional offices to study the
health care needs of local veterans and to develop a plan to
meet those needs.
I support the idea behind CARES--to provide a realignment
of veterans' healthcare services that will enhance care for
those who fought so bravely for our country.
However, as this process has moved forward, there have been
some troubling revelations, and it appears that Chairman
Alvarez has an unenviable job. It seems CARES is driven more by
meeting budget targets than by meeting the healthcare needs of
our veterans. Local experts in my region--which covers
Washington, Oregon, Idaho and Alaska--submitted a plan several
months ago that showed dramatic enrollment growth, and
significant gaps in areas like long term care, primary care and
specialty care. The VA sat on this report for several months.
Then, just 8 days before the scheduled release of the national
report, the VA called up leaders at more than two dozen
facilities--including three in Washington State--with some
shocking news. The VA said that it didn't like their
recommendations. VA headquarters then ordered these regional
leaders to include a new and troubling recommendation--closing
these VA facilities. The next day, I sent Secretary Principi a
letter outlining my objections to the VA's interference with
the regional market plan and expressing my strong opposition to
closing any of the three Washington VA facilities.
The CARES process is supposed to provide an objective,
external perspective as the VA works to meet the increasing
demand for veterans healthcare. Veterans deserve more from the
VA.
Since that time, Secretary Principi personally pledged to
me that one of the Washington State facilities--American Lake
in Tacoma, Washington would not be closed.
I appreciate the Secretary's admission that the possible
closure of American Lake was a tremendously flawed proposal.
Questions remain at the other two facilities in my state--in
Vancouver and Walla Walla--as well as other facilities around
the country.
In Vancouver, instead of the creative community-based
partnerships that were proposed, the VA will potentially shut
this facility in the fastest growing area of Metropolitan
Portland. In fact, patient numbers have risen 17 percent this
year--more than three times as fast as usual--at the combined
Portland / Vancouver medical center.
The city of Vancouver, Clark County and the VA have been
working for years to create an enhanced use facility that would
compliment the services at the Vancouver facility. Now, only a
few months from issuing construction bonds, this plan may be in
jeopardy.
In Walla Walla, veterans may lose a facility that was
shifting to long term care and some other services may be
contracted out. The Walla Walla VA Medical Center is also one
of the largest employers in the community and serves a veterans
population of approximately 69,000.
Closure of the Walla Walla facility would leave area
veterans 180 miles from the Spokane VA Medical Center.
And let's not forget that there is a Federal law--on the
books since 1987--that prohibits changing the mission of the
Veterans Administration Medical Center in Walla Walla.
Veterans in Washington State and across the country are
having a terrible time getting the care they need, but instead
of improving services, the VA is exploring closing facilities.
Another troubling aspect of the CARES process is the
apparent disregard of veterans long-term care needs.
While Secretary Principi has stated that CARES includes a
``commitment to long term care,'' the model used to project
demand did not include long term care or mental health care.
The VA said that the modeling for such care ``needed more
work'' and that ``the Department cannot wait on perfection.''
Yet, the VA readily acknowledges that the number of veterans
age 75 and older will increase from 4 million to 4.5 million by
2010. And, both the VA and the GAO estimate that the veterans
population most in need of nursing home care--veterans 85 years
old or older--is expected to triple to over 1.3 million by 2012
and remain at that level through 2023. Clearly we've got to do
more--not less--to meet this growing need.
A major function of the Vancouver and Walla Walla
facilities is long term care, and I'm going to continue to
speak up for the veterans I represent. They deserve better than
the treatment they're getting from this Administration.
So Mr. Chairman, I will have more questions for the
Secretary to answer this afternoon, just as I did when the VA's
General Counsel testified before this committee.
I fear that the CARES process is losing its legitimacy, and
the good work Chairman Alvarez set out to accomplish is being
driven by budgetary issues within the VA.
Mr. Chairman, I believe this Committee must increase its
oversight. We have to ensure that CARES and the work of the
Department and the Commission are transparent and accessible to
veterans. The VA's stealth effort to potentially close
facilities in Washington State--despite the regional
recommendations and a lack of long-term care data--is a sign
that the CARES process is a growing problem for the VA and the
Congress. Our veterans deserve better, and I'm going to hold
this Administration responsible for the way it's treating the
veterans of Washington State.
----------
Prepared Statement of Hon. Jim Bunning, U.S. Senator From Kentucky
Thank you, Mr. Chairman. Kentucky will be heavily affected
by the CARES Process. The draft proposal now being considered
by the CARES Commission proposes to close a medical center in
Lexington and relocate the Louisville Medical Center. I am very
concerned about that and so are the veterans in Kentucky.
I Certainly support new and improved facilities that
improve VA's ability to provide timely and quality health care.
But any reductions or closures of facilities must be
accompanied with other means to ensure no veteran is unable to
get the help he or she needs. Mr. Secretary, Dr. Roswell, and
Mr. Alvarez, I am counting on you to make proposals that are
good for all our veterans.
At hearings earlier this year I talked about the benefits
of partnerships with university medical schools. The medical
centers in Lexington and Louisville have strong partnerships
with the universities there. I support those partnerships and
encourage you to strengthen those as you move forward. The
draft proposal does that and I hope that remains in the final
plan.
In Lexington there is not much space to expand around the
medical center at the University of Kentucky. Many veterans
have trouble going there because of parking. While those issues
are addressed in the draft proposal, I believe very serious
thought and planning needs to go into any changes in Lexington
to ensure enough capacity is added at the hospital and veterans
are able to get there easily.
The draft proposal recommends a stronger partnership with
the University of Louisville, including a possible new facility
adjacent to University hospital. I support stronger ties with
the University and an upgrading or replacing the current
medical center should be a priority. The Louisville Medical
Center is the oldest in the region. The University of
Louisville is eager to work with VA to develop an innovative
proposal to provide better facilities and more access to the
University's resources.
I strongly support that. If VA decides to move the current
hospital, I hope any new facility is built in partnership with
the University of Louisville.
Mr. Secretary, earlier this year you and I talked about VA
clinics in Kentucky. I am very pleased that the draft proposal
contains several new clinics in the eastern half of the
Commonwealth. Veterans in Kentucky love the clinics and want
more of them. I hope the final proposal adds even more clinics
throughout the Commonwealth, especially in western Kentucky and
places like Owensboro where the community has stepped forward
and offered to help by providing facilities and other
resources.
One final point I want to make is that I encourage VA to
work with the Army to share resources at Fort Knox and Fort
Campbell. Many veterans live around those bases and it only
makes sense that the two departments should work together in
those areas.
Again, I want what is best for our veterans. I urge the VA
to be careful in making any recommendations and to provide
Congress and the public strong evidence for making any changes.
Thank you for coming today. I look forward to hearing your
answers to my questions.
Thank you, Mr. Chairman.
----------
Prepared Statement of Hon. Robert H. Roswell, M.D., Under Secretary for
Health, Department of Veterans Affairs
Mr. Chairman and Members of the Committee: The Secretary has
described the reasons for CARES and the process utilized to develop the
market plans and the Draft National CARES Plan. My statement today will
focus on the Draft National CARES Plan itself.
In preparing the Draft National Plan, VA developed demographic
projections through the year 2022, conducted a comprehensive capital
inventory, assessed usage and vacant space, conducted a clinical
inventory of programs offered at all sites, and developed access
standards for the use of all VA facilities in evaluating accessibility
of their services. The Draft National Plan is based on national themes
such as improving access to high quality health care services, ensuring
outpatient capacity, enhancing access to special disability programs,
and prioritizing the capital infrastructure needed to support delivery
of high quality health care into the future.
The VISN's market plans contain the results of thousands of
decisions regarding how outpatient and inpatient demand will be
managed, i.e., whether space will be leased, renovated, or constructed,
or whether community contracts and DoD sharing will be utilized. The
Draft National Plan, however, is not simply a compilation of market
plans developed at the local level. We also reviewed the plans at the
national level and in many cases requested additional analysis by the
VISN's. CARES represents the most comprehensive and objective
assessment ever completed of the capital infrastructure needed to
support VA health care.
OVERVIEW OF THE DRAFT PLAN
In total, the draft National CARES Plan includes recommendations
that would result in the following actions:
<bullet> 11 million sq. ft. to be renovated
<bullet> 9 million sq. ft. to be constructed
<bullet> 3.6 milion sq. ft. of vacant space eliminated
<bullet> reduction of 600 acute hospital beds
<bullet> projected annual increase of 18.9 to 12.1 million
outpatient clinic stops (in 2012 & 2022, respectively)
<bullet> private sector contracts to meet peak load demand and
access
<bullet> 48 new high priority community-based outreach clinics
(CBOC's)
<bullet> 2 new hospitals (Orlando, FL, and Las Vegas, NV)
<bullet> 1 replacement hospital (Denver)
<bullet> improved access (in terms of driving time) from 72 percent
to 84 percent of enrollees meeting guidelines for access to acute
hospitals; and from 94 percent to 97 percent for tertiary care
hospitals (2001 vs. 2012 and 2022)
<bullet> maintaining enrollee access at 74 percent within primary
care access guidelines, but improving market-level access from 67
percent of markets meeting guidelines to 79 percent, if 48 new proposed
CBOC's implemented
<bullet> preservation of current Special Disability Program
capacity and addition of new locations:
<bullet> 2 new Blind Rehabilitation Centers (VISN's 16 and 22)
<bullet> 4 new Spinal Cord Injury & Disorders (SCI/D) Units
(VISN's 2, 16, 19, and 23)
<bullet> 5 expansions of SCI/D LTC beds (VISN's 8, 9, 10, and
22) and expanded acute/sustaining beds (VISN 7)
<bullet> collaboration within and outside VA:
<bullet> VBA: 13 high priority regional benefits office co-
locations
<bullet> NCA: 7 high priority future cemetery use
opportunities
<bullet> DoD: 21 high priority collaborations/joint ventures
REALIGNMENTS AND CONSOLIDATIONS
I would like to discuss in more detail the decisions I made
regarding realignments of Division II campuses and changing the mission
of small facilities. When I reviewed the results of the market plans, I
concluded that there were opportunities to realign campuses that
improve the quality, access and resource use by examining opportunities
to move these campuses from inpatient to outpatient operations, i.e. by
converting from 24-hour, 7-days/week to 8-hours, 5-days/week
operations. I asked the VISN's to determine how this could be
accomplished at selected sites with the provision that there would be
no loss of services to veterans. I specified that Inpatient services
must be provided at other VAMC's through sharing agreements or
community contracts.
Outpatient services were to be maintained on the campus or in the
local community through leasing of sites or contracting for care. The
realignments focused on moving long-term care sites to sites with an
acute care presence because this would also improve access to
diagnostic and therapeutic services for the long-term care population.
The current physical environment in many sites would require
significant capital investment in older buildings that are more
expensive to renovate than to build a new Nursing Home for example. In
addition, since patients served by long-term care facilities are not
geographically concentrated, i.e. they come from larger geographic
areas, the relocations do not significantly impact access. Where
contracting is combined with relocation of beds to other VAMC's or
where relocation is at a site with a greater concentration of veterans,
access is improved. The draft National CARES Plan realignments are
concept proposals that will be further reviewed and additional cost
benefit information will be provided to the Secretary and the CARES
Commission prior to the final CARES Plan decision. Should the proposals
be improved further, detailed planning would occur as part of
implementation planning. In no case would services be discontinued
without alternative sites of care available and operational. Any
savings or revenues realized from enhanced use leasing of sites will be
used to benefit veterans in the communities where the campuses are
located.
SMALL FACILITIES
The future of small facilities and their role in the VHA health
care system were key components of the CARES process. The issues were
how to ensure that veterans will receive the best diagnostic and
interventional technologies and whether this is feasible in facilities
that are already small and show forecasted declines or remain at
similar bed levels. The trend toward more sophisticated imaging and
advances in invasive techniques, which shorten hospital stays but
require the investment in expensive major equipment, has led to a
further consolidation of care in tertiary care facilities of more
complex cases. Optimal and efficient functioning of the VA's health
care delivery system depends upon early referral and transfer of
patients with complicated conditions and those requiring major surgery,
where outcomes may be volume-dependent.
These trends have led to declines in bed days of care in smaller
facilities to the point at which staff proficiency and outcomes may be
compromised in low-volume sites. Moreover, economies of scale in
provision of the latest medical and imaging technology cannot be
realized. Nevertheless, many small VA medical centers (VAMC's) are
important providers of health care in their communities. The CARES
review of small facilities in the VA has proposed a Critical Access
Hospital (CAH) designation of small facilities, based upon the Center
for Medicare and Medicaid Services model, requiring that they meet
certain operational standards and restricting their ``scope of
practice.'' The intent of this process would be to improve the
efficiency, effectiveness, and to enhance the level of functioning of,
small facilities within the context of VA's national system of health
care delivery. Over the course of the next year, the VA will develop
and implement policies to govern the operation of acute beds in small
VA facilities, which may fit into a CAH-like model of health care
delivery.
ENHANCED USE
Of the top 20 VA facilities identified by the Office of Asset and
Enterprise Management (OAEM) as having the highest potential Enhanced
Use Lease opportunities, 18 have Enhanced Use Lease initiatives
included in the VISN CARES Market Plans. By the end of the CARES
planning timeframe, approximately 4.5 million square feet of vacant
space is expected to be available for enhanced use lease initiatives.
This square footage does not include the acres of land that more than
half of the 18 facilities propose for enhanced use lease initiatives.
CONCLUSION
Mr. Chairman, the draft national plan is currently under intensive
scrutiny by the Secretary's CARES Commission. Following review of the
Commission's recommendations and the subsequent approval of a final
National CARES Plan by the Secretary, implementation will take place
over a period of many years. It will be a multifaceted process,
depending upon whether implementation of specific initiatives requires
additional capital, recurring funding, primarily policy changes, or
realignments. In particular, the complexity of realigning clinical
services and campuses necessitates careful planning in order to ensure
a seamless transition in services. In no case would services be
discontinued without alternative sites of care being available and
operational. And, as I mentioned earlier, savings or revenues realized
from enhanced use leasing will be used to benefit veterans in the
communities where the affected campuses are located.
This concludes my statement. I will now be happy to answer any
questions that you or other members of the Committee might have.
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