[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]
VA HEALTH CARE: ACCESS DELAYED, ACCESS DENIED
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY,
VETERANS AFFAIRS AND INTERNATIONAL
RELATIONS
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
OCTOBER 15, 2002
__________
Serial No. 107-238
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
______
89-163 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpr.gov Phone: toll free (866) 512-1800; (202) 512�091800
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COMMITTEE ON GOVERNMENT REFORM
DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida EDOLPHUS TOWNS, New York
JOHN M. McHUGH, New York PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California CAROLYN B. MALONEY, New York
JOHN L. MICA, Florida ELEANOR HOLMES NORTON, Washington,
THOMAS M. DAVIS, Virginia DC
MARK E. SOUDER, Indiana ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio DENNIS J. KUCINICH, Ohio
BOB BARR, Georgia ROD R. BLAGOJEVICH, Illinois
DAN MILLER, Florida DANNY K. DAVIS, Illinois
DOUG OSE, California JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky JIM TURNER, Texas
JO ANN DAVIS, Virginia THOMAS H. ALLEN, Maine
TODD RUSSELL PLATTS, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
DAVE WELDON, Florida WM. LACY CLAY, Missouri
CHRIS CANNON, Utah DIANE E. WATSON, California
ADAM H. PUTNAM, Florida STEPHEN F. LYNCH, Massachusetts
C.L. ``BUTCH'' OTTER, Idaho ------ ------
EDWARD L. SCHROCK, Virginia ------
JOHN J. DUNCAN, Jr., Tennessee BERNARD SANDERS, Vermont
JOHN SULLIVAN, Oklahoma (Independent)
Kevin Binger, Staff Director
Daniel R. Moll, Deputy Staff Director
James C. Wilson, Chief Counsel
Robert A. Briggs, Chief Clerk
Phil Schiliro, Minority Staff Director
Subcommittee on National Security, Veterans Affairs and International
Relations
CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida DENNIS J. KUCINICH, Ohio
BENJAMIN A. GILMAN, New York BERNARD SANDERS, Vermont
ILEANA ROS-LEHTINEN, Florida THOMAS H. ALLEN, Maine
JOHN M. McHUGH, New York TOM LANTOS, California
STEVEN C. LaTOURETTE, Ohio JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky JANICE D. SCHAKOWSKY, Illinois
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
DAVE WELDON, Florida DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia
Ex Officio
DAN BURTON, Indiana HENRY A. WAXMAN, California
Lawrence J. Halloran, Staff Director and Counsel
Kristine McElroy, Professional Staff Member
Jason Chung, Clerk
C O N T E N T S
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Page
Hearing held on October 15, 2002................................. 1
Statement of:
Burger, Leslie, Network Director, Veterans' Integrated
Service Network, Department of Veterans' Affairs; Wayne
Tippets, Director, Boise Veterans' Administration Medical
Center, Department of Veterans' Affairs; and David K. Lee,
Chief of Staff, Boise Veterans' Administration Medical
Center, Department of Veterans' Affairs.................... 38
Jaurena, Mitchell A., USMC retired, veteran; E. Lee Bean,
veteran; William T. Smith, veteran; and Richard W. Jones,
Administrator, Idaho Division of Veterans' Services........ 13
Letters, statements, etc., submitted for the record by:
Bean, E. Lee, veteran, prepared statement of................. 18
Burger, Leslie, Network Director, Veterans' Integrated
Service Network, Department of Veterans' Affairs, prepared
statement of............................................... 43
Jaurena, Mitchell A., USMC retired, veteran, prepared
statement of............................................... 15
Jones, Richard W., Administrator, Idaho Division of Veterans'
Services, prepared statement of Mr. Teague................. 25
Otter, Hon. C.L. ``Butch'', a Representative in Congress from
the State of Idaho, prepared statement of.................. 7
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut:
Prepared statement of.................................... 3
Prepared statement of Rex T. Young, Meridian, ID......... 36
Smith, William T., veteran, prepared statement of............ 21
VA HEALTH CARE: ACCESS DELAYED, ACCESS DENIED
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TUESDAY, OCTOBER 15, 2002
House of Representatives,
Subcommittee on National Security, Veterans Affairs
and International Relations,
Committee on Government Reform,
Boise, ID.
The subcommittee met, pursuant to notice, at 10 a.m., at
VFW Post 63 Hall, 3008 Chinden Blvd, Boise, ID, Hon.
Christopher Shays (chairman of the subcommittee) presiding.
Members present: Representatives Shays and Otter.
Staff present: Lawrence J. Halloran, staff director and
counsel; Kristine McElroy, professional staff member; and Jason
M. Chung, clerk.
Mr. Shays. A quorum being present, the Subcommittee on
National Security, Veterans' Affairs and International
Relations' hearing entitled, VA Health Care: Access Delayed,
Access Denied, is called to order.
The subcommittee convenes this hearing to continue our
oversight of the Department of Veterans' Affairs, VA, health
care system. We meet this morning in Boise, ID because
Congressman Butch Otter asked us to focus on the unique
challenges facing veterans and the VA in the Northwest service
network. Congressman Otter is an active, extraordinarily active
and very articulate participant in our efforts to make Federal
programs more effective and efficient. It is a privilege and a
pleasure to be here with him today. And I will say he didn't
tell me I could wear jeans.
Regionalization of VA health care held the promise of
delivery modes more directly tailored to local needs and
funding levels more sensitive to area demographics. But rigid
one-size-fits-all rules continue to produce systemic problems
with access and waiting times in many regions. These chronic
shortfalls are addressed only with an episodic infusion of
supplementary resources. A more permanent approach is needed to
match veterans' growing needs with VA health care capacity.
For a variety of reasons, including an attractive
pharmaceutical benefit, many more veterans are seeking access
to VA care. Medical centers and community-based outpatient
clinics are hard-pressed to keep pace with demand relying on
productivity increases alone. At some point, the quality of
care will be affected if we continue to ask smaller medical
staffs to serve more and more patients.
In this region, waiting lists have reduced slightly and
patient satisfaction with the quality of care remains high, but
as we will hear in testimony, access to care for service-
connected veterans can still be long delayed, in effect denied,
amid the crush of enrollment applications by those in lower
eligibility categories. So we ask our witnesses to describe how
the VA health care system can be improved to become the agile,
sophisticated, patient-centered provider envisioned by
Congress. We welcome them, and we look forward to their
testimony.
And I would just like to say I have been in Boise before, I
love being here. It is a great community, a wonderful State,
and I was happy that Butch asked more than once that we come
and to say that this subcommittee is delighted to be here. We
look forward to the testimony from our witnesses, and we will
invite any--at the end, we will invite of those who are in
attendance today to address the committee. We won't swear you
in like we will our panel one and two, but we will invite you
to make testimony to this committee if you would like to.
At this time, the Chair would like to recognize Mr. Otter.
[The prepared statement of Hon. Christopher Shays follows:]
[GRAPHIC] [TIFF OMITTED] T9163.001
[GRAPHIC] [TIFF OMITTED] T9163.002
Mr. Otter. Well, thank you, Chairman Shays, and I
appreciate you accommodating us and holding this meeting in
Boise. I also appreciate all of your efforts and your
accommodation on all our logistical changes, because I think as
the entire audience knows, we had to constantly change time and
place as a result of most of our activities, or in some cases
inactivity, in Washington, DC. And so I also want to say that I
appreciate all the witnesses and them making the accommodations
that they had to make in order to be here today.
Ensuring veterans have adequate access to care at the
Veterans' Administration is an important issue. In the last 7
years, the number of veterans using the VA health system has
doubled. The VA anticipates an increase of another 600,000 next
year. Changes to the VA eligibility standards, the high quality
of care delivered by the VA and the existence of the VA drug
benefit have all added to the increased demand of the VA
services.
Given this increase in enrollment it is easy to see why
veterans in Idaho sometimes wait about a year, in some cases
longer, just to get into see a VA doctor. In fact, there are
approximately 3,000 veterans today waiting in Idaho, and about
two-thirds of those veterans are priority 7 veterans. However,
once in the system Idaho veterans seem to be very pleased with
the delivery of the care service that they receive.
Some have predicted that the creation of a Medicare
prescription drug benefit would help to relieve some of the
backing of the VA, one which both you and I voted for.
Unfortunately, the Senate has not followed likewise. Although
the House passed the legislation in creating a Medicare drug
benefit in June, the Senate, as I said earlier, did not follow
suit. That left the Veterans' Administration again to deal with
the high number of veterans waiting to receive care.
In May, this subcommittee held a hearing examining the
structured problems that are causing the backlog of VA
hospitals all over the country. During that hearing, I
expressed my deep concern that a system of prioritizing
veterans on the waiting list was not in place. I am pleased to
report that on September 26 of this year the Veterans' Health
Administration issued a directive entitled, ``Priority of
Outpatient Medical Services and In-Patient Hospital Care.''
Under this directive, the Veterans' Administration will now
give preference to priority 1 veterans who have a service-
connected disability and a rating of 50 percent or higher and
will make every effort to see that those veterans within the
next 30-day period receive such admission.
I believe this directive is a step in the right direction
in providing veterans with more timely access to the care that
they need. However, the Veterans' Administration estimates that
there are over 280,000 veterans nationwide who will wait 6
months or longer for an appointment with a Veterans'
Administration doctor. This directive will certainly help
reduce that number, but the logistical and financial burdens of
complying with this directive will be a challenging one for the
Veterans' Administration.
I look forward to hearing from those representing the VA on
how they are proceeding in that process. So as we explore ways
to improve the Veterans' Administration's ability to address
the health care needs of veterans, I think that it is important
to factor into the equation a way to provide the VA with the
necessary resources, regulatory or financial, to address those
increasing administrative workloads.
These hearings are an important chance for us and for your
representatives in Congress to listen, to find out your
thoughts on how we can best change the structure of the VA
medical system to better accommodate the needs of Idaho's
veterans. Mr. Chairman, I appreciate your leadership and your
interest. I appreciate all of the hearings that you have had on
this and the deep and sensitive concern that you have shown to
every panel member that has come before us, not only today but
also in Washington, DC. Thank you very much.
[The prepared statement of Hon. C.L. ``Butch'' Otter
follows:]
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[GRAPHIC] [TIFF OMITTED] T9163.006
[GRAPHIC] [TIFF OMITTED] T9163.007
[GRAPHIC] [TIFF OMITTED] T9163.008
[GRAPHIC] [TIFF OMITTED] T9163.009
Mr. Shays. Thank you. I thank the gentleman. First, before
calling our--recognizing our panel and swearing them in, I
would like to get some housekeeping out of the way and ask
unanimous consent that all members of the subcommittee be
permitted to place an opening statement in the record and the
record remain open for 3 days for that purpose. Without
objection, so ordered. I ask further unanimous consent that all
witnesses be permitted to include their written statement in
the record. Without objection, so ordered.
I would also like to note the presence of Major Ed Freeman,
a Congressional Medal of Honor recipient. This committee is
honored that he would be here. Thank you so much for being
here.
And to say that he earned this recognition in his service
in 1965 and 1966 and recently received this long overdue
recognition, and to say that it takes my breath away to think
of the number of flights that he made, I think nearly 30, into
an area that was totally and completely surrounded by the enemy
and over 300 men were saved, in large measure, because of what
he did. I would also point out that many of the enemy--we lost
over 300 men that day or during that battle, and I think that
the North Vietnamese lost nearly 2,000. So it is an honor to
have you here.
But it is also an honor to have everyone who has served our
country. This committee is profoundly grateful, and I can tell
you without hesitation when a Congressman looks at our flag we
try to see this flag through your eyes and recognize that when
you look at this flag you think of the men who never came home,
and you think of the conversations you had with family members
about their lost loved one.
I would also like to recognize any family members who are
here and just say thank you for supporting your family member
in their service to our country. I think sometimes it takes
more out of the family member than it does out of the soldiers
who are actually serving in the battle.
At this time, the committee will recognize our first panel.
Colonel Mitchell Jaurena is a veteran--did I say your name
correctly?
Mr. Jaurena. Close enough.
Mr. Shays. I want it accurate.
Mr. Jaurena. Jaurena.
Mr. Shays. Jaurena. Thank you. That is the way it was----
Mr. Otter. Is that Irish?
Mr. Jaurena. Basque Irish. [Laughter.]
Mr. Shays. Colonel, great to have you here.
Mr. Jaurena. Thank you.
Mr. Shays. We have as well--so the Colonel is a veteran. We
have Mr. Lee Bean, a veteran; Mr. William T. Smith, a veteran;
Mr. Richard W. Jones, administrator, the Idaho Division of
Veterans' Services, which is the State provision for veterans.
At this time, as you may know, we swear in all our witnesses. I
have been chairing the committee now for 8 years, and I will
tell you the only witness I have not sworn in was Senator Byrd,
I chickened out and regret it to this day. [Laughter.]
Would you please stand.
[Witnesses sworn.]
Mr. Shays. We will note for the record all our witnesses
have responded in the affirmative, and Colonel Jaurena, we will
invite you to address us first. And we have a 5-minute rule,
but what we do is we allow you to go into the next 5 minutes
and ask that you stop before 10.
Mr. Jaurena. Yes, sir.
Mr. Shays. But as close to 5 as you can be is appreciated.
STATEMENTS OF MITCHELL A. JAURENA, USMC RETIRED, VETERAN; E.
LEE BEAN, VETERAN; WILLIAM T. SMITH, VETERAN; AND RICHARD W.
JONES, ADMINISTRATOR, IDAHO DIVISION OF VETERANS' SERVICES
Mr. Jaurena. Good morning, Mr. Chairman and Representative
Otter. I am Lieutenant Colonel Mitchell Jaurena, U.S. Marine
Corps, retired. I was transferred to the Permanent Disability
Retirement List on July 1, 2001 after 21 years of honorable
service because of the degenerative nature of injuries I
received during Operation Desert Storm while in the Persian
Gulf. Upon my retirement, I moved back to Idaho and settled in
Nampa. At that time, I attempted to enroll in TriCare Prime,
the military system of health care, but was unable to find a
local provider, as no physician or medical provider in the
Treasure Valley region was accepting, or is accepting, TriCare
Prime patients. Subsequently, however, on November 6, 2001, the
Department of Veterans' Affairs rated me as a 50 percent
service-connected disabled veteran. Now, as a priority 1
category disable veteran, I was automatically enrolled in the
Veterans Health Care system and during December 2001, the Boise
VA hospital issued me my veterans universal access
identification card and assigned me to a health care team in
Boise, ID.
Unfortunately, I was also told at that time that I would be
unable to utilize the Boise VA hospital for any care other than
emergency care, as there was a 2 to 2\1/2\ year-long waiting
list at the hospital for assignment to a doctor. I was also
told that I would be unable to utilize the pharmacy, even if I
had a script provided by a non-VA doctor, as the pharmacy was
only available to those with assigned VA doctor at the Boise
hospital. I was also told that there was a 2 to 3-year wait to
receive optical care but hat I would be able to obtain those
glasses if I could provide them with the prescription from an
outside pharmacist.
Mr. Chairman, I find it absurd that a combat-related 50
percent disabled veteran with service connection should be
required to wait for medical care at a VA hospital while those
without service connection are receiving care. I find it even
more patently absurd that a priority 1 service-connect disable
veteran should have to wait up to 2\1/2\ years for the
assignment of a VA doctor just to be able to fill a
prescription at the VA hospital while they are under the care
of a private physician.
But I do need to point out, as Representative Otter did,
that the landscape has recently changed. The Secretary Principi
has directed that these 50 percent disabled veterans, priority
1 veterans, receive care. And as of this time, I have an
appointment on October 24, so I will have waited 11 months to
receive care at this hospital.
Now, it is really hard to overcome 21 years of training
provided by the Marine Corps. No Marine complains without
providing an alternative solution, but I do realize that
Federal funding is not a bottomless well, and there simply
isn't enough money to go around. I also realize that some
veterans will eventually go without. There have been various
plans proposed also by various service organizations, some of
them to include a financial means test for veterans seeking
care, in essence, turning the VA health care system into a
welfare health care system. I am against any financial means
test as an eligibility requirement for health care. The only
eligibility requirement for health care I would support is
already in place and that is honorable service in the armed
forces of the United States of America in service of our
country.
I do believe that those with the highest need based upon
service connection disability ratings should be seen first. The
VA already has a priority health care system for enrollment in
place. This prioritization starts with priority 1 for 50
percent or greater service-connected disability to priority 7
for non-service connected and non-compensable disabled
veterans. I believe that this already-established system should
also be used for providing health care and scheduling
appointments so that those who have honorably served and have
suffered the most will receive the first use of the limited
assets available.
Now, if we use the health care system, will veterans fall
out if we use that prioritization? Absolutely. Will they be
deserving of care? Certainly. However, this method of
prioritization will allow for the most disabled to receive care
and give Congress and the VA a clear picture of those veterans
left without VA-provided health care. It would allow Congress
to decide on the level of funding that it is willing to
allocate based upon veterans' needs. It would also be up to our
elected officials to reflect the will of the American people to
fund or not fund for the care of its veterans. Thank you for
the opportunity to testify.
[The prepared statement Mr. Jaurena follows:]
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[GRAPHIC] [TIFF OMITTED] T9163.004
Mr. Shays. Thank you very much, Colonel. Would you move
that pitcher so that you could see the light too?
Mr. Jaurena. Yes. I beat it by 12 seconds, Congressman.
Mr. Shays. Thank you. It was an excellent statement.
Excellent statement.
Mr. Bean. OK. Are you ready for me?
Mr. Shays. We are, Mr. Bean. Thank you so much.
Mr. Bean. OK. I am not disabled or anything, I am in pretty
darn good shape, except what I have to say here. I served in
the Navy during World War II aboard ship, and after hearing
that several veterans my age, World War II, getting more income
than I do are receiving prescriptions drugs from the VA----
Mr. Shays. I am going to ask a question. Can people in the
back hear what is being said right now? Let me just say I
apologize for not being able to pick you up. I am going to ask
you--and I am sorry about that, but I am going to ask you to
hold it up, because I think it is important that everybody hear
your statement.
Mr. Bean. My voice is not that good either.
Mr. Shays. Yes. Colonel, I apologize for that.
Mr. Bean. OK. I can certainly start over then.
Mr. Shays. I apologize, yes.
Mr. Bean. U.S. Navy during World War II, and I heard of
veterans receiving prescription drugs from the VA that are in a
similar conditions I am, with more income than me, actually, a
lot of them, and so I decided on December 21, 2000 I went to
the VA Center and enrolled for benefits, gave them my financial
so on and so on. Then in May 2001, after coming home, I found
out that friends of mine had been receiving prescription drugs
without even filling out a financial statement in other VA
hospitals. So then I went to the--called the VA Center and the
nurse told me to come down in an emergency condition. So I went
down and was right in and saw a PA, a nurse's physician's
assistant, and she examined me, questioned me and using my
doctor's prescription enrolled me to start receiving drugs,
which I did for about 1 year. In February 2000, I updated my
income status. In March of this year, I was informed by the VA
that I would no longer receive drugs because I had not been
able to see a doctor. I then contacted Mr. Otter and other
Congressmen, representatives about this.
It is my belief that if prescription drugs are going to be
available for some veterans, they should be available to all
veterans, especially after age 65 whenever you have now become
on Social Security and limited income, also a lot of us being
in those notch years where we don't receive as much Social
Security as other people. I think that the VA should be able to
use my doctor. I belong to an HMO, I have a doctor who writes
my prescriptions. Why can't I take them to the VA? Why can't
they trust my doctor? They're both being paid by government
funds. That's all I am asking.
Now, if it is not available for me, let us not make
available for other people in my situation. I don't have a
Purple Heart, I have a lot of close calls in Australia while I
was in the Navy, I know that. But I know my wife is 73, I am
77, and we both work part-time to supplement our income. So I
am not afraid of that, I am able to do it. That is about all I
have to say. Thank you.
[The prepared statement of Mr. Bean follows:]
[GRAPHIC] [TIFF OMITTED] T9163.010
Mr. Shays. Thank you very much, Mr. Bean. That is very
helpful testimony as well. Mr. Smith. Evidently, these are mics
you have to have pretty close up to you.
Mr. Smith. Can you hear me?
Mr. Shays. We hear you great.
Mr. Smith. Honorable Congressmen, ladies and gentlemen, my
name is William T., Tom, Smith, and I am here to speak--my
reasons for speaking are the very deplorable treatment to
myself and other veterans who are being subject to what I feel
is a completely overloaded and broken down VA system. They are
trying to do their best, but they can only do so much. They are
drastically understaffed and underfunded.
First, they have no cardiac care unit at Boise VA. For
heart treatment, they send you to Seattle VA. When I had my
heart attack in 1996, I spent 5 days at the Boise VA waiting
for space to be transferred to Seattle VA. It took more than 5
days to be evaluated by a cardiac specialist after a heart
attack. This is very hard on patient and family after going to
Seattle twice for heart treatment in a very crowded system, the
stress of traveling and being separated from family at such
critical times. The next time I had a heart problem I requested
to be transferred to St. Luke's for quicker evaluation, and it
was a good thing I did. I was near another heart attack, and I
had immediate bypass surgery, it was a six-way bypass. The VA
denied co-payment on this surgery, and I was left with all the
bills my private insurance did not cover.
Mr. Shays. Mr. Smith, could you just turn the mic the other
way a little bit? Yes.
Mr. Smith. I am rated 100 percent service connected. My
first trip to Seattle they did an angiogram, the second they
did an angioplasty scan implant. The VA always bills my private
insurance for all the treatments and surgery and prescriptions.
The real funny thing about all of this is it would be cheaper
for the VA to pay the co-payment than fly me to Seattle, and
yet they denied the co-payment. It does not make sense. I go to
a cardiologist in private practice because there is not a
cardiologist on staff at the Boise VA. They have one who comes
in once a month for clinic, and you must meet certain criteria
to be seen by him. This is almost a joke if it was not so
serious.
Another problem is my hands. I had surgery on two fingers
on my right hand for trigger finger. I have developed trigger
fingers in my hand, two of them, and I have bone spurs on the
right thumb. And this time it has taken me over a year to get
an appointment for an evaluation. Surgery will be scheduled for
a later date. In the meantime, my fingers are getting worse,
and I can no longer open it fully. Gripping anything with my
right hand is very difficult, and these conditions get worse
daily and less correctable. When I asked my regular physician
about a colonoscopy, I was discouraged about having one. It has
taken over a year to get scheduled for a colonoscopy with the
medical profession recommending you should have one after age
50. This just doesn't seem right.
The problems I have stated above plus some old back
injuries have been shuffled off to a physician's assistant. I
have not seen my regular physician for the last two scheduled
appointments. In addition to the other problems, I have upper
spinal injury which causes tremors and excruciating pain in the
arms and the shoulders. Plus I have had back surgery on the
lower back and two hernia surgeries.
Parking is always horrendous at the VA. If you can find a
place to park, it is generally three to four blocks away from
the entrance, and some days it seems like you can't find any
place to park there. They really need to do something about the
parking there. The lab is another bottleneck when you go in and
if you are going to have any blood work done or anything. It is
not anything to see an hour's wait to have the lab work done.
If you see your doctor and go to the lab and get a prescription
filled, you can spend a day at the VA.
My suggestions would be to have the representative talk to
the people at the VA, get their statements. If you catch them
coming out of there real fresh, you can get some good input. I
am sure they would tell you that they feel like cattle being
herded through or just a number.
And the doctors are very reluctant about letting you see
another doctor about your problem. One of the doctors at the
specialty clinic will ask you how you are today. If you tell
him you have some problems, he will tell you, ``We are all
getting older and expect the aches and pains to be worse.'' And
then he will tell you to come back and see him in 3 months.
It is very reassuring to me to have you Congressmen
investigating trying to assist us veterans with our health care
problems. I truly hope my statements here will help others and
assist you in your fact finding. With my sincerest thank you
for working to make things better for the veterans. Please keep
up the good work.
[The prepared statement of Mr. Smith follows:]
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[GRAPHIC] [TIFF OMITTED] T9163.012
Mr. Shays. Thank you, Mr. Smith, for your helpful
statement. Mr. Jones. I am going to ask if anyone is in the
back and can't hear, you just raise your hand and we will just
make sure that I direct the witnesses to speak more into the
mic.
Mr. Jones. Good morning, sir.
Mr. Shays. Good morning.
Mr. Jones. It is my pleasure to be here this morning and
present the testimony on behalf of Patrick Teague who was not
able to be here and was scheduled to actually provide testimony
before you. I do have his written testimony before me. Patrick
is our program supervisor of the Office of Veterans' Advocacy
for the State of Idaho, so reading his testimony.
Committee members, veterans and guests, I wish to express
my appreciation for being invited to speak on behalf of Idaho's
veterans today. It is indeed an honor and a privilege to appear
before you.
I would like to begin by saying the care at our VA medical
centers serving Idaho's veterans is outstanding. Sure, you have
the occasional horror story of a veteran who has been
mistreated or neglected but these instances are few and even
fewer once investigated. In my job as a veteran service
officer, I speak to veterans and their dependents throughout
the State, and almost to a person they all tell me that once
they get through the door into the VA medical center, they
receive excellent care. Which brings us to the reason we are
here today: Access to our VA medical centers.
If you are a veteran who has been assigned a team, has a
doctor or a physician's assistant, then you are indeed
fortunate. If you are a veteran moving one State to another,
you are facing a wait of up to a year or longer just to gain
access to our VA medical centers. The exceptions to this are 50
percent service-connected veterans or those requiring emergency
care. By far and away, however, the majority of new accounts
are being told to get into an ever-increasing line and don't
call us, we will you.
This is simply unacceptable and must be corrected. The real
tragedy here is that as service officers we are told for years
to go out and find those veterans who have never been enrolled
in our VA medical centers and get them enrolled. When queried
by the service officers if the medical center would be
available to provide care for those veterans, the answer was a
resounding yes, so we did. We went out and found those veterans
who had never been in the system and had them submit their 10-
10EZ forms. Some of those veterans are still waiting to be
assigned a team. In the meantime, for every new account, or
``uniques,'' as the VA calls them, the VA medical center gets
approximately $1,5000 placed in their account. I have no
problem with that, but I do not understand why the veteran is
denied access if the VA medical center has received $1,500 for
enrolling that veteran.
Another problem we have that I do not understand is when
the Boise VA Medical Center cannot provide specialty care at
the Boise VA Medical Center, they then schedule the veteran for
care in Palo Alto or Seattle. If the veteran is sent to
Seattle, the Boise VA Medical Center gives him $40 for a bus
ticket to Seattle. The veteran then finds transportation from
the bus depot to the Seattle VA Medical Center. When the
veteran is finished with is stay in Seattle, he must get the
Seattle VA Medical Center to give him $40 for his trip back to
Boise. Once again, it is up to him to get from the VA Medical
Center to the bus depot. Then he has the long bus ride back to
Boise. In many cases, these veterans are convalescing and the
bus ride takes its toll on them. Wouldn't it be better for the
veteran and their families if the Boise VA Medical Center would
refer them for specialty care at St. Luke's or St. Alphonsus?
The Millennium Health Care Act states that if care in a VA
medical center is not available, then the veteran should be
referred to the community. They do not normally do it as it
impacts the Boise budget more than they can afford. Clearly,
something must be done for these veterans who fall through the
cracks and are sent to other VA medical centers for their care.
We must also address the problem of proper funding for
those who travel for a VA medical center appointment, as Idaho
is one of the most rural States in the Union. Some of our
veterans must travel over 500 miles roundtrip for a medical
appointment. An example of this would be Salmon, ID in Lemhi
County. Those veterans travel 252 miles one way to receive
treatment at the Boise VA Medical Center. Veterans traveling to
those appointments receive 11 cents per mile for that
appointment, and some of them have $6 deducted from that travel
allowance. Any appointment that is not for a compensation and
pension examination will have the $6 deducted from the
veteran's reimbursement, not to exceed $18 in 1 month. This is
simply ludicrous because the VA medical centers are only
reimbursing 11 cents per mile as it is. A raise is certainly in
order to help alleviate the cost of traveling to and from an
appointment.
In summation, I would like to reiterate that once in the
door of the Boise VA Medical Center, the care is excellent. It
is getting through that door that is the problem. We must
secure more funding for our VA medical centers if we are to
make a difference in the current situation. Our Nation's
veterans deserve no less. Thank you for your attention.
[The prepared statement of Mr. Teague follows:]
[GRAPHIC] [TIFF OMITTED] T9163.013
[GRAPHIC] [TIFF OMITTED] T9163.014
Mr. Shays. Thank you very much, Mr. Jones; appreciate it.
We are going to start off with Mr. Otter asking some questions,
and I will have some questions as well. And if we ask one of
you but another of you wants to answer the question as well,
just jump in after that person is finished speaking.
Mr. Otter. Well, thank you, Mr. Chairman, and I would
direct this question to all of the panelists. During our
hearings, several hearings, that we had earlier this year and
one late last year, there were--obviously, we heard about an
awful lot of horror stories, and I think that is what
precipitated the priority 1 change that came about September
26. I can remember in the committee room me offering an example
that I am prior service but I have no service disability, no
service-connected disability. And yet if I showed up at the VA
hospital with a rodeo accident, I would certainly be put ahead
of, depending upon if I showed up on that priority list, I
would be put ahead of anybody who may have gotten some
disability as a result of any military action or any other
military service. We thought that was patently unfair.
My question actually as a result of listening to several
folks that testified and trying to come up with some sort of a
recipe, if you will, that said that the level of service-
connected disability coupled with age should bring us some sort
of a ratio of setting priorities. Would you agree or disagree,
and I am not prepared to say you have got to be a certain age
with a certain disability, but would you agree or disagree with
setting a priority, No. 1, based upon the disability and the
level of disability and, No. 2, the age of that veteran that is
disabled?
Mr. Jaurena. I will kick it off here, Representative Otter.
I agree with you on the first part. Service connection and the
type of disability, I would absolutely agree with that.
However, it makes no difference whether you are 46 like I am or
76 is if you have a degenerative disease caused by a service
injury that you are required to take medication for. As it
stands now, I cannot get in to get my medication at the VA
hospital simply because I have been bumped by priority 7
people. So I do not believe an age requirement is justifiable.
You have a system already established within the health care.
It is priority 1 through priority 7. Priority 1 group is 50
percent or greater, priority 2 is 30 or 40, priority 3 is
former POWs, 10 or 20's or Purple Hearts. Those folks have a
service connection. We have already established a system to
determine whether they are eligible or not and set a priority
group. I believe we should stick to it and not deal with the
age issue.
Mr. Otter. Great. Thanks, Mitch. Lee.
Mr. Bean. I think age partly should be involved because of
your ability to go out and make a living. If I have a good
income to where I could go out to dinner once in a while and
things like that, I wouldn't even be here. I wouldn't be asking
for prescription drugs, and that is all I am asking for. And
one of the reasons I am asking for that is I have a lot of
friends who are getting these prescription drugs from other VA
hospitals by walking in and getting them.
Mr. Otter. My apologies for stopping you right there.
Mr. Bean. OK.
Mr. Otter. That is another question I am going to ask, and
since you brought it up I want to ask you that now. If we had
seen a successful conclusion of the house-passed Medicare drug
benefit bill, which was $350 billion over 10-years, would you
then seek access to your drugs through the Medicare program
rather than through the VA program?
Mr. Bean. I probably would, yes, because I am paying for
health insurance right now, and the high cost of drugs is what
is killing some of us; $55 a month for health care--
supplemental health care in an HMO is not a big deal, but when
you start paying a couple hundred dollars a month for two
pills, it gets a little ridiculous.
Mr. Otter. Thanks, Lee. Tom.
Mr. Smith. I don't think that age should really play a
factor in it. I think that any disability, any disabled vet
should be--the care should be accessible for him. I agree with
Mr. Bean that there is a lot of people out there that are
getting medication that--I know some that are getting
medication and Mr. Bean would be just as entitled to it as they
are. I don't have anything further, I don't think.
Mr. Jones. I agree with the comments by the other
panelists. I am concerned that it should be based upon their
disability. My concern is that you have individuals who had
degenerative conditions and other conditions that with such an
undo waiting list, undo waiting time, their condition would
deteriorate so significantly from the time that they attempted
to enroll to the time that they would actually be seen by a
physician and receiving care. I don't believe that this is
correct.
Mr. Otter. All right. Let me start with the entire panel
again, and I will start with you first, Mr. Jones, because you
brought it up in your testimony that you represented in Mr.
Teague's place, you mentioned out-contracting or community
contracting. Do you know that is now the practice in any other
place in the United States where they actually have out-
contracting within a Veterans' Administration region?
Mr. Jones. I am not aware, but I can find out and let you
know very quickly.
Mr. Otter. I think we will probably get some testimony from
Mr. Tippets or Dr. Lee a little later on on that. How about
you, Tom?
Mr. Smith. Really, I don't know of any other place where
they are contracting out. However, I do know that the VA here
does contract some out to St. Luke's. I think I would like to
see the heart care increase a little beyond that, because after
a heart attack or anything it is important to get the treatment
and know where you are at immediately.
Mr. Otter. Tom, relative to your experience between Boise
and Seattle and traveling back and forth from the operation,
the six-way bypass that you had in Seattle, do you think you
are----
Mr. Smith. No, I had the six-way bypass here at St. Luke's.
Mr. Otter. Oh, excuse me. I misunderstood. Was your--so you
rehabilitation was actually right here in Boise in your home--
--
Mr. Smith. Oh, yes.
Mr. Otter [continuing]. Around your family.
Mr. Smith. That is right.
Mr. Otter. OK. Well, let me ask you the question anyway in
a hypothetical sense. Do you believe that your healing process,
that your rehab process was much faster as a result of being
home within your own community and around your own surroundings
than it would have been had you had to have that in Seattle?
Mr. Smith. OK. Now, I can relate on that a little bit
further here. After my heart attack I went to Seattle. I waited
5 days here for a bed in Seattle in the Cardiac Care Unit. I
went to Seattle, and I came back--when I came back I was
probably more distressed than I was before I left. The second
time I went to Seattle and they did a skin implant and I came
back, I was feeling better because the stint was pretty
successful, and it is not a real invasive procedure. And I was
feeling better and so recovery was probably good. But when I
had the six-way bypass, if I would have had to travel from
Seattle back to here after a six-way bypass, I don't know how I
would have done it. It is just unbelievable to me that people
do that. I don't know.
Mr. Otter. OK. Lee.
Mr. Bean. No. I have nothing to say about that. The only
thing I was talking about age is that I think all service-
connected veterans should all be first, No. 1. All I am talking
about are medications. That is all I am talking about when it
comes to age.
Mr. Otter. OK. Thanks, Lee.
Mr. Jaurena. I know of no outsourcing. I haven't had any
medical care here yet, so I can't talk intelligently about it.
Mr. Otter. But in your testimony didn't you offer to us
that your prescription that you got from your own doctor was
initially filled through the VA facility?
Mr. Jaurena. No, it was not.
Mr. Otter. Oh, I am sorry.
Mr. Jaurena. It was not. They will not fill the script here
from a private physician. You must have a physician in the VA
hospitals before they will fill the script here in the
hospital. That is one of the things I find absurd.
Mr. Otter. I see. I am sorry, Lee. I guess it was you, just
one more question. Lee, I think it was you that said that your
prescription which you received from your own doctor was
eventually filled.
Mr. Bean. Yes. I saw a physician's assistant, a nurse, and
she looked me over. I didn't see a doctor, no, but I got my
prescription for 1 year cutoff because I didn't see a doctor.
Mr. Otter. Thank you, Mr. Chair.
Mr. Shays. Thank the gentleman. I am delighted that this
committee is here, and I was thinking before we started that we
talked about how the first hearings of the Supreme Court were
wherever they could have a hearing, sometimes in taverns, and I
just will note that while we are at a tavern of sorts, the bar
is not open. [Laughter.]
And also to say that our perspectives are so different. I
am a Yankee, grew up in New England area, and my constituents
have some real complaints but they are a little different. I
will just say as a side when I was in Whitefish, Montana with a
close friend there were three cars coming in on a main street
that we were trying to get on and my friend was driving, and I
wanted to see how she had to react because she had to wait as
one car went by, then another car went by and then another car
went by and then we got on the main thoroughfare, and she
turned to me as she was driving and she said, ``I hate
traffic,'' and I was thinking, boy, you would have to wait for
30 cars before you could get on a main street where I live. And
then I was thinking of distances and I was thinking, though,
that my veterans, if they have to go 60 miles, consider that an
outrage. And you all have to go the equivalent in my area where
I live near New York of having to go up to Boston or to
Columbus, Ohio, in one or two instances, to get the kind of
service you need. So it is important that Members of Congress
get exposed to these different perspectives, because ultimately
we are looking for ways to write legislation that is going to
meet the needs of the veterans but is flexible to the different
groups.
My first question then relates to this. I will start with
you. Are there any community-based health care clinics? For
instance, in Connecticut, as small a State as we are, we are
like a county here, we have one main facility in Westhaven
which is kind of centrally located, at least between the north
and the east and west, right on Long Island Sound, but we have
about four community-based health clinics that our veterans can
go to to get the kind of prescription services that you need,
not to have a bypass but to go there. So are there any
community-based health care clinics that you get to utilize?
Mr. Jaurena. There is, Mr. Congressman, there are several
out here, but I have not used them so I can't speak
intelligently about them. I don't even know where they are at
yet, because I haven't had any appointment.
Mr. Shays. We will be able to ask the second panel about
this.
Mr. Jaurena. I think Mr. Jones and down the line will know
about them also.
Mr. Shays. But I would be anxious just to know if any of
you--Mr. Smith, did it ever serve your need, or Mr. Bean, to go
to a community-based health care clinic? Are they a big deal in
this area or not that important?
Mr. Smith. Not me.
Mr. Shays. OK.
Mr. Smith. The only thing I have done was St. Luke's with
the heart bypass.
Mr. Shays. Mr. Bean, did you have occasion to use a
community-based health clinic as opposed to coming to the main
facility?
Mr. Bean. St. Luke's or St. Jones.
Mr. Shays. Yes, Mr. Jones; yes, sir.
Mr. Jones. Congressman Shays, there are three community-
based outpatient clinics in Idaho: One in Pocatelo, which is I
believe under the Salt Lake VAMC; one in Twin Falls, which is
under the Boise VAMC; and one in Lewiston. The one in Lewiston
is a part-time--part-time it opens. In all three, it is my
understanding is that you still run into the same situation
that there is a waiting list, and you would still need to go
through the VA enrollment process to receive those services. It
is unfortunate that recently, and I would have to look up the
name, of the individual that had given a directive that we were
to stop advertising the community-based outpatient clinics, and
that has resulted in a lot of flack that she has received for
that. But those are in existence and working in discussions
with the CARES Group there are discussions of additional
community-based outreach clinics opening up, and I think it is
a very appropriate outlet to reduce the pressure on the VAMCs.
Mr. Shays. The VA does a lot of things quite well, and one
of the things, though, there had been this debate and I would--
this may seem a little off the subject, but it would be helpful
to know. I want to take advantage of knowing how you all would
feel in this part of the country. There are some that argue,
and I frankly took this argument but have backed off a little
bit because of the response from the veterans, and that was
that there are some who say why not give a veteran a card that
notes that they are a veteran and let them go to any hospital
in the country and get service? I am not going to tell you what
the answers were of my veterans, I want to know what your
answers are, and then I am going to respond to that. Colonel,
we will again start with you. In other words, if you could get
a card that said you are a veteran, you can go to any facility
and you wouldn't have to just go to a veterans' facility, would
you like to see that kind of system?
Mr. Jaurena. I run parallel. I have a card from DOD, it is
called TriCare Prime. I can't get a doctor to take it because
the Federal Government doesn't pay enough to those doctors and
pays in such a poor manner and so late that they refuse to take
it. I believe the same thing would roll with the VA system. I
am in a system already that does that, and I wouldn't adhere to
any other system that does the same thing. It doesn't get me
care, so we need----
Mr. Shays. You would rather be treated in a VA facility.
Mr. Jaurena. I would rather be treated in a VA facility
because our payments, I believe, will never keep up with what
the civilian community is going to require, and they will not
take us. I would even take it if we did and had a reasonable
copayment, sure, but I don't believe we can keep up with it.
The DOD can't keep up with it, I see no reason the VA can keep
up with it.
Mr. Shays. Mr. Bean? You know what I think I am going to
do, I am going to rotate so that way you can switch the
microphone. We will go to you Mr. Smith, and then I will go to
Mr. Bean. So the question is would you prefer to be treated in
a veterans' facility or if you could have a card and go to the
hospital in the Nation and prefer that?
Mr. Smith. Well, right now I would say that the treatment
at the VA center is excellent for what you get, and then I
would like to stay with the VA system. However, it is terribly
underfunded here and understaffed, and with the understaffing
and underfunding, I am seeing a cardiologist right now on the
outside because we don't have one on staff full-time here at
Boise VA.
Mr. Shays. Well, you trigger a second question, and that is
would you want to see a hybrid? In other words, if, for
instance, at Boise they couldn't provide the cardiac type of
health care that you needed, would you like to be able to go to
a non-VA hospital and get that kind of care so you wouldn't
have to go to Seattle to get the care that you needed?
Mr. Smith. Yes.
Mr. Shays. OK. Mr. Bean.
Mr. Bean. I don't think I really qualify because I am not
disabled, I am not in full claims.
Mr. Shays. No, you qualify because you are a veteran and I
want to know what you think as a veteran.
Mr. Bean. I would just as soon use my Medicare and if the
government can help with a supplemental insurance type thing go
to the regular hospital because there are more available.
Mr. Shays. OK. Mr. Jones.
Mr. Jones. I would prefer to go to the VA medical center,
but if services at that center were not available, I would
prefer outsourcing within the community so that I wouldn't have
to leave the community for service.
Mr. Shays. And let me just say that is kind of the way I
should have said it. In other words, we outsourced it in the
community.
Mr. Jaurena. Mr. Shays.
Mr. Shays. Yes.
Mr. Jaurena. Again, I would like to jump back in. Now that
you have thrown a second one into the pile, absolutely, I would
like to go to the VA and then if they could not provide those
services, outsource it out for specialty care.
Mr. Shays. So you could be local.
Mr. Jaurena. I believe that system would work wonderfully.
Mr. Shays. I can't think of it being more difficult, Mr.
Smith, than to go to--to have a major operation, I mean one
that is one safe but a major operation and not be relative near
your home, near your family, near your friends. So I have that
sense.
Mr. Smith. I just can't agree any more than what you said
there. If you are not near your family, you are worrying about
them, they are worrying about you, the whole situation is not
good.
Mr. Shays. Now, let me just say to any veteran or anyone
else who wants to testify, after we finish one or two, that
question would be something I would be interested for you to
address. The response from my veterans is they are afraid that
if we get rid of the VA system, that ultimately the card will
become meaningless, and they at least like to know they have
got this pole in the ground that basically says this is a VA
facility. Also, they feel that the VA facilities have a little
more sensitivity to the illnesses of veterans but also to
understanding their perspective. So the outsourcing, I think,
probably would be more--my own constituents would be more
inclined as long as they didn't see it replacing the VA
facility.
Let me just--I have some questions that staff believes I
need to put on the record, so let me just run through this as
well, and we will start with you, Mr. Bean, since you have
the--have you felt that a communication with the VA facility
has been done in a professional way, and do you feel that you
have always been kept informed by the VA when you have had
requests out there?
Mr. Bean. I don't feel like I have been kept informed, but
any time I have called to talk to them they have been very
nice, no problem there at all, but I have not been informed.
Mr. Shays. Mr. Smith.
Mr. Smith. Yes. They have been very professional.
Mr. Shays. And they stay and keep you informed.
Mr. Smith. And they keep me informed.
Mr. Shays. OK.
Mr. Smith. The appointments are noted and mailed, and
everything is--if I call with a question, it is answered. There
is not any real problem there.
Mr. Shays. Colonel.
Mr. Jaurena. They have been very professional and very
informative. Not only do they send an initial appointment
letter, they send a reminder letter. So they have been very
good. The level of care I can't talk about.
Mr. Shays. Let me just ask another question. When you go
into the facility you have to wait to get there, but once you
are there do you have long waits?
Mr. Jaurena. I can't talk to that. I walked in and
registered and got my card, and they said, ``Don't call us, we
will call you.''
Mr. Shays. Right. OK. So you are a work in process right
now. Mr. Smith.
Mr. Smith. There can be some long waits. As I noted, the
lab is small for that size hospital. I feel there are not
enough people in there. They can't get people through that need
to be done. The pharmacy is a little bit of a bottleneck. It is
better than it used to be, they are trying to improve things.
It is the funding and the staffing.
Mr. Shays. I would just ask you to answer that question,
Mr. Bean, and then, Mr. Jones, I will finish up with you.
Mr. Bean. I was only there two times and each time I had to
wait, oh, maybe half an hour, something like that, which was
reasonable as far as I was concerned.
Mr. Shays. In my part of the country, veterans will
sometimes literally wait half a day before they get--they come,
they are told to get there, and they are queued up in big lines
and so on. Source of tremendous disappointment. You know, they
wait a long time to get there, and once they are there they
wait.
One of the things I want to put on the record is that the
VA has one of the best drug programs in the Nation, if not the
best, because we buy in bulk and we pass on the savings, and
the savings are considerable. And we are using the VA model as
a way to look at Medicare, because Medicare purchases by the
government are basically paid for individually at individual
prices, not at bulk prices. Totally understandable why anyone
who is needing drug assistance would go to the VA facility,
because you pay a fraction of what your neighbor may pay if you
are fortunate enough to get in that system. And I understand
why, Mr. Bean, you would be working overtime to have that
happen.
Mr. Jones, just in a--we need to get to the next panel so
we need to move along, but let me just ask you this: Describe
to me how the State VA facility interfaces with the Federal
system as briefly as you can do that.
Mr. Smith. Certainly. Let me just start off by saying they
have been extremely professional. The Division of Veterans'
Services in Idaho operates three State veterans' homes located
around the State. Each of these veterans' homes is being
serviced by a different VAMC, so I am able to relate and
respond not only to the Boise VA but to the one in Spokane and
the one in Salt Lake as well. In each case, they have been
highly professional. The veterans' homes received a much
greater level of service from the VAMCs prior to the State-
directed certification by Medicaid. Once they were certified by
Medicaid, there were a number of services that had been
previously available and provided by the VAMCs that were no
longer available to the veterans who were residents within the
veterans' homes. The VAMCs also operate long-term skilled
facilities themselves, and that is certainly an issue that is
being addressed by the Mill bill and some things like this. But
a long story short, they have been very professional.
Mr. Shays. I would just note for the record that when we
had a hearing in New York State about 2 hours north of the
city, the room was packed. It was about a little smaller than
this, it probably had about 300 people in it. And at one point,
I was defending the VA, which was not the mood of the group,
and a police officer came up to me and whispered in my ear, he
said, ``In case you have to leave early, there is a door in the
back.'' And I just want to thank you for the fact I can go out
the front door in this hearing. [Laughter.]
If there are no more--do you have any other questions?
Mr. Otter. No, I have none.
Mr. Shays. Let me say that you all--your statements were
really pertinent and ripe to the topics of the questions, so we
had a number of questions to ask, but you answered them in the
questions. So I just thank you for your participation, you have
been wonderful witnesses, very helpful to the committee and we
will go on to the next panel, unless there is just--I usually
do this, I forgot to do this. Is there any closing comment that
anyone on this panel would like to make? Yes, Mr. Smith.
Mr. Smith. I would like to make one. There is just one
statement I would like to make and that is the things that I
have had here and everything are true, but the main thing that
I would like to see is on heart care. I just hate to think
about somebody laying up there for 5 days like I did the first
time when I had the heart attack and then transferring to
Seattle. Five days waiting to find out how much heart damage
you have got is just unreasonable.
Mr. Shays. It is.
Mr. Smith. And I would like to see something like that
changed.
Mr. Shays. And I think both Mr. Otter and I would totally
and completely agree with you. Probably some people in the VA
would as well. So we are going to try to find a way to solve
that problem.
Mr. Smith. Thank you.
Mr. Shays. Any other comments? At this time, then, let me
call Dr. Leslie Burger, Network Director, Veterans' Integrated
Service Network, Department of Veterans' Affairs; accompanied
by Mr. Wayne Tippets, Director of Boise Veterans'
Administration Medical Center, Department of Veterans' Affairs;
accompanied by Dr. David K. Lee, Chief of Staff, Boise
Veterans' Administration Medical Center, Department of
Veterans' Affairs.
Before I swear in the first panel, I do want to put in the
record another witness who was going to be here, Rex T. Young,
from Meridian, ID. Meridian, I am sorry, Meridian. And the part
of the statement he said, ``With all the emphasis on early
detection and early treatment, it is not very comforting to be
told by a doctor after an examination that I need to see a
urologist and also need a colonoscopy and be told the
urologists are making appointments 9 months out and having a
colonoscopy appointment made 9 months out.'' He basically said
the delay on seeing the urologist and obtaining a colonoscopy
through the VA system could have life-threatening. He was in
fact told to have one because there was a concern about his
life. That is I think consistent with what we have heard in
other places around the country and consistent with the panel.
We will put this, without objection, his entire statement on
the record.
[The prepared statement of Mr. Young follows:]
[GRAPHIC] [TIFF OMITTED] T9163.015
[GRAPHIC] [TIFF OMITTED] T9163.016
Mr. Shays. He would have liked to have been here. I don't
know if it is the hunting season and he is out hunting. Is that
a possibility? I understand. OK.
If you would, please, rise before you. Raise your right
hand. Thank you.
[Witnesses sworn.]
Mr. Shays. Note for the record our witnesses have responded
in the affirmative, and we have one testimony. Our testimony is
from you, Dr. Burger, but all three will respond to questions,
if necessary.
Mr. Burger. And we will all give some testimony too if you
would permit.
Mr. Shays. Right. Oh, you all three want to give some? That
is fine. Yes, that is fine. Let me ask you, though, I am going
to ask you to hold that mic up but close enough so we can hear
you.
Mr. Burger. Usually I am pretty loud.
Mr. Shays. OK. Well, Dr. Burger, delighted that you are
here. Thank you, and be happy to take your testimony.
STATEMENTS OF LESLIE BURGER, NETWORK DIRECTOR, VETERANS'
INTEGRATED SERVICE NETWORK, DEPARTMENT OF VETERANS' AFFAIRS;
WAYNE TIPPETS, DIRECTOR, BOISE VETERANS' ADMINISTRATION MEDICAL
CENTER, DEPARTMENT OF VETERANS' AFFAIRS; AND DAVID K. LEE,
CHIEF OF STAFF, BOISE VETERANS' ADMINISTRATION MEDICAL CENTER,
DEPARTMENT OF VETERANS' AFFAIRS
Mr. Burger. Thank you, sir. Mr. Chairman, members of the
committee, on behalf of more than the 7,600 dedicated----
Mr. Shays. I am going to ask you to put the mic closer.
Mr. Burger [continuing]. Employees at the eight facilities
and 17 community-based outpatient clinics of VISN 20, the
Northwest Network----
Mr. Shays. Tell me, the Northwest Network includes how many
States?
Mr. Burger. Four, Mr. Chairman: Alaska, Washington, Oregon
and much of Idaho.
Mr. Shays. OK.
Mr. Burger. We claim to be the--we encompass 23 percent of
the geography of our great country, actually, and that does
present, as you alluded to, one of the major issues that we
have. Our facilities are several hundred miles apart, getting
patients seen up in Anchorage, Alaska and so on and. The idea
is our CBOCs, even though we have 17 CBOCs, they are still a
considerable distance among all our facilities. It has been a
major challenge for us.
Mr. Shays. Let me just parenthetically ask you, I know a
lot of service men and women who have had the opportunity to
serve in Alaska and then decided to retire there, so are you
getting a fairly large population of veterans going to Alaska?
Mr. Burger. Yes, sir. We serve between 10 and 15,000
veterans in Alaska and have opened a couple of CBOCs there and
again have really challenges of getting people from Nome and
Barrow and the Keeneye Peninsula and so on.
Mr. Shays. How many veterans total in the VISN 20?
Mr. Burger. How many are living there?
Mr. Shays. You know what? Get on with your statement. I
shouldn't get this--get right to your statement, please.
Mr. Burger. We served 11,000 veterans this past year in
Alaska.
Mr. Shays. OK.
Mr. Burger. If I might, before I make the statement, to
respond to a couple of the questions that were raised from
panel one, just some data for you. We indeed do use contract
care considerably in the network, and fee schedule, fee basis
care. I have some data for that. Non-VA care amounted to over
$76 million last year across our network. And I did comment to
you about the CBOCs that now number 17. About half of those
opened in the last few years.
My statement, since the inception of the Veterans
Integrated Service Network some 7 years ago, our network has
been a recognized leader in the quality of care it provides to
veterans in the Northwest. Winner of several quality awards, we
really are proud of the fact, as we heard from the first panel,
that those veterans who use our services consistently rate us
among the best in VHA in the patient satisfaction surveys that
we do. And something that we are equally proud of is that our
employees rate us very highly in employee satisfaction surveys.
I have provided for you a copy of the Malcolm Baldrige National
Quality Award application. We have been applying--have applied
for the Malcolm Baldrige Award. A health care organization,
private or public, has never won this award, and we are really
pleased in how we are progressing in doing that. That really
does speak to the quality of our organization.
Mr. Shays. Good luck.
Mr. Burger. And as you have heard here from the first
panel, with the passage of eligibility reform and the opening
of several CBOCs across our network, our veteran users have
grown some 32 percent, from 125,000 in 1997 to approximately
165,000 this past year. This represents an overall market share
of about 17 percent of the more than 1 million veterans that
live in our network catchment area.
We have consistently served the highest percentage of
priority 1 through 6 veterans in VHA, and that accounts for
about 82 percent of our workload. We are No. 1 in VHA in
serving priority 1 through 6 veterans. Our market share of
service-connected and low-income veterans in our area is 33
percent. I would point out to you, Mr. Chairman, that with
approximately 30 percent of our patients being age 65 or older,
we are one of the youngest networks, demographically speaking,
and we will face many of the issues that you face back east in
the next decade or so as our veterans age.
Mr. Shays. I am going to ask you to put the mic a little
closer. See, we hear you all right, but I just want to make
sure.
Mr. Burger. OK. Maintaining high quality and increasing
productivity has been achieved in no small measure by dramatic
shifts from in-patient care to ambulatory care and from acute
episodic care to a patient-focused primary care and disease
prevention strategy. There have been many innovative practices
that have allowed us to drive down or otherwise control
increased costs in laboratory and pharmacy and radiology. We
have adopted changes in care delivery to include such things as
group visits, the use of more structured telephone followup
care, by establishing a 24 by 7 telephone care system for our,
by improving patient flow in clinical areas and advanced
telemedicine to deliver patient care and other staff activities
and advanced clinic access for appointing. These are some of
the many practices that have really changed the health care
delivery landscape for us and helped us to provide more and
more care more efficiently for our veterans. Each of these
innovations is really patient-focused, designed to empower our
veterans as well as to improve our efficiency.
Speaking to budget for a moment, approximately 96 percent
of our network's budget is allocated through the Veterans
Equity Resource Allocation model, the VERA model. This
distribution formula takes into account workload, patient
complexity and other local factors. Without sizable increase in
workload over the past several years, our network has fared
fairly well in this distribution process, receiving more funds
percentage-wise than the national average in all but one of the
last 6 years.
I have provided an attachment in the testimony that really
speaks to the marked increase in the numbers of patients that
we have taken care of, while at the same time we have been able
to hold down the costs for veterans served, which is really a
tribute to the staff and being able to accomplish that.
Until recently, we have been able to keep pace with these
demands for services, but as you know with the economic
downturn here in the Northwest, unemployment is one of the
highest in the country. As of a couple of weeks ago by looking
at the Bureau of Labor and Statistics Web site, Alaska was 51st
in unemployment, highest unemployment in the country,
Washington State was 50th, Oregon was 49th, Idaho was 30th. So
unemployment is a major issue for us here in the Northwest. The
States of Washington and Oregon have been heavily penetrated by
health maintenance organizations, and over the last couple of
years some of these health maintenance organizations have
dropped coverage on thousands and thousands of beneficiaries,
many of whom are veterans.
I would also point out that health care inflation is at
least twice the overall inflation rate, and the growing cost of
medication, which is up some 15 to 19 percent these past couple
of years, and a shortage of health care workers all together
have made it such that the demand for health care services have
now exceeded our ability to provide those services.
The backlog, as you have heard from the first panel,
patients waiting for their first appointment and those waiting
for more than 30 days for appointments has dramatically
increased. I would point out that this is a very dynamic
waiting list. Every month, hundreds and hundreds of people are
taken off the waiting list and there are hundreds and hundreds
more people that are placed on the waiting list.
Mr. Shays. Yes. The tragedy, though, is in order to get
service, sometimes you are waiting for someone to die.
Mr. Burger. I would comment to that, sir, and that is that
as our veterans enroll we are now using a questionnaire, so our
veterans are asked about their health status and what it is
they are actually seeking from us. We are trying to find those
veterans who have a medical acute need, and we are placing
those folks, trying to give them appointments right away.
Mr. Shays. No, but I am not trying to incite here, I am
just trying to suggest not that we are denying someone services
who is about to die, but in order for a veteran to get service
he has to sometimes wait, or she, but has to sometimes to wait
for people to literally pass away so that they are then on that
list, and that is a challenge for us.
Mr. Burger. OK. Another comment to that, it turns out that
about 25 or 30 percent of our veterans turn over every year.
Many of those----
Mr. Shays. I want the definition of turnover.
Mr. Burger. Many veterans come to us for a single purpose--
single visit for a single purpose. They don't come back by
their choice. Other veterans indeed to pass on, and another
group of veterans actually are transient, they are no longer
living here. And that really accounts for most of that 25
percent turnover. I point this out to mean that of the 165,000
veterans that we have served this year, that means that 40,000
of those we did not serve last year and we have taken on, in
addition to that, another 9,000. We have increased about 5
percent over last year. So of that 165,000 veterans, about
49,000 of them did not come to us for care last year. So it is
a very dynamic process. But even so we are not keeping up.
There are more people coming on that list than we are capable
of taking off that list.
We have taken many measures to cope with this increased
demand. I mentioned that we are querying people at the
enrollment process so if there is medical circumstances that
require it, we give people appointments quickly. We have
expanded clinic hours, we have increased our patient panel size
to 1,000 to 1,200 patients for each of our primary care
providers, we have applied supplemental funding that the
Congress has given us, we have begun the process of expanding
our ability to provide primary and specialty care with that
money. In the past 2 months, our waiting list for primary and
specialty care across our network has decreased more than 20
percent. It was as high as 30,000. It is currently well under
23,000. And Mr. Tippets and Dr. Lee will address Boise
specifically about that. On October 1, we did institute a plan
to give priority for appointments to veterans with 50 percent
or greater service-connected disability. We have begun to
contact those veterans by phone and by mail.
We have taken a balanced approach now with the additional
resources that have been provided in order to meet the full
spectrum of the needs of our veterans. That includes primary
care, specialty care, long-term care and to meet the dramatic
increased demand for compensation and p pension examinations.
We can't do one without the other. These are all connected, and
we are trying to do this in a balanced way. We have tried to
craft a plan that will be sustainable by bringing on some new
staff, by calling on our affiliated universities to assist, by
contracting for some services and using fee schedule for
others.
I would emphasize to the committee, as you pointed out,
that the application of supplemental funding is a temporary
solution for us. With this year's budget, we will not be able
to sustain a large number of--the increase that we have taken
on and sustain these services next year. For this reason, there
is a hesitancy for us to hire employees as the sole means of
dealing with this increased demand.
Mr. Shays. Let me just ask a question. Your compatriots are
also going to testify. It is 10 minutes now, I did interrupt
you a few times here. How much longer do you think you need?
Mr. Burger. I have just a closing comment.
Mr. Shays. OK.
Mr. Burger. I just wanted to summarize by saying we have
been a consistent leader in VHA and the quality of care that we
are providing, and in spite of the many efforts we are putting
forth to provide care efficiently and effectively, including
the increase in resources we have been given, we really have
come to a point where the demand has far exceeded our ability
to do that. We are assuring that patients with acute medical
needs are having those needs met. We are getting priority to
veterans with 50 percent or greater service connection, and we
do anticipate in the very near future giving priority for
others for their service-connected conditions. Thank you very
much.
[The prepared statement of Mr. Burger follows:]
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Mr. Shays. Dr. Burger, you would have easily finished
within the 10 minutes had I not interrupted you. And also I
think both Butch and I--Congressman Otter and I would want you
to know is that we do know demand exceeds supply, so we are not
coming here asking why you are not able to do all the things we
want you to do. We have to provide you the resources to do it.
Also, just say for the record, we have 600--we are increasing
the number of veterans who are served nationwide about 600,000
a year. So we are trying to get more, but there is more than
600,000 that need help, particularly because of our drug
benefit. We have got a lot of new customers.
Mr. Otter. Mr. Chairman, if I may note for the record----
Mr. Shays. Sure.
Mr. Otter [continuing]. Dr. Burger, your entire statement
in its entirety, and having read that it is very informative,
will be submitted for the permanent record.
Mr. Shays. Absolutely.
Mr. Burger. Thank you.
Mr. Shays. And also to say that I don't know which of you
gentlemen, Mr. Lee or Mr. Tippets, should go next.
Mr. Tippets. I will go.
Mr. Shays. Yes. Thank you, Mr. Tippets.
Mr. Tippets. Chairman Shays, Congressman Otter----
Mr. Shays. Is that mic on? Yes.
Mr. Tippets. Chairman Shays, Congressman Otter, it is my
privilege to make a few remarks regarding the patient care at
the Boise VA Medical Center. Just briefly, I will discuss
workload, access to care, the current waiting list and the use
of supplemental funds to decrease the waiting list. If I could
refer you to page 9 of the written testimony, attachment A. In
fiscal year 1997, we treated 10,654 patients; in fiscal year
2002, which just ended, that has increased to 15,329 patients.
That is an increase of 44 percent. In fiscal year 1997, we had
99,000 outpatient visits; in fiscal year 2002, that has
increased to 155,000 outpatient visits. That is an increase of
57 percent. During this same time period, funding per patient
has fallen from $4,895 per patient to $4,489 per patient. That
is a decrease of 8 percent in funding over that time period in
spite of the workload going up.
Mr. Shays. Give me the time period again.
Mr. Tippets. 1997 to 2002, for 5 years.
Mr. Shays. So you have less per patient today than you had
5 years ago.
Mr. Tippets. Yes, sir.
Mr. Otter. By 400 bucks.
Mr. Tippets. Yes. About 8 percent less.
Mr. Shays. And if you then equate to increased costs, then
the number would be even----
Mr. Tippets. If you--yes. We did not do this on this
attachment, but if you actually put in the medical inflation,
that figure goes down to $3,500 or $3,600 per patient, yes.
Access. During that time period, we have opened a CBOC in
Twin Falls, which is approximately 120 miles east of here. We
staff that CBOC with two physician's assistants, two nurses,
three clerks and a mental health provider. Each one of the
physician's assistants treat about 800 patients. We currently
have a waiting list of about 800 patients at that CBOC. We are
actively recruiting a physician and during the last couple of
months have been interviewing. We think we might have a
physician to go to Twin Falls. If we do, that should eliminate
that waiting list at Twin Falls CBOC. At least right now it
would eliminate it, but the waiting list will grow again.
At the Boise Hospital, we currently have a waiting list of
about 3,600 veterans that are waiting for primary care
appointments, and that is broken out approximately into 50
percent category 1 through 6 and 50 percent category 7s. And
like I said, the Twin Falls CBOC has approximately 800 patients
on their waiting list. With the new directive, if a priority 1
service-connected veteran walks in the hospital, that
individual gets an appointment within 30 days. We have
approximately 200 service-connected veterans, 50 percent and
over, that are on our waiting list. We have, I believe,
scheduled half of those people, and we are in the process of
scheduling the other half for appointments, so that is being
taken care fairly rapidly.
Let me talk a little bit about supplemental funds. In the
fourth quarter of 2002, Congress passed supplemental funds to
the Veterans' Administration in the amount of $142 million. As
a result of that, this hospital got approximately $1 million.
And I would like to tell you what we have done with that money.
If you look at primary care, we have hired two physician's
assistants. Each one of those physician's assistants will take
approximately 800 patients. And we are in the process of
recruiting for a physician at the Twin Falls CBOC, which, like
I said, should eliminate the 800-patient waiting list there.
We feed in the community about 65 procedures in
orthopaedics. These are patients that are on the waiting list.
We also did about 150 patients that needed cataracts surgery,
that was feed in the community. We took care of about 194
patients in the urology clinic. These are patients that either
needed clinic appointments or surgery. We took care of about
182 patients for audiology exams and we increased EMT to take
care of about 36 patients that either needed clinic
appointments or surgery. So these funds were used to reduce the
waiting list by feeding out most of the care to community
providers. In order to continue this, of course, the
supplemental funds need to be recurring or we will have to--we
will not be able to do that.
I am going to stop there, and those are all the comments I
have. Thank you very much.
Mr. Shays. Thank you, Mr. Tippets. Dr. Lee. I understand,
Dr. Burger, you are also a Major General.
Mr. Burger. Yes, sir.
Mr. Shays. Yes. Hard to know which----
Mr. Burger. Retired, sir.
Mr. Shays. Retired. OK.
Mr. Lee. Chairman Shays, Congressman Otter, it is indeed my
honor as well to be able to testify to your committee. I just
wanted to comment on a few clinical issues as a physician
beyond the data that you have already heard from my colleagues.
One that I think has already been made a matter of the record
but just to emphasize it is that the waiting lists really are a
matter of operational necessity, and we have heard that the
high quality of care once you start receiving care is good and
appreciated, and we value that. But the reason we can keep that
quality high is because we do have to have the waiting lists in
order to constrain the workload to something that can be
manageable. It is a highly regrettable situation, however, and
one thing I would like to say on behalf of the providers is
that most of us went into health care because we were driven to
help people. Most of us went into veterans health care because
we love taking care of our veterans. And so it is very
difficult and in fact even a bit corrosive, I think, at times
for our providers to face veterans who have legitimate needs
and not be able to meet them. So the voice in the face of the
provider, I think, is something else that we should put on the
table here.
And then we heard eloquently, I think, from panel one the
human cost to many of the patients. With a supplemental funding
that Mr. Tippets alluded to earlier, I had a real chance to
kind of experience up close and personal many of the people on
the waiting list. And in fact probably about 90 percent of the
people that we took off toward the end of the last fiscal year
with the supplemental funding indeed wanted their medications.
But some of those were heartrending stories of people whose
medication bills exceeded their Social Security monthly income.
And in addition to that, I wouldn't want it to be said that
many of these people didn't have fairly serious health care
needs. And just to paint that I saw two patients, one of whom
had very uncontrolled hypertension, and in fact I would
characterize as a stroke waiting to happen, and another patient
who had gangrenous foot that we had to put in for a rather
urgent vascular surgery. So there are many people on that
waiting list with rather urgent health care needs that are not
being met, and of course there is a very real human cost to
that. I would be happy to respond to any questions, but I
wanted to put a human face to those things.
One last thing, since I have the opportunity, is that Mr.
Smith, I think, raised a very good point, which is a policy
issue. And that is many years ago we were able to use VA funds
to copay Medicare or private insurance, but there is a general
council opinion that we cannot copay Medicare, and I am told
that general council opinions have the force of law. And there
is a VA regulation that says we cannot copay private insurance.
And so for those two reasons, we are sometimes I think
restricted unreasonably from being able to provide local care
while local specialty care might be available through one of
those two mechanisms. And that is a policy that I would think
that you gentleman could change. Thank you.
Mr. Shays. Appreciate the testimony of all three of you and
we will also thank all three of you for going the usual
protocol, which is the government official goes first and then
the so-called general witnesses go after. We have in this
committee learned that it is very important to have the human
face go first, and you touched on it, Dr. Lee, and you
listened, all of you did, which is what we like, because then
you can comment on that human face as you have already begun to
have done. So I do want to thank you, though, because it is not
a slight, it is just wanting to make sure that we have--you get
the point. I don't have to go on. Congressman Otter.
Mr. Otter. Thank you, Mr. Chairman. I guess I will start
with you, Dr. Burger. In your region, has the reduction in cost
per patient, is that fairly representative of what has happened
in the entire region of what Mr. Tippets and Dr. Lee have had
experience in Idaho? It seems to me there are $406 reduction in
5 years not adjusted for inflation. Is that pretty
representative of the entire region? Take your time.
Mr. Burger. I believe it is, Congressman Otter. If you look
in attachment B, as well, we tried to display the data the same
way for the entire region and then for Boise. As you can see,
the cost per veteran has basically gone down across the board
for us as a network as well. Now, part of that has to do with
efficiencies and trying to become more efficient, but, clearly,
we can't keep up. No matter how efficient we get, we can't keep
up with the fact that more and more veterans as we get older
take more and more medications. That is true across the
country, and the cost of pharmacy care has gone up 15 to 19
percent. So we are losing ground in that regard. But, yes, sir,
that is a general statement.
Mr. Otter. How much of the supplemental--we heard what
Boise got, $1 million of the $142 million, which I am going to
have to look into that, but how much did the region get?
Mr. Burger. We received several million dollars as part of
the supplemental, and we allocated that money by bringing all
of our medical center directors together and looking at how we
would distribute those resources. Our start point is usually
looking at the overall patients, the numbers of patients served
across the system and where the greatest needs are. We actually
probably two or three different times, it was about $7 million,
but we two or three times went back to each of our facilities
and looked at--because the money came to us so late in the
fiscal year trying to spend that money became an issue, so we
went back to the facilities and asked, ``If we gave you more
money, could you, are the providers in the community willing to
take our patients and do that in a timely way?''
Mr. Otter. And their answer was?
Mr. Burger. In some cases, yes; in some cases, no.
Mr. Otter. Is that because there is a fixed national cost
for some of these, standard?
Mr. Burger. There is a demand for services across our
region, and it is not so easy to find a cardiologist or an
orthopaedic surgeon or a urologist that has openings, that can
take our patients in a timely way.
Mr. Otter. Or will provide openings if he doesn't think
that he is getting his service paid for.
Mr. Burger. That is true, but on the fee, the way we
provide that by fee, that fee is not set in any particular
amount, as was referred to about----
Mr. Otter. So that can be regionally adjusted.
Mr. Burger. That can be regionally adjusted.
Mr. Otter. Well, it would seem to me that if you handle,
and in your testimony I picked up on 17 percent of all vets?
Mr. Burger. That is correct.
Mr. Otter. Is that right?
Mr. Burger. That is correct.
Mr. Otter. Twenty-three percent of the land mass but 17
percent of all vets.
Mr. Burger. Right.
Mr. Otter. It would seem to me that you should have
received about $22 million--17 percent of $142 million
supplement.
Mr. Burger. That is one way of looking at it.
Mr. Otter. Well, my concern is unless it was higher cost of
delivering the service in some other area of the country, why
didn't we receive our full rata share?
Mr. Burger. I can't respond to that, Mr. Congressman. I
don't know the answer to that question.
Mr. Otter. If you could find the answer, would you provide
the answer?
Mr. Burger. I indeed will.
Mr. Otter. Mr. Chairman, I would ask that answer that was
provided be made part of the permanent record when we receive
it.
Mr. Shays. Absolutely.
Mr. Otter. Let me ask you a question about the prescription
drugs, and we heard in the testimony from when we were trying
to put a face and a voice to the person that needs the care
that why can't we provide drugs, filling prescriptions, whether
it is eye or visual or whatever, from a physician? If the
person has a doctor's degree and fills out a prescription, it
would seem to me--and if they brought that prescription, No. 1,
it would certainly reduce part of the workload of that waiting
list that may be the care out of private insurance paid for the
issuing of the prescription and all ours would be quite simple
in just filling out the prescription. Why can't we do that? Is
there something stopping us from doing that?
Mr. Burger. I will respond, and I will ask the others to
respond as well. I believe that is a policy decision that needs
to be made. The Veterans' Health----
Mr. Otter. Made or changed?
Mr. Burger. Changed.
Mr. Otter. Oh, OK.
Mr. Burger. The Veterans' Health Administration thinks of
itself as providing comprehensive, longitudinal care to the
veterans it serves, as opposed to just filling a prescription
for someone.
Mr. Otter. I would yield on that.
Mr. Shays. Yes. I think so we can have a candid
conversation there is a part of me that believes it is a way of
restricting the use of these facilities because there is the
question of whether they could keep up with all the
pharmaceutical demand. And there is also, I am wondering as
well, not a concern that a doctor on the outside is just going
to basically maybe be a little more lax in terms of deciding
which type of prescription. In the VA, there are only certain
prescriptions that are filled. I mean it is not all
prescriptions, right, or is it all?
Mr. Burger. If we have the medication in our formulary,
yes.
Mr. Shays. Yes. It has to be part of the formulary.
Mr. Burger. The formulary.
Mr. Shays. Yes. I mean there can be three drugs that
provide the same service, and you may only provide one of them
in the VA, and it sometimes raises the question to the doctor
through advertising and others might decide that this other
prescription is good, and then there is going to be pressure on
the VA to provide that one. So I think there are other subtle
things that they may not be good reasons but I think they are
all--and I am suggesting that may be a factor and I am curious
to have a more candid response.
Mr. Burger. As you all know, the Department of Defense
provides a pharmacy benefit to military retirees and military
dependents. Using our formulary, the experiences that we have
had in working with the providers in the community, I really
don't believe that what you have just mentioned would be an
overwhelming issue that we could not overcome.
Mr. Shays. OK.
Mr. Burger. By sharing our formulary--actually, our network
formulary is on our Web site, it is on the Internet. It is very
easy for providers in the community to know which of those
drugs we do carry so they can prescribe those specific drugs
for our patients. So I don't see that as really a major issue.
Mr. Shays. Would the gentleman continue to yield?
Mr. Otter. Yes.
Mr. Tippets. Let me make just a couple, then I know Dr. Lee
wants to address this issue. Our copay is $7, which has got to
be the best prescription benefit that perhaps exists in the
country, including any of us that have insurance. I pay more
than $7.
Mr. Shays. Yes. That one beats it.
Mr. Tippets. And I guess the other thing I would say, and
Dr. Lee will talk about a couple of the issues regarding this,
we can do anything that the Congress wants us to do as long as
we have adequate money to do it. The average patient that walks
in our medical center, the average patient probably has, the
last time we calculated, $800 to $1,000 worth of drugs. That is
the average patient.
Mr. Shays. Per?
Mr. Tippets. Per patient, per year. Per patient, per year.
And if we were to provide this benefit, we could certainly do
that, but you are talking about--I have no idea how much, but
you are talking about a lot of people that want this service
and you are talking about a lot of money. With that, I will
pass it to Dr. Lee.
Mr. Lee. Yes. If I could respond, I think I would say that
it really is not a clinical issue. I think that clinically that
could be done. I think it is a policy and it is an economic
issue. It is VA policy that they only provide care to those who
are actively receiving care and that it be written by a VA
physician.
Mr. Shays. And I think your point, policy/economic, I think
it has to do with just the incredible potential costs.
Mr. Lee. Yes. But responding to the formulary piece,
actually physicians in the private sector are very used to
dealing with different formularies right now, and most health
care plans have to do that. So I suspect that if we worked in
combination with the private clinicians, that they would be
able to adjust to our formulary.
Mr. Burger. Yes. If I might make one other comment about
that. We are very proud in our system of having a computerized
patient record that is probably the best in the Nation,
probably the best in the world, the CPRS system. And over the
last several years now we are getting to the point where Dr.
Lee for one of his patients has an icon on his screen and he
can call up where that patient has been seen anywhere in the
country, and we know the records. One of the real issues about
receiving care outside our system is the idea of how do I know
what that provider outside did to that patient, what was that
lab test that was done, what was that copy of the x-ray or of
the electrocardiogram and what have you? So the recordkeeping
is really a major issue for us. It is an issue in dealing with
the Department of Defense in how we are trying to share
patients together, because we use two different computer
systems. So the recordkeeping is really important. If we more
and more allow our patients care in the private sector, which
makes sense for them to have care--for all of us to get care
locally, how do you get that record incorporated?
Mr. Otter. Well, reclaiming my time, I also--you know, I
recognize the importance of single provider in order to make
sure that we don't oversupply a patient with needs. But it
would seem to me that there is, besides the costs in terms of
facilities and operation that we talk about here, it seems to
me that there is also a human cost, and I sometimes wonder when
I hear these veterans calling into my office and I get a chance
to talk to some of them, my staff talks to all of them, that
there is a--it would seem to me that there is always a stress
level that goes up when they know they need the drug, they know
that they need the--need to be provided their pharmaceuticals
within 30 days because they are going to be out, and they say,
``Well, we can't get you in for 90.'' And it would seem to me
that if there were a way that we could facilitate the private
prescription, the prescription outside the system, to be filled
within the system and maybe an audit or maybe a check or
something like that, you folks have to tell me. You tell me
where to go, and I will start calling the cadence, as far as I
am concerned, because you are the ones who are going to have to
tell us what is going to work in this system.
Let me go to the formulary. Now, does this mean that on the
formulary there is a list of drugs that you can provide and
then on that same list there may be some drugs you can't
provide?
Mr. Burger. There is a national formulary that lists all
the drugs that are available across the whole system. We have
within our network each of our facilities modifies that for its
own special needs. Those are the drugs that are available
through the formulary. If there is a medication that is needed
outside, then the physician or the provider must ask--must make
a request of that and actually goes to the chief of staff at
each of our facilities to approve that to be purchased outside
of the formulary system.
Mr. Otter. Is the formulary that we use for the vets any
different than the formulary that we use for active military?
Mr. Burger. Yes, there is a difference.
Mr. Otter. Why?
Mr. Burger. Different populations, different contracts. You
can get a drug better from one company than another. I believe
we do very well with DOD in pharmacy and buying things
together, and I believe Mr. Tippets is correct, we probably
purchase drugs less expensively than anyone else in the
country.
Mr. Otter. No question about it. And we are grateful for
that, because it is needed. Mr. Tippets, let me ask you around
this whole question of the availability of pharmaceuticals. The
new Regional Center for Pharmaceutical Dispersement, is that
going to help us?
Mr. Tippets. It should make the timing much better, because
that is going to be up in the Seattle area. Will that help us
take care of more veterans that want prescriptions? No, I don't
think so.
Mr. Burger. What we are concerned about with the
consolidated mail order pharmacy is turnaround time. The
quality--and it is an excellent product. I think we will give
all of our veterans in the Northwest better turnaround time if
we have such a facility, and we are also, as you probably know,
working with DOD. There are also 1 million DOD beneficiaries in
the Northwest. So if we can combine those two things
geographically, that would make it far more efficient from a
turnaround point of view. Right now we are using the Levenworth
CMOP and I believe that our patients are fairly satisfied with
that. We have had some problems, but I think we have had those
turned around. The turnaround times are pretty good now.
Mr. Otter. Dr. Lee.
Mr. Lee. Yes, I would agree. we have actually had a very
active and ongoing process with full formulary adherence and
using the centralized mail pharmacy system at Levenworth, which
has driven, to some degree, the cost per patient that Mr.
Tippets alluded to. But that having been said, I think that
when we get the new regional one here up in the Northwest, it
will probably improve timeliness but probably won't change much
else. I think the quality and the cost will still be about the
same.
Mr. Otter. Mr. Chairman, I appreciate your endurance here
with me. Let me ask just one more question, Dr. Burger, about
the facilities as a whole.
[Changing microphone cords.]
Mr. Otter. We do have utility in our Congressman from
Connecticut; he can do anything. [Laughter.]
Tell me about the facilities. We have talked about the
delivery of care services and the locations where they are and
where they are not, but what about the state of our facilities?
Are we investing in the latest care service or are we going to
have to continue to go to the local hospitals, the local
caregivers in order to maintain our up-to-date delivery of
health care services to our veterans?
Mr. Burger. As to the facilities themselves, we have some
really aging facilities across our network, I think you know
that. Actually, Mr. Tippets is our chief facility management
officer, and he really helps us, as we get funds from the
Congress and from VHA, to renew our facilities and do
construction. He has been very much a player in that. We are
really faced with a seismic problem right now in the Northwest,
the whole Pacific Rim, and we have some buildings that really
need seismic improvement. VHA is addressing that as money
becomes available, but that is a continuing issue.
The operational dollars, the need to bring more and more
veterans, I think Dr. Lee alluded to that, makes it very
challenging in how one allocates the money that we have. We
have this year, as we do each year toward the end of the year,
look at where we are in buying the very latest in equipment and
do the best we can to provide the latest equipment. I believe
that when we think in terms of colonoscopes and endoscopes and
radiology equipment, by and large we are doing a good job in
having state-of-the-art equipment to take care of our patients.
That matches what is available in the community. But there are
pockets in places. As we get into digital imaging, for example,
that is very expensive to do that, and the technology changes
so often that when you make a capital purchase, 3 or 4 years
later you are faced with doing the same thing again. Computers,
we just made a choice to purchase--to replace 25 percent of our
computers. Trying to keep in that cycle has been very
challenging, but I think the answer is that we are keeping up
but it is a challenge. Would you add anything to that?
Mr. Lee. I think the facilities that we have in Boise,
while aging, have been kept up exceptionally well, and I think
they are really quite good. There really are not enough of
them, and one of the things I have to face all the time is even
if I got more clinical providers, I wouldn't have a space to
put them. And so clinic space for more primary care is an
urgent need.
And a few of the other things that exist in Boise are very
capital-intensive, and that includes things like cardiac
catheterization laboratories and radiation therapy. And, again,
Mr. Smith, I think was very eloquent about the fact that he had
to wait before he could be transferred to Seattle for cardiac
catheterization. And Boise simply does not have enough size at
the VA to warrant that kind of a capital investment. Those
sorts of things I think we would still need to continue to
partner with our community.
But I would say we heard from Mr. Smith about the
difficulty of having a life-threatening illness, having to wait
a bit, frankly because of nursing shortages in Seattle, to be
transferred out there in a timely way, and then be out there
away from his family when he is having a myocardial infarction.
And similar with the radiation therapy, the necessity of
transferring cancer patients who don't have long to live to a
distance place away from their family and support systems in
their last days. And, frankly, many of those clinicians regard
it as nearly inhumane.
Mr. Otter. Thank you, Mr. Chairman.
Mr. Shays. Thank you. If the gentleman has more questions
after, we can come back to you. I represent probably four-
fifths of a county, and in the county there are about 250,000
veterans. I represent a wealthy district and candidly many
choose not to use the VA facilities, some, simply because they
would just as soon go to their neighborhood hospital or the
community hospital, which is--in my congressional district, we
have six hospitals. But what has started to happen is they may
be paying $3,000 a year for--or $2,000 or $4,000 for their
pharmaceuticals, and they are saying, ``My gosh, I can get the
best deal in town.'' So they seem to feel guilty in one sense
that they are not taking advantage of the program, in another
sense, they say, ``Well, we have the resources, we have been
able to deal with it.'' But it is just--after a while they
think they are stupid not to take advantage of this service
which they are entitled to as a veteran. So what has happened
is they have started to really push the VA facility. Now, I
know it is being pushed in a lot of places, but these are
people in many cases who have some resources. My question to
all of you is, all things being the same, if you did not
provide a pharmaceutical benefit, just wasn't provided, I am
not even suggesting we not, I am going to suggest the opposite,
but if you didn't provide it, would there be a backlog?
Mr. Burger. You will have to speak to Boise specifically,
but as I mentioned in my testimony, 82 percent of our patients
are priorities 1 through 6 already. We lead VHA in that regard.
Mr. Shays. But 1 through 6 has nothing to do, forgetting
even the wealthy, has nothing to----
Mr. Burger. But the priority 7s are mainly the individuals
that are seeking a pharmacy benefit or are more and more
populating the waiting list. What I was trying to get at was
that as we now take off the 50 percent service connected and
soon we will be taking those seeking care for service-connected
conditions, what is going to be left on the waiting list are
really priority 7 veterans, and the vast majority of priority 7
veterans are the ones that you describe are there for the
pharmacy benefit. So that will become the case.
Across our system, as we have grown----
Mr. Shays. Let me just say, which would suggest, and then
don't forget your thought, that if we dealt with it the way
that Congressman Otter is suggesting, I mean if we could have
all the prescription basically handled outside the VA, your
backlog would disappear significantly, but then you would have
to make sure your facility could handle the incredible amount
of demand on the pharmaceutical.
Mr. Burger. That is true.
Mr. Otter. Would the gentleman yield?
Mr. Shays. Sure, absolutely.
Mr. Otter. What if we just did that for a certain period of
time to reduce the list and go from first time service to
ongoing maintenance? In other words, what if we just did that
for 6 months? What if we just took the outside prescriptions
for 6 months to reduce the folks that you have got on your
list?
Mr. Burger. That would get rid of the list, but there are
lots of other people that are being added to the list. That is
the idea of the supplemental kind of funding. It is a one-time
solution, it would get the list down, but the other reasons why
people are coming in the Northwest with HMOs not being
available and those kinds of things, health care in general not
being available, I think the list would grow again for us,
specifically.
Mr. Otter. Yield back.
Mr. Shays. You wanted to respond as well, Dr. Lee.
Mr. Lee. Yes. The other issue I think is the vast majority
of the medications these people are seeking are actually
chronic medications. Having had that window of time and looking
at them toward the end of last year, they are mostly for
diabetes, hypertension and heart disease. And at the end of 6
months, those conditions will continue on, and so we wouldn't
need to have a mechanism to continue to provide for those
medications after the 6-month window.
Mr. Otter. Excuse me, Dr. Lee. Perhaps I didn't make my
question clear, which is not unusual for me.
Mr. Shays. That is simply not an accurate statement. Be
careful now, he is being very subtle here.
Mr. Otter. I am just saying that looking at the total list
in its totality, and it just seems sometimes overwhelming, and
the stress that goes on with those names that are on the list,
and I want to go back to the human cost in terms of not only
the individual themselves but the family. And I am just
suggesting that if we used a time period here where we said we
are going to allow those people to bring in the prescription
from their own doctor and for a certain period of time until we
get them into our system and can get them off the list of
waiting and get them on to the list of maintenance, is that
still a problem?
Mr. Lee. Oh, I couldn't agree you with more. You know, we
have heard about the human costs. I just think we have to be
very careful about making sure that we had capacity when the 6-
months ran out to make sure that we can handle it. We are all
on the same wavelength here, we want to provide that care.
Mr. Burger. If you were to suggest a pilot, and I know Mr.
Tippets once before said he would be willing to raise his hand
to try that to see, but I think, Dr. Lee, really, it is what
happens at the end of 6 months? I wanted to just mention that
through that last month in our 5 percent increase in total
numbers of veterans, about 3 percent of that was in the
category A, the 1 through 6s, and about 16 percent was in the
priority 7 veterans. So, again, even in our network where the
vast majority of patients are priority 1 through 6, it is the
priority 7 veterans that are overwhelming our system for the
drug benefit.
Mr. Shays. And most they are interested in what is truly
the best drug program in the country, if not the world.
Mr. Lee. Yes, sir; that is exactly right.
Mr. Tippets. Yes. A very high percentage of them are. I
think if you did that, yes, you would--again, this depends on
the facility, the hospital you are talking about. Yes, you
would probably either greatly reduce or eliminate the waiting
list but then you have to figure out what to do with those
patients when they need to come into the hospital.
Mr. Shays. In regards to--what neither of us want to do is
screw up a program that is pretty outstanding--which is
outstanding, but at the same time, when you hear Colonel
Jaurena speak, he is service connected and yet he is having to
wait, it blows my mind. I mean it is service-related, it is not
an injury that he has had as a veteran afterwards but totally
connected to the service in Vietnam. And by the way, our
committee has had countless hearings on the whole issue of Gulf
War illnesses, and we have learned that there are many who are
in fact sick because of their service, and it has been a long
struggle to get the VA kind of to sort it out themselves.
Let me just ask you, as it relates--and I will get on
beyond the pharmaceutical--but the pilot program, it seems to
me, is a no-brainer that we should try seeing what is the
impact of prescriptions being filled by outside physicians.
Will they start to suggest more? Since they don't really--a VA
doctor is going to focus on his patient, but he is also going
to know the capabilities of the system, and so will there be
more drugs per patient being prescribed versus what a VA doctor
is going to do? Who knows. Maybe not, maybe there shouldn't be,
but it would be interesting to know. And it would be
interesting to know how the VA then fills in actually providing
this greater supply now of pharmaceuticals, because you are
going to have to be able to manage more drugs in and out.
One of the things that has been a source of aggravation is
that you can get a 30-day supply and you have to come in and
pick them up. In some cases--I don't know, in some cases, are
they allowed to be sent to the patient? They are being sent to
the patient?
Mr. Lee. Yes. The Department of Defense has the 30-day
supply scriptures; the VA actually has 90-day supplies of
medications and mail-out refills. So we are more user-friendly
in that respect.
Mr. Shays. So you are sending them out.
Mr. Lee. Yes.
Mr. Shays. OK. Well, that is interesting. Let me ask you
the question of the supply of physicians, nurses, technicians,
administrators. Is your biggest challenge nurses, biggest
challenge doctors, biggest challenge technicians? Where is your
biggest challenge?
Mr. Tippets. It is not administrators, by the way.
[Laughter.]
Mr. Burger. That is my biggest challenge. Let me speak from
a network perspective. You know, it is interesting that we are
geographically isolated in the Northwest, and that really is an
issue for us. When you actually look at the number of nursing
schools or even medical schools, we only have two: One in
Oregon, in Portland, and one in Seattle, in Washington, in our
area if you look at the number of nursing schools and pharmacy
schools and so on. So there is a restriction right there, and I
have already heard from nurses that nursing schools are paying
faculty enough to attract faculty, so they can't expand the
size of their classes and so on.
On the nurse side, it becomes very obvious, because nurses
take care of patients that are in-patients, in bed. There is a
dramatic shortage of nurses and that is going to continue to
grow. Within VHA, the average age of our nurses is approaching
50.
Mr. Shays. This is all over the country. I just don't know
what the--and I am told it is not just getting--well, you
answer your question, I am sorry.
Mr. Burger. And it is. It is a national issue, and it is
getting worse as we all get older and need more care and so on.
For us, specifically, in the Northwest, several of the medical
specialties there is a dramatic shortage--medical
technologists, informatic specialists, laboratory technicians.
Imaging technicians are among those areas that have an absolute
traumatic shortage. We have decided as a network, as VHA has
decided, to start training its own. There are debt reduction
programs now in people who are going to various schools. We are
in the process now of trying to figure out how----
Mr. Shays. Is this that debt forgiveness for graduate
schools?
Mr. Burger. Yes. So we are going to try to train our own
people in medical technology or in imaging or as prosthetics
managers and that kind of thing. It is a national issue that I
believe requires a national solution.
Mr. Shays. OK. I hear you.
Mr. Burger. It is really getting to be--we are already in
that crisis. I guess you hear that from your constituents.
Mr. Shays. Right.
Mr. Burger. People who drive ambulances drive around our
cities, can't find beds. And I am not talking about the VA, I
am talking about in general. I just saw a statistic that said
the average wait for one of our Nation's citizens to see their
physician with an acute problem is 7 days. That is a national
issue, so it is a problem.
Mr. Shays. Mr. Tippets.
Mr. Tippets. We have a pretty severe problem with nurses
going back--oh, it probably started a couple years ago, and I
have been the administrator of the hospital here for just about
10 years, and for the first time ever we actually had to go to
the nurse registry and--you know what the nurse registry is, I
am sure; yes, that is where you go to get contract nurses from
a private agency to come into your hospital.
Mr. Shays. And your costs go up about 30 percent?
Mr. Tippets. Well, yes. Let me just give you an example. To
get a nurse from the nurse registry costs us about $70 an hour,
so we probably should have all gone to nursing school.
Mr. Shays. It is not too late. [Laughter.]
Mr. Tippets. We have increased our salaries. We have to be
competitive with two major hospitals in town. We have increased
our salaries, we are doing fairly well right now. In addition
to that, in conjunction with the Idaho Hospital Association, we
have met with the local university, Boise State, and they have
agreed to increase their nurse class size by 30, and I believe
that started this fall.
Mr. Shays. But the bottom line is nurses are a concern. How
about doctors?
Mr. Tippets. I will let Dr. Lee address that.
Mr. Lee. Yes.
Mr. Shays. Dr. Lee, before you answer, if there is any--we
are going to be set pretty soon to go to our open mic, and so
if you would like to speak, Jason, would you raise your hand
there? Jason has a mic, and what we will do is we will want you
to fill out a form so we can give the transcriber your name and
address and so on so we have it for the record. You won't be
sworn in but you will be invited to address us. Yes, sir. I am
sorry, Dr. Lee.
Mr. Lee. Just a comment on the health professions in
general. I regard it as an ecosystem, and you have to have just
about all the species in the ecosystem to make the whole thing
function. And so we have, from time to time, seen various
things, like imaging technicians become mission critical
because of near shortages. As far as physicians are concerned,
we are actually not too unsuccessful in recruiting most primary
care physicians, but several of the specialties we need most
for aging veterans, like urologists and orthopaedic surgeons,
are actually earning two to three times what the maximum VA
salary is in the community. And, of course, that makes it much
harder to recruit them, and that means that there are backlogs
in some very critical specialties that our veterans need.
Mr. Burger. And you can't buy those services either,
because the demand is there in the community as well.
Mr. Shays. Let me just--you talked about, Dr. Lee,
listening to the face of the issue in terms of listening to
what the veterans were saying, and when you heard Mr. Smith
speak about the cardiac care, what would be the challenge and
what is the logic against not having him receive cardiac care
in Boise? I am sure that exists here, correct?
Mr. Lee. Oh, yes. Our private medical community in Boise is
absolutely wonderful. The specialists are good, well qualified,
and actually we value a fairly close working relationship as
far as the VA and the community----
Mr. Shays. So let us just talk about that particular issue,
the cardiac care. Is that going to be a subjective decision?
Would he have had the right to petition to get it in Boise or
would he not even have the right to do that?
Mr. Lee. Well, he certainly could ask, and it is really
largely an economic issue. We have talked about the fact that
we have large waiting lists and we try to stretch the Federal
dollars we get absolutely as far as we possibly can. And one of
the ways we do that is to send cardiac specialty care to
Seattle.
Mr. Shays. Anybody else care to----
Mr. Burger. I would echo that. I think it is an economic
issue about how much care. We could attempt to contract with a
group to try to negotiate prices, but, again, the demand for
the care in the community for cardiology care in the community
is such that there is an unwillingness to enter in any----
Mr. Shays. So bottom line is you would be paying top
dollar.
Mr. Burger. We would be paying top dollar.
Mr. Shays. And so I am reading into your answer that if
some of these fairly expensive procedures, if you contracted
for the cardiac care but then added all the others that you
could logically include with that, I mean different services,
your budget would disappear real quick.
Mr. Burger. Sure.
Mr. Shays. OK. Is there anything that you all--Congressman
Otter, is there anything you want to ask before we get to the
floor?
I know we are going to have to--in order to make that
flight, we are going to have to----
Mr. Shays. Let me just say, we will stay and take the next
flight if we have to, but I am just curious to know if there is
anything you have to add.
Mr. Otter. Yes. I would just like to ask Dr. Lee one
question about his ecosystem, which I thought was very
analogous to what our needs are. But one of the things when I
take a look at the inventory of our assets, and being prior
military, my prior military was in the 116th Armored Cat. I
joined initially 139th engineers and then we were reorganized
during the Vietnam into the 116th Armored Cat. And we had
several medical units attached to us, and it wasn't unusual
during our summer, our 2 months--or I should say our 2 weeks in
the summer or our monthly meetings it wasn't unusual for a
medical unit to come in, provide us with the necessary
physicals that were required for that year and that sort of
thing. But it also wasn't unusual, though I wasn't part of the
medical group, I was in reconnaissance, for them not to have
much to do.
And I wonder if we have even taken a look at maybe perhaps
tapping that into asset for an occasional reduction or maybe a
review of some of those lists. Is there any way we can take
these assets and work them together and maybe have a Guard
medical unit come in for a weekend or something like that when
they are on their weekend drill and maybe work on part of this
list, because they are highly professional folks, and every one
of them have a physician?
Mr. Burger. Can I address that, actually. Well, go ahead,
David.
Mr. Lee. Well, I will briefly address and then turn it to
Dr. Burger. Yes, I think there is a lot of promise to that, and
in fact some of that happens, and we have a number of people
who do their Reserve duty, or at least part of it, by coming
out to us. In fact, we have one physician from Emmit who comes
to us on a regular basis, and he has helped a great deal with
some of the workload and the backlog, and we do have other
units that come in on the weekend. And during those weekend
drills, they do provide us with substantial help, although it
takes a while to orient them and get them up to speed and
working with us.
Mr. Burger. Just a technical point there. When the military
restructured itself, the vast majority of the medical units are
in the Reserve, not the Guard, actually, and I don't know what
USAR units or other--well, Reserve units might be here but not
in the Guard.
May I please respond to the question, you caught me unaware
when you said 17 percent before, and it has been rattling on
me. It is not 17. Seventeen percent is our market share. The
$142 million was distributed by VERA by workload, and we did
get our fair share. So that----
Mr. Otter. We got a per capita.
Mr. Burger. We got a per capita. We got like everybody
else. The 17 percent relates to our market share of our million
veterans.
Mr. Otter. There is no sense in us leaving any money laying
on the table.
Mr. Burger. No. We did get our fair share of that money.
Mr. Otter. Thank you. Thank you, Mr. Chairman.
Mr. Shays. Let me invite the three of you to stay, and I am
going to let you have closing comments. We may have just one or
two veterans, participants, here who may want to make some
comments. So if you could just--so if you would identify
yourself for the record. I know you have given us a sheet, but
identify yourself.
Mr. Harris. Good morning.
Mr. Shays. Good morning.
Mr. Harris. Representative Shays and Otter, I am Eldon
Harris. I am a retired Navy chief petty officer. I retired in
1958, enlisted in 1938. I have seen many changes in health care
to losing lifetime health care in the Navy. I then go into
civilian life and I have a company promise of lifetime health
care; later, lose that. So I am almost appalled at the
arguments we have or what we have to present regarding
basically the pharmaceutical plan, or what we don't have as a
plan, available for our veterans down at the VA hospital.
I have gone through pharmaceutical plans that you won't
believe. At the present time, I am just about as good as I can
get. We get our prescription filled through DOD, the wife and I
both, and we also have available through Fred Meyer's, a local
chain store here, we can get prescription drugs filled here for
$3 a prescription, and that is for your regular prescriptions
if they are generic and $9 for the others. So to me, we are
missing an awful lot someplace. I think we need to go back
clear up to where this ball starts to roll and go to these
pharmaceutical companies.
Another appalling thing is that if you go to our borders in
Mexico and Canada, 40 percent, or maybe more, of the people
going across the border to fill their prescriptions are either
retired farmers or retired military that don't have a medical
plan or they are not qualifying for it. This is sickening. If
these pharmaceutical companies can go to Mexico or go to
Canada, sell the plant and sell these drugs for that price
outside of losing their lobbying policies here in the United
States, there is no reason they can't do it here. We have got
to be as good a country for the companies as anybody is.
Mr. Shays. Let me say we had a hearing in Boston on the
whole issue of the pharmaceutical program, and if you leave
your address with us, we will send you the--should we send the
transcript--yes, we can send you the transcript of that and be
interested in your comment. One of the challenges that exists
for pharmaceutical companies, you know that they are basically
price controls in both. I wager to say there has been no major
medical breakthrough of any pharmaceutical company in Mexico
because of it. And I would say to you there is one company in
California that has invested $1 billion in hoping to retard the
deterioration into Alzheimer's. They thought they were going to
have a major breakthrough, had a lot of investors in, but right
now it has not proved successful. That $1 billion is out the
window. So we are trying to find the way you get the
pharmaceuticals to create the new drugs and invest and risk and
so on, get a return far more than what it costs to produce but
for all they are investing.
What we did do was we did vote in the House for legislation
to say that if you could get a drug cheaper in Mexico or
Canada, as long as it was FDA-approved, that you could import
it in as a way to see if we could kind of level pricing in the
United States. It is very controversial. Your program that you
get, though, you are not getting from the VA, you are getting
through the Department of Defense.
Mr. Harris. This is true, what they call the TriCare type
thing.
Mr. Shays. And your testimony is that you are content with
that program.
Mr. Harris. Yes. This is a fantastic deal.
Mr. Shays. Yes.
Mr. Harris. But here, again, you have to be over 65.
Mr. Shays. Right.
Mr. Harris. One other thing on this, I noticed in the
conversation there is a difference between minimum copay
through the VA and what I can get it at Fred Meyer's.
Evidently, Fred Meyer's is getting paid for the difference
through Medicare, but the DOD or VA should be getting----
Mr. Shays. What the VA, I don't know if DOD does as well,
is we buy in bulk, and we are able to basically pass on that
savings to the veteran.
Mr. Harris. Well, this rings in another problem, just to
touch on it in a minute. My wife has a condition that takes a
special pill. When we first moved here 3 years ago from
Washington State we went to Mountain Home Pharmacy, and it got
to the point where she could not get her prescription filled
there, because they had no generic, no crossover. And then we
come to find out that the small pharmacies they only order
enough of this one pill for prescriptions for their local
people on the base. So here again you have a cost breakdown. I
did forget when I introduced myself, I am the president of the
Fleet Reserve Association Branch 382. I have been a member for
49 years, so I have seen a lot of changes and have followed
this man the last 3 years too. The man sitting behind me and I
have run across a few years, so I am watching all of you. I
haven't got many years to go but I am watching. I thank you for
this opportunity.
Mr. Shays. Thank you. It is an honor to have you testify
before the committee. Thank you very much. Mr. Smith, I think
you also wanted to make a comment.
Mr. Smith. I am Tom Smith, of course. The comment I had to
make was that the medical flights to Seattle. On the Cardiac
Unit, if you are in there on an emergency, they do fly you up.
They fly you up with a medical plane, a nurse's assistant and
the pilot. And the plane, I am sure that costs a bunch, and
when we start figuring things out, the copay with my insurance
would have been far cheaper than to have the medical procedure
done in Seattle. So I don't understand why that there is a
regulation here that stops the VA from paying a copay with my
private insurance when my private insurance took care of
everything but. And it is just a fine line here, and I don't
understand what it is and why it should be there.
Mr. Shays. You know, I should know the answer to the
question. I understand why it exists in Medicare because it is
the same thing: It is the government paying the government. So
whether the government is VA or the government is Medicare, to
get a copayment from Medicare is just taking one part of the
government to the other, but I don't know the private side and
why we are not able to do it on the private side. Can you speak
to that at all? Mr. Smith, you should sit down, I am sorry,
because the transcriber has the mic.
Now we have one other person who is going to--OK. And we
will go to the next person afterwards.
Mr. Lee. Yes. I am very well-versed on that one. The
copayment of the private insurance is a matter of VA
regulation, and I am told I can be disciplined if I ignore VA
regulations.
Mr. Shays. No, I understand you have got to follow
regulations. Usually when something seems absolutely absurd
there is a reason, and you may not agree with it, yes, but
there is a reason why, and I wish I had why we don't do it
because it seems like a no-brainer.
Mr. Lee. Yes. I don't understand the rationale either. I
agree with Mr. Smith. By the way, the cost of the air ambulance
is about $4,000.
Mr. Smith. The copay on that would have been less.
Mr. Shays. Right. But how much is an operation in a
hospital, what would that have been in a private hospital?
Mr. Lee. You are looking right around $45,000.
Mr. Shays. Right, 45. And at the facility, how much at your
facility?
Mr. Burger. Probably well under $25,000.
Mr. Shays. Right. So you are getting your--you are looking
at total costs. But in the end, we have got to decide there is
a point that even costs notwithstanding there should be a
critical mass of service provided for a veteran, and I don't
think anyone here is denying that. We put these administrators
in a difficult circumstance. We give them a certain amount of
money, we have a lot more veterans each year, and we could yell
at them, but it really rests on Congressman Otter's and my
shoulder to just keeping running out more benefits for--more
money for the hospitals, which we do every year, but it is
never quite enough.
Mr. Smith. I agree that there is not much money to go
around, that is No. 1. And the only thing that I can't
understand and still don't understand is why that they wouldn't
be able to have a copay that would pay with my insurance if----
Mr. Shays. I don't have the answer to your private--why the
private insurance, and you have--I am going to leave this as a
requirement of my committee staff. You are looking at the
Director, Larry Halloran. Larry will make sure you get an
answer and Butch and I get an answer as to why there is not the
private copay and then if there is anyone in the audience who
could answer, I would love it. But I should know it, I think I
was told and I think I have forgotten. But it may make sense or
may not, and we will look into it, and this is one of the
values of the hearing. So you have made a number of
contributions today, and I thank you.
I think we will get to our last witness, not our witness
but our last person invited to make comments. And you have
given a form to--OK, yes.
Mr. Williams. My name is Gordon Williams, and I am combat-
wounded Marine, and I am 6-year paratrooper, 22 years active
service. And unlike the rest of the people that testified, I,
like a commander, see the people in action at the VA hospital
because my wife and I volunteer there 2 or 3 days a week. We
work there to supplement the people that get paid. I can tell
you that this is one of the best hospitals that I have ever
been in. I have been in a few. They have the best medical staff
and they are overworked and in most cases underpaid. Mr.
Tippets runs a tight ship. There are no wall-leaners, there are
no clipboard carriers, they work. Anytime you--and they always
go the extra mile. If you need a question answered by a doctor
and you are in there, he will take the time to do it, although
many people sit out there. And I guess I am beating a drum for
this hospital, and I damn sure am.
Mr. Shays. Well, you know what? I was going to ask if any
of the gentleman want to have a closing comment, but I think
you would be foolish to respond. [Laughter.]
And we are going to let your comment be the last word, how
about that?
Mr. Williams. How about that.
Mr. Shays. OK.
Mr. Williams. Semper fi.
Mr. Shays. Thank you very much. We will close this hearing.
Thank you very much. Oh, excuse me, before we close, I want you
to sit down. I do want to thank very much the people who worked
hard on arranging this hearing. Cheryl Miller, Business Manager
of VWF Post 63, thank you very much, Cheryl. We thank Jim
Adams, Congressman Otter's district staff, from his staff, and
Mark Warbiss, Communications Director as well from the staff of
Congressman Otter. And also Gayle Ruts, Northwest Transcripts
Court Reporter. Thank you Gayle. Is there anyone else we should
thank?
Well, I just want to thank all of you for participating. It
has been a wonderful hearing, very educational. I am delighted
that the committee came out. I just apologize to Butch that we
didn't come out sooner, but we will back on other issues as
well. And thank you all very much. Butch, do you have anything?
Mr. Otter. No. I thank everybody for being here. I really
want to thank Congressman Shays, Chairman Shays and the entire
staff, Larry, everybody, for coming out, because I know how
important, and I think you too, know how important it is to
these folks that were here in this room here today, and I thank
you very much, Mr. Chairman.
Mr. Shays. Thank you very much. This hearing is adjourned.
This first adjourn didn't happen.
[Whereupon, at 12 p.m., the subcommittee was adjourned.]