[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
CHALLENGES IN RURAL AMERICA: VA ACCESS AND MENTAL HEALTHCARE
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HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, AUGUST 6, 2014
__________
Serial No. 113-83
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman CORRINE BROWN, Florida
DAVID P. ROE, Tennessee MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
JEFF DENHAM, California DINA TITUS, Nevada
JON RUNYAN, New Jersey ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan RAUL RUIZ, California
TIM HUELSKAMP, Kansas GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
Jon Towers, Staff Director
Nancy Dolan, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Wednesday, August 6, 2014
Page
Challenges in Rural America: VA Access and Mental Healthcare..... 1
OPENING STATEMENTS
Hon. Jeff Miller, Chairman....................................... 1
Prepared Statement........................................... 32
Hon. Steve Pearce................................................ 4
WITNESSES
John Taylor, Veteran............................................. 5
Prepared Statement........................................... 33
Richard Moncrief, Veteran........................................ 8
Prepared Statement........................................... 35
Dawn Tschabrun, Chief Executive Officer, Lovelace Hospital....... 10
Lisa Freeman, Interim Network Director, Veterans Integrated
Service Network (VISN) 18, Veterans Health Administration, U.S.
Department of Veterans' Affairs................................ 19
Prepared Statement........................................... 35
Accompanied by:
James Robbins M.D., Interim Medical Center Director New
Mexico VA Healthcare System, Veterans Integrated
Service Network (VISN) 18, Veterans Health
Administration, U.S. Department of Veterans Affairs;
And
Lori Highberger M.D., Deputy Chief Medical Officer and
Mental Health Lead, Veterans Integrated Service
Network (VISN) 18, Veterans Health Administration,
U.S. Department of Veterans Affairs
CHALLENGES IN RURAL AMERICA: VA ACCESS AND MENTAL HEALTHCARE
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Wednesday, August 6, 2014
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, D.C.
The committee met, pursuant to notice, at 11:15 a.m., at
the Roswell Convention and Civic Center, 912 North Main Street,
Roswell, New Mexico, Hon. Jeff Miller [chairman of the
committee] presiding.
Present: Representatives Miller and Lamborn.
OPENING STATEMENT OF CHAIRMAN JEFF MILLER
The Chairman. The meeting will come to order. Before I
begin, there's something we need to take care of today. And I
would ask unanimous consent for our colleague, Steve Pearce, to
be allowed to sit at the dais today and participate in today's
proceedings.
Without objection, so ordered.
Good morning, everybody. I'm pleased to be back. It was one
year ago that I had my first opportunity to come to Roswell
after driving down from Albuquerque with Congressman Steve
Pearce. So it's a pleasure to be here.
I'm Jeff Miller, Chairman of the House Committee on
Veterans' Affairs. I flew in this morning from Pensacola,
Florida, where we have more water than you do, Steve.
I'm joined by senior committee member from Colorado, Doug
Lamborn. I'm pleased to have him here today. And, of course,
our friend and colleague, Steve Pearce.
The Chairman. I know I speak for Representative Lamborn
because we both feel the same way. Our friend, Steve Pearce, is
a dedicated member of Congress. We actually sit together on the
floor of the House almost every time we have a series of votes.
And I know that he is keenly interested in the veteran
community and the things that are going on not only here, but
all over the United States of America. So it's a pleasure,
Steve, to have you joining us today.
Mr. Pearce. Thank you.
The Chairman. And I'm grateful to him for inviting us to
come back and have a chance to listen to some individuals who
are going to testify today.
Before we begin, I'd like to just ask, you're a veteran,
please stand. If you are not able to stand, raise your hand. We
want to recognize you and say thank you for your service to our
nation.
The Chairman. Again thank you so much for your service and
continuing to help, as do many of you here in Roswell, your
fellow veterans.
Ensuring that you and your neighbors and colleagues in New
Mexico and around the country have timely access to quality
healthcare through the Department of Veterans Affairs is why
we're here today. I'm grateful to each of you for joining us
because it is a very timely topic that we discuss right now.
As you know our committee has been involved for quite
sometime, but in a much more diligent fashion, holdings two
full committee hearings a week through the summer months
because of the crisis that exists right now within the
Department of Veterans' Affairs.
We knew that there were wait times, we knew that there were
issues. What we did not know until recently, and I say
recently, late last year, when we actually started
investigating, was the corruption, the lying, the cheating, and
the stealing that was going on by some employees within the
Department of Veterans Affairs as it relates to wait times.
Because of that, we fashioned a piece of legislation that
the President will sign tomorrow that I think will go a long
way to starting the process of fixing VA.
One thing is you cannot legislate morality, you cannot
legislate common sense, you cannot legislate people doing the
right thing. But what we did do was give the Secretary the
ability to fire individuals who aren't doing their job or who
find that they forced other people to manipulate the numbers so
that they can receive bonuses.
We still think there may be some potential criminal claims
that may be lodged against some of these supervisors because to
change numbers at the federal level to get a promotion or a
bonus of some type is, in fact, a violation of the law. We have
asked the Department of Justice and the FBI to get involved,
and they have.
In the four months since this broke, April 9th was when we
actually broke the story, CNN has covered it quite ostensibly.
They didn't even really start covering it until the end of
April. But we have held as I said about two meetings a week.
And we have continued our oversight.
Now, for people all across the country, the media will have
you believing that we are on a five-week vacation. That's not
quite what the August recess is supposed to be.
The August recess is supposed to be an opportunity not only
for us to go back and reconnect with our constituents, but also
to travel all across the country as I do as the chairman, as
Doug Lamborn does, and as Steve will do with me tomorrow when
we go to El Paso to look at the issues over there as well.
We are continuing to keep shining a light on VA to make
sure that they, in fact, are changing the way they do business.
Unfortunately it's not going to change overnight. You know
that. It didn't happen overnight, it's not going to change
overnight.
But I think the new Secretary has the right attitude. My
caution to him is don't let the bureaucracy eat you up, because
that's what happened to Secretary Shinseki. The unfortunate
thing about the Secretary's departure is that the very people
that caused the problems are still employed by the Department
of Veterans Affairs. But the Secretary was lied to and he's
gone.
So, you know, the VA's nationwide access audit found
troubling scheduling practices were in place in Albuquerque at
the medical center there. And we're going to hear from some of
our witnesses this morning about issues that they have had to
confront.
And, look, it may not all be bad. I'm not here just to hear
the bad stuff. I want to hear some of the good things, because
out of the 330,000 VA employees that are out there today, let
me assure you that there are a lot of good ones that are going
to work every day at the VA because they want to serve veterans
and because they want to do the right thing.
But we've got to fix the problem and get rid of the people
who are the dead wood inside that system so that you are served
better and you get the care that you've earned.
I look forward to our discussion this morning. I thank you
all for being here. I will now turn to my good friend Mr.
Lamborn for his opening statement.
Mr. Lamborn. Very briefly, thank you, Mr. Chairman, for
having this hearing. It's great to be in Roswell, it's great to
be among veterans.
My father was a World War II veteran. He passed away a
couple of years ago. He fought in 11 campaigns in North Africa,
Sicily, and Italy. And it changed his life. I mean it made him
a different person.
It was something he talked about. He was someone who talked
about his experiences. And almost every day for the rest of his
life. And so it was just great to sit at his feet and learn
about the greatest generation.
And then my oldest son has served in the Army. And one week
after high school he was in for three years, serving in support
of the 82nd Airborne at Fort Bragg. So I'm honored to be part
of the VA committee.
And let me just say, Chairman Miller, you may already know
this. But he is so dedicated to veterans, his care and his
concern and stewardship of the taxpayer dollars, and the
clinics and hospitals. He's doing such a great job. But you
know that. And that's why he's here in Roswell, that's why
we're having this hearing.
So it's an honor to serve with him. And it's an honor to
serve with Steve Pearce. As a veteran himself, he knows these
issues. But beyond that Steve Pearce is legendary in Congress
for his dedication to the person, a person off the street
living in his Congressional district.
They've written about him in The Wall Street Journal. And I
don't want to embarrass you, Steve. But he sets a great example
that many of us appreciate and learn from and have benefited
from. So it's just great to be here, Mr. Chairman. Thanks for
having this hearing.
The Chairman. Thanks very much, Doug. I'm going to
recognize Congressman Pearce in just a minute and introduce our
witnesses.
But first I want to thank them for their presence here
today and for participating in this hearing and doing all the
things that you do for the veterans in this local community and
around this region.
I would also like to gently remind you, if possible, we do
have a five-minute opening statement rule. What will happen is
these little lights will pop up. It will go green. And when you
get to one minute, it will go to yellow. And then when you get
to red, that means your time is expired.
Now, if you go longer than a minute after red, I can't
promise what will happen. We want to hear your entire
statement. So they are here certainly to kind of help keep
people on time with their statements. But we appreciate you
being here to talk to us.
At this time let me ask Steve Pearce if he would introduce
our panelists. Thanks.
Mr. Pearce. Thank you, Mr. Chairman. Thank you for being
here. Also thanks, Mr. Lamborn.
OPENING STATEMENT OF HON. STEVE PEARCE
Mr. Lamborn last night was going to get on the plane to
come here. They had thunderstorms that were going to keep him
from flying. So he and his wife got in the car and drove here.
So I think we need to recognize the dedication that people have
when they make commitments in Congress. It's a very serious
thing.
The reason we're here today has been amplified in the last
two days since I've been home. Since being here back in New
Mexico, I ran across one veteran that was driven from here to
Albuquerque to receive an injection in the index finger.
That's the reason we have set this pilot project up here
today, to stop using those kinds of long trips for things that
could be done locally.
Another veteran that we saw just yesterday in Jal had
hearing loss from cannon fire back in Korea. His hearing aids
broke. They sent him to the VA in Big Springs.
Big Springs VA paid him miles to go there. Big Springs sent
him to Albuquerque the next week. They paid him mileage there.
They kept him there three days. After assessing him, then they
returned him back to Big Springs and said he ought to have gone
there to start with.
And then he finally got the hearing aids and they didn't
work so he's still using his old ones. And it's that sort of
ineffectiveness and inefficiencies that cause veterans
tremendous problems.
Then this morning I was on a call-in radio program. The
young lady carried her 88-year-old father yesterday to the
Artesia clinic. She had a card in her hand for the appointment
time. It was made for 31 days later.
They showed up. And they said they had no record. They were
three veterans trying to get into the Artesia clinic just
yesterday all with the same problem. And the arrogance of them
is what really made people mad.
The arrogance that you don't have a right to be here, we
told you, you don't have an appointment, while they're holding
the cards. These are the things that drive us all.
Today we have John Taylor. He was a combat sniper in
Vietnam, a hospital administrator in his private life. He has a
100 percent disability rating for PTSD. He's been an advocate
for veterans throughout New Mexico. He's a contributor to the
Roswell Daily Record on veterans affairs.
Secondly, we have Richard Moncrief, a veteran living with
PTSD. He'll talk about services due to limited access to
physical doctors he declares to be less than viable. He's a
veteran service officer for New Mexico Veterans Department. He
works on a daily basis for the betterment of our veterans.
We have Harry McGraw that was scheduled on this first
panel. I'm not sure if he's on a later panel. I'll introduce
him later if he's going to come up. But again we appreciate
Chairman Miller remembering his promise and coming back here.
I would like to also acknowledge that the VA in Albuquerque
has been cordial in two visits since the problems were first
noted by the chairman and became a national crisis.
Those meetings have been congenial, they've been
transparent, they have honored the promise that we would indeed
set up a pilot project. It's ongoing today and for a couple of
days where we're actually letting local veterans see local
providers.
When the VA's problems erupted nationwide, there was a kind
of a clamor to take a look at what we might do. And I
appreciate the fact that Chairman Miller looked back at what's
called Healthy Vets that we've had filed for the last four
Congresses, for the last eight years, basically saying, if you
have to drive more than a certain distance, you can go to your
local providers.
So Chairman Miller inserted that as one of the key
provisions in one of the most dramatic reforms in the VA system
since its inception. I think that the chairman has done a
tremendous job in getting this bill through.
It's approved by the House, Senate, and is set to be signed
by the President later this week. So I just think, if it's
approved in committee procedures, I think we ought to give the
chairman a round of applause for remembering the rural veterans
of this country.
Mr. Pearce. The VA has a lot of people who care deeply
about the veterans. And they serve well and they do their job
well. But the abuses and the problems have dominated.
And that's the reason that we're here in Roswell today, to
hold the first hearing nationwide after the passage of that
historic legislation. And the chairman will see the pilot
project in operation here in Roswell today.
So thank you very much for being here. And I will yield
back my time, Mr. Chairman.
The Chairman. Thank you very much, Steve.
And we will begin with Mr. Taylor. We recognize you for
your opening statement.
STATEMENT OF JOHN TAYLOR
Mr. Taylor. Chairman Miller, Congressman Lamborn, and
Congressman Pearce, it is an honor to provide testimony before
you today.
My active duty combat military experience was with the
101st Airborne Rangers in Vietnam. After seeing many of my
brothers die in heated combat situations within the infamous A
Shau Valley area of Thua Thien/Hue and being shot twice and
bayoneted on the same day, dying on the MASH unit surgery
table, and obviously returned to life, I never imagined any of
us would come back home to die directly related to post-combat
medical care in our VA hospitals. Sadly, as you are now aware,
that has become a painful reality.
In the interest of saving this committee time, with respect
to my evaluations and solution recommendations, the last
committee hearing we held on ``Service should not lead to
suicide,'' one of my fellow compatriots, Sergeant Josh
Renschler, had a very good, very detailed analysis. And I would
put that as a reference to what I have coming up.
For my side, I would like to look more at the unique
situation that we have here in our area of Southeastern New
Mexico, a significant variation that I would term `acute
rurality'. Being in a rural desert community, systemic problems
encountered throughout the country are greatly intensified in
Southeastern New Mexico.
As a quick example, following the CARES Commission findings
during President Bush's last term in office, a Director of
Rural Administration was created to help eliminate our acute
problems with rural access in our area.
As it turned out, that rural administrator responsible for
resolving our problems was none other than our administrator of
the Albuquerque VA Hospital, obviously the very person
historically refusing our requests for local fee-based
services. Ineffectual outcomes are obvious. A fox in the
henhouse type situation.
For the last nine years, I've published a weekly Veterans
Advocate column in our local newspaper, the Roswell Daily
Record. The column is a volunteered, not compensated, freelance
work having no allegiance to any person or group except to my
brother and sister veterans.
Over the years I've made members of both sides of the aisle
uncomfortable to say the least. However, the majority of my
rants have now shown to be true. Like so many of the other
public forum veterans' advocates, we're asking why did it take
the recent deaths of so many of us to prove what we have been
claiming for so many years, over ten as far as myself goes.
It is important to note that our deaths were majorly not
due to medical care provided by our VA medical professionals.
Physicians, nurses, support personnel, and even support
administrative people are doing a great job. That goes without
question.
But the administrative games played by VA administrative
leaders and by system oversight groups, that's the problem.
I've made that statement publicly several times over the past
nine years only to be ignored and politically told either we're
working on a resolution or you're not correct in your
accusations.
Finally, saddest of all, my claims have been validated with
the many deaths recently uncovered and still being uncovered
thanks to courageous whistleblowers within the system.
Veterans' families and friends have continued to not come
forward due of fear of reprisal. You guys have seen that in
action also.
The VA has historically denied this to be true. But as you
yourself have recently seen, the VA seems to have a problem
with the truth. I personally can offer proof that this has
occurred long before the recent awakening.
I respectfully submitted a few of my VET ADVO columns in
support of my testimony today, most of which are six to nine
years old. But it's the same theme coming forward.
This illustrates real-life catastrophes I have encountered
over my nine years as advocate, which were literally ignored or
denied as being accurate by our state VA administrators and
government officials.
We all know now how invalid the VA denials were and still
are. Two specific sets of columns illustrate factually the
problems and battles we have faced with the Albuquerque VA
Hospital administrators, consistently denied by the VA as being
accurate.
Number one, the first was a series of columns I did on a
chronic PTSD veteran who over the space of more than one year
threatened to commit suicide due to his Desert Storm
nightmares. His wife approached Colonel Ron McKay, USMC
Retired, and me with horror stories of her lack of effective
treatment for her husband by the VA.
Apache, my column name for my brother to respect his
privacy, had undergone several treatable modalities listing
from three days to three months inpatient sessions. More than
once he was sent home in a cab for a two and a half hour drive,
before which he would ask the driver to swing by the nearest
Albuquerque liquor store to make his journey easier.
His primary substance abuse/dependency directly related to
his PTSD was alcohol. Knowing this his treatment team and/or
patient discharge planner should have known this was a perfect
storm doomed to failure. Each time Apache returned home totally
inebriated, once again threatening suicide.
He was instructed by his VA treatment clinician to report
to a local VA social worker for aftercare. During the first
visit by Apache and his wife, as reported by his wife, the
counselor asked, ``So what is it you want me to do? You know,
you could go to the A.A. and get some help.'' So a furious
Apache and his wife got up and left.
In my experience as a director of a psychiatric center and
an inpatient substance abuse center, aftercare for either
malady requires at a minimum the services of a certified
psychiatric counselor or certified substance abuse counselor.
In Texas and New Mexico, this is required for licensure, not a
social worker.
Eventually Apache was found dead one night outside his
house in spite of repeated requests to the VA for help keeping
him alive. The VA response? He was noncompliant. In other
words, they gave up.
The second set of columns dealt with several cases that I
did through the years. One in particular was an 87-year-old
veteran who I was proud to two or three times a month drive to
Albuquerque, a three and a half hour round trip. He had an
active catheter. And his 87-year-old wife, who was in poor
health, did the drive. There's the problem.
His response to me several times was, ``My people don't
lie.'' I have reliable witnesses to that encounter. This was in
a situation where I had actual proof that the VA did, in fact,
lie. Not miscommunicate as politically correct, but lie.
And when I approached the administrator, he didn't want to
hear it. He said, ``My people don't lie.'' I said I can give
you incontrovertible truth. ``My people don't lie. You're
done.''
All right. Last week I measured the actual distance from
our nearest CBOC in Artesia and found it to be about 45 miles.
We've been excluded from a lot of the improvements because we
didn't qualify for the ``less than 40 mile'' rule. Obviously
I'm 45 miles so I'm five miles over that limit.
I apologize for this lengthy testimony. But after nine
years of reporting on these issues and warning everyone of the
obvious, predictable outcomes, I hope this report does not once
again fall on deaf ears.
Simply stated, systems monitored by its own department
members, no matter the claims of independent watchdog status,
do not and will not work. Paying bonuses to upper echelon
administrators is a crafty mechanism created by upper
management to milk the system. I know. I've been there.
In my many years as a medical administrator my reward,
bonus, if you please, was continued employment for the next
year. That was my bonus. The contrived reason for VA bonuses
reported in other House and Senate committee hearings is to
entice and retain competent administrators.
That, Honorable Committee Members, is a fallacy perpetrated
on those who have not worked in the medical arena. Competence
in our current VA administration based on this bonus rule has
been proven grossly lacking among our current VA handpicked
wonder kids.
In my experience it's safe to say you would find a
sufficient queue of qualified applicants for each VA
administrative position you currently find not up to par.
Current doctors and medical administrators being RIF'd, which
is reduction in force, in the administration's military
drawdown could easily and effectively be placed in certain
comparable positions recently found lacking in the VA
administrator network.
I sincerely hope my testimony and attached resource
materials will help you with your enormous task of keeping my
brother and sister veterans alive once they return home after
surviving death on the battlefield.
I would be pleased and honored to answer any questions you
may have of me. God bless you in your efforts, God bless our
brother and sister veterans, and God bless our nation. Thank
you.
[The prepared statement of John Taylor appears in the
Appendix]
The Chairman. Thank you very much, Mr. Taylor. And we'll
ask questions after everybody has already given their
testimony.
Mr. Moncrief, you're recognized here. Please go ahead.
STATEMENT OF RICHARD MONCRIEF
Mr. Moncrief. Thank you. I would like to thank the
committee for giving me the chance to speak out about the lack
of mental healthcare in the southeast corner of the state.
I have been using the mental health services in the Artesia
clinic for several years now. With the loss of Dr. Peter
Hochla, we are now being forced to use the telemed system,
which is a very impersonal way of conducting mental health.
The men and women who suffer from PTSD and TBI need to have
a live physical being to talk to. Better yet to have group
therapy with a skilled group leader and a psychologist would
even be better.
Having a warm body to talk to in person is better than a
flat screen for a patient. The talk is more personal and you
can see the body movement and make better eye contact with the
person doing the counseling.
Dr. Hochla, when he would come, he would come every three
to six months and make appointments for people. Well, I still
needed somebody to talk to because I had to let my hair down
and relax every once in a while.
I ended up hiring my own Licensed Professional Clinical
Counselor. I tried to use TRICARE since I was retired, but they
didn't pay enough money. They didn't pay up to Medicare
standards. So I ended up paying for the counselor myself. And
there's a great need for some kind of skilled counselor in this
part of the country.
There are many more problems that need to be addressed. I
have been given medication to increase my blood pressure after
the hospital had already told me I had high blood pressure.
Is the pharmacy or the doctor supposed to check to see if
there's a problem or is it my job as a working person without
medical experience to see if the medication is bad for me. I
take it it would be up to the medical staff to figure that one
out.
I was given a hearing test last year at the VA Medical
Center. The doctor said my hearing had gotten worse. I didn't
receive hearing aids. I asked why. He didn't say.
So here in town this lady invited me to come over to check
on a hearing test. And after giving me a hearing test, she said
yes, my hearing was getting worse and it would be best if I got
hearing aids for both ears before I lose my hearing totally.
There is a shortage of housing spaces for homeless veterans
in Southeast New Mexico. I have had to send people to
Albuquerque to get any help either way or we have to find funds
to be able to put them up in hotels and money to feed them.
The major problem of veterans having a nice resting spot
now has been solved here in the City of Roswell. We now have
our own veterans cemetery that's been dedicated and it's in use
as of today.
I had to call the Hospital Executive Assistant to the
Director to have my 100 percent total disability and permanent
disability put in the hospital computer after nine months of
waiting. The hospital didn't even recognize that I was 100
percent disabled.
And now my last question is why do veterans have to drive
200 miles to get medical attention in Southeast New Mexico?
Thank you.
[The prepared statement of Richard Moncrief appears in the
Appendix]
The Chairman. Thank you very much, Mr. Moncrief.
I understand Ms. Tschabrun is a late addition to the
witness table. We appreciate you being here and willing to
stand in. Thank you for what you have been doing. If you could
in your statement tell us a little bit about what Lovelace is
doing.
STATEMENT OF DAWN TSCHABRUN
Ms. Tschabrun. Thank you, Chairman. Congressman Pearce,
thank you. My name is Dawn Tschabrun. I am the CEO, chief
executive officer, of Lovelace Regional Hospital here in
Roswell.
I'm coming to you today to say that we've seen some
improvements. The Demonstration Project is working. As of this
morning, we've seen five veterans in our clinic and it's been
very, very successful.
We will see a balance of nine by the end of the week. And
it's been a huge satisfier to our veterans who live here in
Roswell as well as in Southeast New Mexico. So kudos and thank
you for that.
My other comment is Lovelace stands ready to come to the
table and discuss the needs of veterans in Roswell and
Southeast New Mexico to eliminate travel to Albuquerque so that
veterans can be seen at home.
We have qualified, competent care providers from physicians
to nurse practitioners right here in Roswell that are willing
and able to serve our veterans. Thank you very much.
[The prepared statement of Dawn Tschabrun appears in the
Appendix]
The Chairman. Thank you very much. What we'll do now is
we'll start a round of questions. We'll go through one round
and then we may have a second round.
And, of course, in the legislation that will be signed
tomorrow, it does have a 40-mile requirement; if you are
further than 40 miles, the VA has to allow you to go outside
the system if you choose. In the past the VA has had the
ability to do that.
They've obviously made it very, very difficult. This is
supposed to open that gate specifically for the rural
communities, much like Roswell.
And, look, in the panhandle of Florida, where I live, we
have more veterans than any Congressional district in the
country. We do not have a VA Hospital, my veterans have to go
to Biloxi.
So they have about a three-hour drive to go to the
hospital. We have three major medical facilities in Pensacola.
It just doesn't make sense.
But let me also tell you that this entire process is in no
way an attempt to tear the VA apart brick by brick. We're
trying to help supplement what they already do with local
providers, local facilities, because it's better for the
veteran, it's better for the taxpayers.
They don't have to pay for mileage to Albuquerque and
putting somebody up only to get there and find out your
appointment has been cancelled and you have to turn around and
come back tomorrow or next week, whatever it may be. A lot of
things are going to change.
Now, this is a finite program. It was originally designed
because of the wait list that exists out there today. But the
intent is that it will carry on. We will have to appropriate
more money to it.
There is some fear among veteran service organizations. And
probably the most vocal is the Disabled American Veterans. The
Disabled American Veterans, they don't like this at all. They
think that this is the first step in trying to rip the VA
apart.
Again they need to listen to you, the veterans, who have to
drive hours to access care and understand what you're having to
go through. And hopefully everybody will come to like this
program.
Some will stay in the VA, some will go outside the VA and
get their healthcare, continuity of care. All of those things
are issues that we have to watch and provide oversight to. But
our intent is to get the care quickly and ensure quality of
care is available to you.
So to Mr. Taylor and Mr. Moncrief, what I'd like to ask is
the scheduling issues at Albuquerque, can you kind of go into
detail a little bit and have you seen any changes in the way
the scheduling has been done over the last several months?
Because we're hearing from certain people around the
country that there are positive changes. And we want those
changes to be permanent changes, not just temporary.
Mr. Taylor. Chairman Miller, Congressman Pearce brought
this up in one of his telephone town meetings, has anything
changed locally. And I think there are excellent VA hospitals
in the country, there are some obviously not. I'll give you a
personal example just last week how things have changed.
I have to literally, excuse the pun, pull teeth in order to
get dental fee-based service down here in Roswell. So last week
I called. And I had a really painful wisdom tooth that was
going nuts on me.
So I called the dentist. He said, well, you have to call to
Albuquerque and get the approvals. So I did. I called in, I got
the dental clinic. It took 50 minutes going down the line,
you're the fifth caller. Finally I got to be the next caller.
So after 50 minutes, I finally get a ring from the phone.
I get another message saying I'm sorry, sir, the system is
down. We're sorry, the system is down, please call back. I did
this morning and evening. And I did it the next morning and
still the same thing.
So have things improved? I'm hearing not. Some people have
said yeah. But certainly in my experience this is an example of
trying to get into the system.
The Chairman. Mr. Moncrief.
Mr. Moncrief. I haven't had as much trouble getting
appointments. I've been able to clinics. I had to forego an
appointment this morning to be on this counsel this morning. I
thank you for that.
But I've had a lot of people that have come to talk to me
and ask why they're having a problem getting into the VA
Hospital, getting into the system. And a lot of people have
come in with the idea that they're going to be able to get in
into the healthcare system just because they're a veteran.
Well, if you're anything other than service connected and
you make over $30,000 as a husband and wife, you're going to
have a hard time getting into the VA healthcare system because
the bar has been set. That's as high as it's going to go. It's
on welfare.
So there are a lot of people that I had to turn out and say
I'm sorry, we're just not going to be able to get you anything.
So, of course, they're not going to be able to get
appointments.
There's been a few people that have had a lot of problems
with appointments. But I have been able to contact one very
important person at the hospital. And she's sitting right
behind me back here, Kara Catton. And she is super at taking
care of a lot of the problems that I've had to deal with
veterans.
The Chairman. Mr. Lamborn.
Mr. Lamborn. Thank you, Mr. Chairman, Ms. Tschabrun, I hope
I pronounce your name correctly.
Ms. Tschabrun. Close enough.
Mr. Lamborn. Okay. One of the issues that we need to be
really careful about when we start using more fee basis, which
is the private sector providing healthcare, is the custody and
the chain of custody of medical records.
Because someone may have been going to a VA clinic or
hospital for decades and now they're going to like maybe your
facility. And it just is important that the medical records
have continuity.
So how is the best way to address that?
Ms. Tschabrun. There's a couple of ways to address that,
sir. What we've demonstrated today and through this week is the
VA worked very collaboratively with us and sent those records
electronically to us so that our providers here could review
the history so that we were not starting from a zero playing
field.
Our providers have the opportunity to review that. And
then, as we transition that care, you speak of continuity of
care. That's essential. Not only for veterans but for everyone.
So as we see those veterans today through the week, we will
then put that electronic record back to the VA so they can see
what happened in their visit here. So absolutely we can do hard
paper, we can fax, we can download to disks, we can transfer
electronically through HIPAA secure mechanisms so that we keep
that data safe.
Mr. Lamborn. And it could be a two-way street?
Ms. Tschabrun. Absolutely.
Mr. Lamborn. So after receiving care in your facility, they
go back to the VA, it will be returned to them?
Ms. Tschabrun. Yes, sir. That's imperative, because the
bottom line is patient care, assuring that whoever the patient
is, through that continuum of care, that the providers are
knowledgeable about what occurred. And if either side fails to
do that, then we've let the patient down from my perspective.
Mr. Lamborn. Well, I think that that's such an important
thing. We're going to have to really stay on top of that
because there are some IT issues there that may have to be
addressed.
Ms. Tschabrun. Sure.
Mr. Lamborn. Also I would like to ask about telemedicine.
And, Mr. Moncrief, you expressed concern that, let's say, for
counseling or therapy, that there were some things lacking
through telemedicine.
We know that telemedicine negates the need for taking a
long car trip; however, you have pointed to drawbacks. What are
the pluses and minuses of telemedicine in your opinion? And,
Ms. Tschabrun, your opinion also.
Mr. Moncrief. The problem that I see with telemedicine,
sir, is it's great if you are going to take your blood
pressure, you are going to do things that surgically you can
talk to the doctors and things like that.
But talking to somebody mentally, you need a physical body
there; somebody to talk to that you know is concerned about
you. How can a TV set tell you you've got--you can't show it. I
mean it's a little--it's impersonal.
As far as I'm concerned, it's the wrong way to be doing
mental health. You need to have a live human being sitting
there that can understand you and see and be able--what are
they going to do, request a TV camera? It's not going to walk
over and pat you on the back or make you feel better.
Mr. Lamborn. Ms. Tschabrun.
Ms. Tschabrun. I think it's a huge challenge. Quite
honestly there is a deficit of providers in certain fields of
medicine. So that brought about the telemedicine option.
In Roswell and Southeast New Mexico, extremely rural, it's
difficult to recruit some providers in some specialties. And
medical schools are not producing at the rate that they had
been.
So telemedicine offers a different approach to prevent
travel. I think there are some very good uses of telemedicine.
Pulmonology, even perhaps cardiology if it's not that initial
visit. I think initial visits need to be face to face.
But telemedicine I think can help us bridge that gap. When
we do not have perhaps the ability to recruit that provider
into our area, it allows us to link into that provider so that
we don't have a deficit of care for our community.
Mr. Lamborn. I want to thank you all for being here. Mr.
Chairman, thank you.
The Chairman. Mr. Pearce.
Mr. Pearce. Thank you, Mr. Chairman.
Mr. Moncrief, you mentioned in your testimony that you pay
for your own counseling service. Where is that counseling
service located?
Mr. Moncrief. Right here in town, sir.
Mr. Pearce. And how much did you pay for a session, if you
don't mind saying in front of a room?
Mr. Moncrief. It was 75 to $100.
Mr. Pearce. How much?
Mr. Moncrief. Seventy-five to $100.
Mr. Pearce. Seventy-five to $100. In the next panel, I'll
be talking about how, in a very heated exchange with myself and
the VA in Albuquerque, one of the senior staff members there
was declaring he could not get people seen for less than the
price of gasoline. How much do you get paid to drive for
gasoline?
Mr. Moncrief. Over $160 to go up and come back.
Mr. Pearce. So you get paid $160 in gas money. Then you see
the psychologist there in Albuquerque and come back. For $75
and no gas money, you are able to see someone here.
Mr. Moncrief. And it's very personal, sir.
Mr. Pearce. Ms. Tschabrun, you said that you're seeing six
or eight people right now, you're seeing five people a day and
nine by the end of the week. What's the scope of services
provided?
Ms. Tschabrun. This is family practice.
Mr. Pearce. So just typical stuff?
Ms. Tschabrun. Just general stuff, general checkups,
general reviews, ongoing type of things.
Mr. Pearce. What is the cost that you are going to be
charging for those visits today? I don't want to get into your
data. If you don't want to say it, that's fine.
Ms. Tschabrun. I would prefer not to say it.
Mr. Pearce. Okay. That would be fine.
Mr. Chairman, I also notice that the Secretary of Veterans
Affairs for New Mexico is here, Mr. Hale, if we could recognize
him. Mr. Hale is of service to his company and country and a
veteran himself. So thank you for being here.
Mr. Taylor, you have probably as much experience as dealing
with the people here in this area. What has been your
experience in fee-for-service here in the Roswell area?
Mr. Taylor. Overall I found it to be excellent.
Mr. Pearce. I mean how easy is it to get fee-for-service
payment back from the VA? How has the process worked? Can you
just call up there and say I feel bad, I can't make the drive,
how does it work?
Mr. Taylor. Right now the only one that I can use is the
dental. And in that case, you know, I do the visit. The dentist
will bill the VA for the services. And it's considerably less
than what is billed obviously. And then they pay and the
dentist accepts whatever.
Mr. Pearce. Does everybody that wants fee-for-service get
accepted for that or is that 10 percent, 90 percent?
Mr. Taylor. Well, right now it's 100 percent.
Mr. Pearce. I'm talking about the last couple of years. If
you want to get fee-for-service, you can get fee-for-service?
Mr. Taylor. You have to get the approval. There's a fee-
based director at the hospital.
Mr. Pearce. Mr. Moncrief, you appear to be wanting to say
something. Do you want to add anything to that?
Mr. Moncrief. I'd like to say that, when you go down to the
Artesia clinic and they have to get an x-ray, they send you
over to the Artesia Hospital. Well, Artesia ends up billing us.
And I'd like to know why.
Because it's the VA sending us there, it's not the Artesia
Hospital. And the same thing if you get blood work, anything
like that, done. You end up getting a bill.
Mr. Pearce. The gentleman in the audience today that talked
about being required to drive to Albuquerque for blood tests
and then have to go back to get the results. I mean again you
all deal with as many veterans in this area.
When people request to have their blood work done here,
blood tests taken here, at least a sample are they given that
permission or is that very difficult to achieve? Is that a
single, isolated incident?
Mr. Taylor. For the most part, let's say the physician at
Artesia needs that done. He can have that done and there's not
much of a hassle there. Again let me make one statement.
A large chunk of our problems--there's two areas that, if
they can be covered locally, it would eliminate a lot of
problems. One being urgent care and one being emergency care.
Now, if we can get that done locally, it would be a
tremendous savings. Plus it's no fun driving with a 102-degree
temperature even 45 minutes to Artesia. Try it sometime. It's
not comfortable.
So if we had a local doc in the box or urgent care center
and we had the tie-in to an emergency room, that comfortably
the vet can feel that it will be paid for. I mean we have the
option now.
Like I say, if you've got a problem, call 911 or go to the
hospital. Many of my vets go to the hospital and find out
they're going to have to pay for it.
Mr. Pearce. One last question, Mr. Chairman and Ms.
Tschabrun. One of the things that I hear frequently from
veterans or providers, when they provide service, many in the
VA process say you can go see someone because it's an
emergency. But then there's trouble getting payment. What is
your experience receiving payment for the services provided?
Ms. Tschabrun. My experience is that it's very late in
payments coming back from the VA that extend beyond other
commercial payers.
Mr. Pearce. Had you ever not get paid for anything and have
to go back to the veteran?
Ms. Tschabrun. Yeah, that occasionally happens. If we do
not receive payment, then we will circle around back to the
individual patient and seek payment from them.
Mr. Pearce. Thank you. I yield back, Mr. Chairman.
The Chairman. Thank you, Mr. Pearce.
Ms. Tschabrun, one of the things as you well know in the
bill and, of course, most of the hospitals know as well is that
the language was inserted into the legislation. It mostly was a
repetition of existing law.
But it does baffle me that an agency the size of the VA,
especially when they have approved much of what gets done, have
a hard time with it.
I'd like to know, how has your experience been with the VA
in trying to set up the pilot program and have they reached out
to you since this legislation passed both houses? Because
that's the main focus. Folks need to get prepared. They've got
90 days with which to write the rules in order to implement
this. Has there been a proactive part on the VA?
Ms. Tschabrun. Absolutely, sir. Polly from Albuquerque VA
reached out to our clinic and said I have this list of patients
that we would like to get care at your facility, can we arrange
those appointments. So they were done right there.
But it was proactive on the VA's part giving us a call. We
were notified that we would be receiving X number. We didn't
know exactly what X meant. But then Polly was very, very quick
to give us the phone call and say we want these patients seen
and I'll be shipping their records to you.
The Chairman. And how quickly were you able to see the
patient?
Ms. Tschabrun. We made the appointments within five days of
notification.
The Chairman. Do you do that by telephone or do you do it
with a letter or a card?
Ms. Tschabrun. That was by telephone, sir.
The Chairman. One of the biggest complaints that we heard
and I don't know if it's been a problem here, is that VA in the
past has felt like the best way to do it was with the Pony
Express.
It definitely was not the time that few chose at the time
they chose. You may not have been able to make your
appointment. If you can't make that appointment, then you
cancelled it and/or you didn't settle in the first place. So
that's something that we hope VA will be able to rectify as we
move forward.
Let me ask, we talked about the bad things and, John, you
talked about that too. I'd like to hear something good about
VA. So, John, if you want to follow up with my comment.
Mr. Taylor. Definitely. There's a lot of good particularly
with the applied--the actual patient care. As I said the care
professionals do an excellent job.
Fortunately we have as Richard mentioned Kara Catton and
Sonya Brown at the VA Hospital in Albuquerque. They are quick
to respond when we've got a problem and then they do a fine job
in getting it done.
The problem is they're putting out fires. When I was an
administrator, I didn't want my people running around putting
out fires. It's just like the next step is a forest fire, which
is obviously what happened here.
If you have a forest fire, you find out what caused it. You
go to the system and systemically you solve the problem. So
it's good to do firefighting. But that should not be the course
of business that you take. It's not helpful.
So several times now I just--at Artesia last week, I spent
about an hour and a half, which is way over what my physician
there says to spend. But we've got several problems.
And after five heart attacks, he needed to do an extended
workups on me. He took the time with the personnel out there.
And I've heard some mention, well, they're a little short
tempered.
Yeah. I guess, if you are facing a bunch of us old codgers,
we tend to get on everybody's nerves I'm sure. On the whole
they're professional and they get the job done.
So again there are a lot of positives there. It's the
possible death outcome that has me concerned.
Again I had a fellow vet that called me. To me he presented
as having appendicitis. Of course, I couldn't make that
judgment. But he had all the classic symptoms.
I called Artesia. They said, well, if he's that bad, we can
take him in about two weeks. We can't take him today. Call 911
or go to the emergency room. Well, he was in bad shape.
Before I could get back to him and tell him, okay, you can
go, he didn't have the money to pay for it. So he and his wife
were already driving up to Albuquerque.
So here's a guy with an almost 102 temperature and acute
abdominal pain, nausea. He can't be seen by anybody and he
can't go to the emergency room because he can't afford it.
These are the real-life problems. It's just you can't use
firefighting as your course of business.
If we had an urgent care center here, what we used to call
doc in the box, they can go over and take care of the immediate
problem. So you can triage the problem, but you've got to have
the first step, which is either the urgent care center, a low
cost way of doing something, or the emergency room for
critical.
So yes, they're very positive. But we in total have to get
on these shortcomings.
The Chairman. Richard.
Mr. Moncrief. Since receiving my 100 percent, I've been
able to use the dental clinic up there. And they have been very
responsible to me. And I haven't had any problem of getting fee
basis down here.
They have gone out of their way to send me down here
instead of having to go up there to get certain work done. They
do implants and everything up there. But down here they'll let
you get local crowns and things like that put on. And I'd like
to commend them for the job they've done for me. Most of the
time they're very good.
I've had people call me from Carlsbad. A gentleman was--his
wife was on chemotherapy. And he was supposed to go up to the
dental clinic in Albuquerque to get work done. I called up
there, got a hold of one of the doctors, and they gave him a
fee basis to get it all done down there in Carlsbad and he
wouldn't have to leave his wife on chemotherapy.
So I haven't had problems with them. Certainly I've had a
lot more problems using the orthopedics and things like that up
there.
The Chairman. Mr. Lamborn.
Mr. Lamborn. I want to follow up a little bit more on the
medical records issue. Let's say someone is using fee basis and
they come to your facility. And they have shipped you the
medical records of the past history.
Do you have 100 percent assurance that you are getting the
complete set of medical records? If something is left out, that
can, you know, trigger a real problem.
Ms. Tschabrun. You know, to address that, I can't say with
certainty. ``I've got all of it''. I have to believe in faith
that they are sending what is appropriate to send for that
specific instance in this--in the demonstration that we're in
right now.
I would expect on a go-forward basis that we--as the
project continues, as the veterans have choice, that they can
then really give that full medical record. And in turn we also
turn that back, because it's got to be a collaborative
partnership between the both of us to be successful.
Mr. Lamborn. I just think, as we go forward, this is
something to really monitor closely.
Ms. Tschabrun. Absolutely.
Mr. Lamborn. So I look forward to what's being developed
here.
Mr. Chairman, that's all I have for this time.
The Chairman. Do you get the physical record or do you have
the ability to put eyes on the VA record or how does it work?
Ms. Tschabrun. These records were actually faxed to us. So
we have the bulk of, you know, a period of time that their
providers went back and reviewed prior to the meeting with that
patient today.
The Chairman. And then your physician or whoever saw them
makes whatever----
Ms. Tschabrun. Makes their notes.
The Chairman. Do you destroy then the set of records that
you have or do you have the ability to keep them?
Ms. Tschabrun. I don't think that we would destroy those
records, because they're a permanent part then of a patient
being seen. So we would create a patient file in this facility
that we saw them in. And then that would be an ongoing file for
that patient.
They may become an inactive patient for us. But they may
remain active. But we would still maintain that encounter.
The Chairman. Okay. Mr. Pearce.
Mr. Pearce. Thank you, Mr. Chairman. I'll just make a
couple comments and yield back.
But you were asking for the good things that happen. So as
I travel around, we hear those stories of people very
satisfied. So we recently ran a poll of all the veterans in the
district.
So the result was--I can't remember the exact numbers. But
it was a significant number, maybe 45 percent, were extremely
satisfied with the care. And so I do like to give those
positive things.
Also in our first meeting that we had with the VA after the
scandal broke and the Albuquerque VA actually showed up on the
list and we had the meeting, we took about six or seven
veterans in there.
And I don't remember exactly the records that we made notes
of at the meeting. But about three or four of the veterans had
problems. But they expressed that they were content with the
care when they got there. It was the scheduling or the distance
they had to drive or whatever.
And so I like to share those positive things, because there
are good people working inside the system. It's just the system
has serious flaws and breaks in that system.
And the last comment that I'll make in recognition of both
the Albuquerque and the El Paso VA, when we started seeing
problems--this is when I was elected in 2002--I kept hearing
the same problems over and over. So we made a list of those.
There are about 23 recurring problems. At every meeting,
every single one of the 23 things would be a problem. So I did
set up corollary meetings with the lead administrator, the head
of the Albuquerque VA Hospital.
And to their credit he would bring his assistant. And he
would come to different places in this big Second District.
Every quarter we would address those. And as they started
working from that list of 23 recurring things, those began to
improve.
And they were things like sending people all the way to
Albuquerque, having cancelled their appointment four days
before they get there. And one of the big complaints was they
were being paid $0.11 for gasoline. And that didn't come close
to even covering it.
So those meetings have continued and they still continue.
And we can pay attention to the smaller things. But the big
systemic problems that your committee has uncovered is what
we're dealing with and very difficult systemic problems.
So again I appreciate the hearing here. And I wanted to
pass along those good things that I do hear along with the
criticisms and complaints. And I'll yield back.
The Chairman. Thank you very much. I want to say thank you
to the first panel. We've got a second panel that we want to
hear from.
So with that you're excused. And thank you very much.
The Chairman. I want to go ahead and call up the second
panel while they're getting everything set.
We have Lisa Freeman, acting network director for Veterans
Integrated Service Network 18. She is accompanied by Dr. James
Robbins. He's the interim medical center director for the
Albuquerque VA Medical Center and Dr. Lori Highberger, the
deputy chief medical officer and mental health lead for VISN
18. Thank you now for being here.
You do need to get right up into that microphone. Don't be
afraid, it's not going to bite you. It's very difficult to
hear.
And, Ms. Freeman, you're recognized. Please proceed with
your testimony.
STATEMENT OF ELIZABETH FREEMAN, INTERIM NETWORK DIRECTOR
VETERANS INTEGRATED SERVICE NETWORK (VISN) 18, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY JAMES ROBBINS M.D., INTERIM MEDICAL CENTER
DIRECTOR NEW MEXICO VA healthcare SYSTEM, VETERANS INTEGRATED
SERVICE NETWORK (VISN) 18, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND LORI HIGHBERGER M.D.,DEPUTY
CHIEF MEDICAL OFFICER AND MENTAL HEALTH LEAD, VETERANS
INTEGRATED SERVICE NETWORK (VISN) 18, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF ELIZABETH FREEMAN
Ms. Freeman. Thank you. Good morning, Chairman Miller,
Congressman Pearce, and Congressman Lamborn. I too want to
thank all the veterans who are here today for your service to
this country.
And I also want to thank the previous panel members. And I
look forward to addressing together their concerns.
Thank you for the opportunity to discuss the New Mexico VA
healthcare system's commitment to providing veterans
accessible, high-quality, patient-centered care and to
specifically address rural healthcare and access to mental
healthcare in New Mexico.
The New Mexico VA healthcare system serves veterans in New
Mexico, Southern Colorado, and West Texas. The New Mexico VA
healthcare system includes the Raymond G. Murphy VA Medical
Center and 13 community-based outpatient clinics.
The VA Medical Center is a joint commission accredited
tertiary care referral center located in the heart of
Albuquerque. It provides a full range of patient care services
with state-of-the-art technology as well as education and
research. It is the only VA medical center in New Mexico.
Approximately 75,000 New Mexico veterans are enrolled in VA
healthcare. And 47 percent of those enrolled veterans live in
rural areas.
The VHA Office of Rural Health currently supports nine
projects, for a total of nearly $1.9 million in the State of
New Mexico. These projects increase rural veteran access to
mental healthcare, women's healthcare, primary care, pharmacy
services, and neurology services. Five of these nine projects
use telehealth to deliver healthcare closer to veterans' homes.
One currently funded Office of Rural Health initiative is
home-based primary care for veterans residing in rural areas
near Santa Fe and Artesia. The home-based primary care program
provides primary care for frail, chronically ill veterans in
their own homes.
There is an increased support for group specialty care
through the expanded use of clinical video telehealth or CVT
technology. The use of this technology in homes is on the rise,
especially aiming to assist American Indian veterans who are
the most rural, isolated, and transportation challenged.
In fiscal year 2013, the New Mexico VA healthcare system
served over 5,000 veterans through telehealth. And 59 percent
of these veterans lived in rural areas. Of these 1,000 veterans
accessed mental health services through CVT, 90 percent of whom
live in rural areas.
The New Mexico VA healthcare system has a robust expanding
telehealth program including more than 30 telehealth programs
offering additional modalities to CVT including home
telehealth, video to home, storage for telehealth, secure
messaging, e-consultations, and Specialty Care Access Network-
Extension for Community healthcare Outcomes known as SCAN-ECHO.
The New Mexico VA healthcare system has been aggressive in
providing comprehensive mental healthcare for veterans from
prior wars and conflicts to the current OEF, OAF, O & D
conflicts.
This includes primary care, mental health integration, and
an approach that considers the mental health need of veterans
with a course that is designed to promote an optimal level of
social and occupational function and participation in family
and community life for our veterans.
We continue to promote early recognition of mental health
problems. Veterans are routinely screened in primary care for
PTSD, depression, substance abuse, traumatic brain injury, and
military sexual trauma. Screening for this array of mental
health problems helps support effective identification of
veterans needing mental health services. And it promotes our
suicide prevention efforts.
In September of 2013, the New Mexico VA healthcare system
hosted a mental health summit with over 87 community
participants. The New Mexico VA healthcare system will be
hosting another mental health seminar in September of this year
with a focus on mental health access. And there will also be a
separate track on homelessness.
There are four vet centers in New Mexico including
Albuquerque, Farmington, Santa Fe, and Las Cruces.
The New Mexico VA healthcare system is committed to
providing high-quality, safe, and accessible care for our
veterans. We will continue to focus on improving veterans'
access to care and have instituted numerous changes that are
showing positive results.
Our location presents unique challenges with regard to
distance, culture, and constrained healthcare markets. Our
rural health programs are robust. And we will continue to
strive to meet the needs of veterans in rural areas.
Mr. Chairman, this concludes my statement. Thank you for
the opportunity to appear before you today in my 30th day on
this job. My colleagues and I will be pleased to respond to any
questions you or other members of the committee have.
[The prepared statement of Elizabeth Freeman appears in the
Appendix]
The Chairman. Thank you very much for your testimony.
Earlier this year PC3 was initiated. How has PC3 been utilized
here in the Roswell area?
Ms. Freeman. Mr. Chairman, I'll ask Dr. Robbins to respond.
Dr. Robbins. I'm happy to.
Mr. Chairman, I believe it's actually been utilized--it's
been utilized to some degree. But not as much as would be
optimal. And one of the--although there is fee basis in this
area to the tune of about $300,000 or more, PC3 has been not
utilized very well.
That's one of the reasons we actually had the CEO of
TRICARE come to the facility and meet with us about issues and
found that to be a very productive conversation.
And one reason that we are looking at mental health access
in the Roswell area is that those individuals go to PC3. So
we're beginning to lay the tracks and do more interaction with
them.
The Chairman. Can you just explain for us a little bit why
it hasn't been utilized as much. It's my understanding that
there are ten mental health providers here in the area. And
that obviously is a key.
Obviously the older veterans seem to want to have a face-
to-face. Many of the returning Iraq and Afghanistan veterans
seem to be comfortable with video teleconference, they Skype a
lot with their families so they're okay skyping with a
physician. But why do you think you're not utilizing PC3 much
here?
Dr. Robbins. Sir, I think the VA model has largely been--we
provide what we can in-house and send out-of-house as a
secondary plan. I think that's something that's one of the very
things we need to reevaluate now. And we're in the process of
redoing that.
The Chairman. I hope you do. I think what we found is that
the VA, although they do provide quality healthcare and many
veterans are satisfied with the healthcare that they're
receiving, it has become very apparent to me that the VA wants
to grow itself to the detriment in many cases of the veteran.
Even in your comments, Ms. Freeman, you talked about
testimony, initiatives, where you're recruiting and adding
mental health specialists, increasing telehealth, and
reorganizing programs. But you didn't in your testimony talk
about face-to-face visits in the local communities.
VA always seems to want to protect its own bureaucracy.
Veterans need to be able to get the care they need where they
want to get it and when they want to get it. And we are
delivering healthcare today, the whole of healthcare.
But the model is the same model for civilians. Forcing
people to drive to facilities? Why? Because you have to have
the patient census in those facilities in order to justify the
facility being here.
That's not necessarily in the patients' best interest. So
why do you think it's--and I'm not going to pick on you really.
Why do you think it's so hard? Is it just because of the
way we have been doing it for so long?
Ms. Freeman. So if you don't mind, Mr. Chairman, my
comments are from my experience in Palo Alto. We have
facilities from Palo Alto to Sonora down to Monterey. And we do
face that same struggle.
Sometimes it isn't the desire to keep it in-house because
we do want to treat each unique veteran and give him or her the
care he or she needs and has earned. Sometimes it's just a
matter of, as one of the previous panelists had mentioned, just
finding the right providers; that we know we want to ensure one
standard of care in having the highest quality of care that we
can provide to the veterans.
But I do think that the choice act is going to give us more
latitude to partner with community providers to provide those
services closer to home.
Dr. Highberger. I'd like to speak to that just from a
mental health standpoint too.
There are two things that I think are very unique in the VA
providing care. And I can say that my father was a Korean war
combat veteran. He unfortunately was not eligible to get VA
services because of income. And he had his own insurance and
that's fine.
I do think it would have been really beneficial to have had
the primary care services that VA has because it can pick up on
these things that are very specific to people who have served
overseas.
There are things medically that we look for, we hunt for
these, to make sure they get addressed. I think that's
something very unique about primary care. And that's why you
see it close to home. I think it's the same way with mental
health.
So I have worked in the community. I know what I see when
people come in to me and they're diagnosed with bipolar
disorder. No one has ever asked them if they've served.
So there's this sense of protectiveness I think that we've
had. And it's not about the bureaucracy or the agency. It's
just very frustrating for us, when we feel like we own that
care and we're responsible for that care and we want the best
care, that primary care and mental health are so tied to having
served that we do tend to hold it more than sometimes I think
we should.
And I think that this process going forward will push us to
really help with the community, help them understand what they
need to be looking for. Because there are other veterans who
are not eligible for VA care who will benefit them from that
knowledge.
The Chairman. And I think that's a great thing, because VA
does a lot of outreach, trying to get veterans to come into the
system and be able to use the system.
But I think you need to have outreach as well to the local
providers. I think that's a great first step. And mental health
I think is one of the those things that, VA has to be in charge
of.
You can still do some of it on a non-VA care basis. But
again why force a veteran to go to VA and get a flu shot. Why
even knee or, hip replacements, those kind of things can be
done outside VA to allow you to do the things that only you can
do. So I appreciate that.
Mr. Lamborn.
Mr. Lamborn. Thank you, Mr. Chairman.
Ms. Freeman, you heard Mr. Moncrief earlier talk about
telehealth in regards to mental health counseling. And he felt
it was impersonal.
Is that a drawback that can be overcome or is it unique to
each individual or how do you respond to that concern?
Ms. Freeman. So my experience has been that I think, as the
chairman just mentioned, that with the newer veterans they're
much more comfortable with the video telehealth. And they even
say why would you do it any other way. But then you have other
veterans of other eras.
And, you know, I think it's incumbent upon us to meet each
veteran where he or she is and provide the kind of services
that are going to be effective for them. If telehealth medicine
is not going to be effective for veterans of other eras, then
we have to find a way to provide that face-to-face care, we
have to find the providers that we know, the protocols that we
know how to treat those symptoms that are unique to servers of
this country.
Mr. Lamborn. Okay. Thank you. Now, you said in your
testimony that you were doing an outreach by going to different
communities. Could you elaborate on that, especially concerning
Roswell in particular, where you've sent teams out to meet the
folks.
Ms. Freeman. Sure. If you don't mind if I ask Dr.
Highberger to talk about that.
Dr. Highberger. Yes. What I would say is that in general
we're trying to partner a lot more with the community in many
ways. So, for example, the issue of homelessness was brought up
and how do we help, you know. You're a service officer here and
you're trying to help, you know, your colleague and what is
there.
And I think there are times where I think as VA we have to
recognize we aren't the answer in every way, shape, or form,
that we have to work with the community. There may be times
where we need to help develop something up.
One way that I think we've demonstrated that we can do that
is through the SSVF program, which is supporting veterans and
their families through national grants.
If those grants can help a community agency who is
interested and committed in working with veterans to develop
that kind of service that the veteran service officers and the
veterans and other stakeholders are all identifying as a
definite need, then that's a good way of trying to partner in
this and get those solutions together.
So we might not be able from VA to be in every city and
every county and have our staff there. And I think we just have
to accept that it's not all about us. It's really about the
community as well. And they've got great services that can
assist us.
We've got several instances of that throughout with
incredible partnerships that really work as if they all work
for the same agency. So I think that's really a demonstration
of success is where you find it.
Dr. Robbins. I also think that one of the things that
happens certainly in New Mexico and probably in other locations
is it's very easy to sit at the home facility and think of that
as the world. And I think part of what we have to do is make
specific and conscious efforts to reach out individually and
personally to locations around the state and set up events
here.
I know that we have a plan to begin visiting the different
parts of the state every month by a member of senior
management. And we have a homeless stand down coming up in I
think it's Carlsbad and one other location in the Southeast.
So part of it is a conscious effort to reach out,
understand the problems, and be on the ground in places like
Roswell, Artesia, and others.
Mr. Lamborn. Ms. Freeman, what do you think the Patient
Centered Community Care program, PC3 in shorthand, what do you
think about that program?
Ms. Freeman. So I think any vehicle that we have where we
can provide more timely access and high-quality care to the
veterans is fantastic.
And I really appreciated it when Dr. Robbins told me that
Mr. McIntyre personally came to the Albuquerque VA last Friday.
And when Mr. Gibson was Acting Secretary, he had asked us if we
had any challenges with PC3.
And he mentioned how closely Mr. McIntyre and TriWest is
working with VA. And I think that personal meeting demonstrates
the kind of commitment that TriWest has to meet the VA's needs
and providing care closer where veterans live.
Mr. Lamborn. Okay. Thank you.
The Chairman. Mr. Pearce.
Mr. Pearce. Thank you, Mr. Chairman. Ms. Freeman, you've
heard the comments about the payment and it's something that I
hear frequently by providers. Is that something that you all
dedicate an office to or staff to or how do you handle those
complaints?
Ms. Freeman. Sure. So there is a centralized process for
fee payments; is that correct?
Dr. Robbins. For the New Mexico VA health, there is a
coherent centralized office under one management.
Mr. Pearce. So it exists already?
Dr. Robbins. Yes.
Dr. Highberger. Well, there are two separate things. And I
think what you may be asking about is the actual payment of the
bill. So the payment of the bill is actually a partnership that
VISN 18 has developed with VISN 19.
We were struggling with paying our venders. We knew that
was not good for our relationship and that ultimately hurts our
veterans. So what we did was we found a VISN who was doing it
well. And instead of trying to rebuild or duplicate, we said
can we partner.
And we helped with resources to them to then pay our bills.
So in the facilities we have a non-VA care office who
coordinates, who makes sure that everything is functioning
correctly, who makes sure that the billing to VISN 19 is going
to pay our bills.
Ms. Freeman. If I may add. A target level similar to what
occurred a few years ago in the third--in the medical care
costs recovery, whatever the acronym for that is, for veterans
paying in when they have a co-pay. That was centralized
regionally with a similar effort that should be going forward
in FY 15 to further centralize those payments.
Mr. Pearce. I'm just trying to draw attention with a little
WD40, because it doesn't work very well a lot of times.
Ms. Freeman, does the honor guard come under VA? Honor
guards for burials, is that a part of the VA?
Ms. Freeman. I would be happy to follow up on that.
Mr. Pearce. Let me make a comment in case it does. I've got
a young soldier here that came today. He just got notified by
text message that they were going to cut that department out or
they were going to cut funding to it.
First of all, that's not the way that you should be telling
people that have been cut back. And then secondly, you wonder
why. Because the VA budget is not being cut. So it may not come
under you. I've been asking questions about that. And I still
don't have an answer for myself.
Mr. Robbins, thank you very much for making sure this pilot
project is ongoing, because it is buzzing around the state.
People have heard about it, there's a sense of excitement,
there's a sense of relief. And I appreciate that you have
honored your promise there at that meeting.
How many people are going to actually be seen in this pilot
project? Our agreement was one day. They've actually made it
several more days to make it more comprehensive. How many
people are we going to see, just give us an ideas of that?
Dr. Robbins. It's roughly nine, it should be nine patients
today and tomorrow that are primary care.
Mr. Pearce. At one point you had 35 or 36. Did they just
not materialize, what happened there?
Dr. Robbins. It was a variety of issues. The primary issue
was the primary care was wanting to focus on a small enough
group to where we could be sure that we got something going as
an additional start.
Mr. Pearce. Do you have an attempt to kind of continue this
on and then maybe expand it out? Because the further you get
away from Albuquerque, the longer the drive and the more
intensity.
So I was in Hobbs, Jal, and back around. They were saying
when are we going to get our pilot project. So what's your
intent on the longer term?
Dr. Robbins. Yes, sir. I just want to comment that I want
to thank you very much for raising this issue to us and for
collaborating with us. It's been an excellent experience, very
positive for the veterans. And we are thoroughly committed to
this and intend to continue it.
Mr. Pearce. Mr. Chairman, I have more questions I would
like to save for the second round.
The Chairman. Ms. Freeman, in May of last year, the
Undersecretary for Health instructed you to hold the health
summit. And you did hold a mental health summit. And you've
said you've got another one coming up I guess in September or
October.
One of the things they asked you to do was identify
community partners. Who did you identify as your most active
community partners during that summit? And did you enter into
any formal agreements with any of them?
Dr. Robbins. Sir, we did not. The New Mexico VA did not
enter into any formal agreements based on that summit. There
was a lot of dialogue. There were two very important issues
discussed and I believe improved on.
One was access by who to call, who to call if you have a
problem. We're in the VA, we're in the VA system to call. And
the second was the suicide prevention coordinator developed
some additional contacts and ability to do more outreach.
The Chairman. How do you schedule your appointments now,
how is that working? And mostly primary, maybe mental health.
This is the whole thing that blew up.
Dr. Highberger. Right. I can speak to that. What we're
doing and we have been doing for several years in VISN 18 is
trying to audit, trying to find those areas to recommend
specifically to a facility to modify, and trying to get to
where we're in compliance with the scheduling directive; and
most importantly that we're able to thus get people the
appointments when they need them, where they want them.
And it has been a challenge. It's taking a long time. The
efforts that we've been doing we've ramped up the speed of. I
think it's been hard for our schedulers to fully understand and
implement. I think it's a complicated process. It's taking a
lot of reteaching to get it right. But we're making sure we get
it right.
The Chairman. What's the complicated process?
Dr. Highberger. So in that system, again it's a blue screen
DOS system, it is a challenge for the staff.
The Chairman. I'm sorry. But is that not part of the
problem, you've got a DOS system today?
Dr. Highberger. I agree. I absolutely agree.
The Chairman. Do you know how many hundreds of millions of
dollars have been appropriated to VA for IT and we're still
using a DOS scheduling system?
Dr. Highberger. I agree.
The Chairman. Not your fault.
Dr. Highberger. I agree. And when people come in, some
people--I'm old enough, I remember the DOS system and blue
screens and how you have to type commands prior to better
technology. Some people have never even seen that technology
and they're hired into those roles. So that's one issue.
The second issue that I think is more important is lot of
people who were doing it wrong had no clue they were doing it
wrong, including even now with retraining we have some people
speak up, they say this is what you do, they are able to
verbalize it.
And one of the benefits of--our staff went down observing
them scheduling--is that they will then not do it correctly
even after they just verbalized it correctly.
So there's more education and more communication that has
to occur. There's a lot of auditing that has to occur. We want
to get it right. We're trying every which way to get it right.
But it's still a work in progress.
The Chairman. Whose responsibility is it to make sure it is
done correctly?
Dr. Highberger. I think it comes at many levels. I think
one is that we have a direction that we're given that is
challenging, it's not what we do in the community. So we talk
about desire dates.
These are things that don't get looked at or examined in
the community. So it's a new concept to try to teach people.
These are entry level positions typically in the system. So
these are people's first exposure to VA. And there's a lot of
learning.
They're also high turnover positions. So even if you are
doing the right thing and supervising, you're following through
and you're educating, your staff are turning over repeatedly.
And it's a good thing because they're usually getting
promoted. Most of these people are veterans, most of them are
getting promoted up through the system. But you've got to start
over then.
So I think it comes from the supervisor, it comes from the
employee, it comes from what we're directing above, you know,
about what to do. And it's not been a simple thing to fix.
The Chairman. Doctor, one of the things that I've heard
from physicians in particular is that they have no control over
the scheduling system themselves.
And so if you say this patient should be seen within five
days, you don't know whether that patient gets seen within five
days. And we now have horror stories out there that have
occurred because the doctor's orders were not followed. How do
you prevent errors like that from occurring?
Dr. Robbins. So I agree, sir, that that is probably one of
the worst things that can happen. And one thing that we've done
is in our facility, one of the barriers to getting the
scheduling process right has been that the schedulers were
scattered all across the facility or organization.
We're beginning to unify that and pull in schedulers into a
single organizational unit so that we can train them
consistently, so that they can feel that they're getting a
consistent message about that.
I will say that, because of my concern about that specific
area, when I went around to each of the CBOCs and as well as in
the main facility, that is something I specifically asked about
for everyone.
If the physician orders something, the physician orders
some follow-up, and you cannot meet that, meet what the
physician wants, you must go back to the physician or the
provider and get clarification. It has to be a medical
decision.
The Chairman. As the acting interim medical center
director, do you still see patients?
Dr. Robbins. I do not, sir.
The Chairman. Are you credentialed?
Dr. Robbins. Sir, I have credentials as a part of my normal
job as CMO. But I don't have privileges so I'm not able to
practice.
The Chairman. We keep talking about lack of physicians, yet
we have physicians all through the VA system that don't see
patients. I mean I know there's a lot of things you can't do.
But in an emergency, when we need to serve the people I
find that hard to believe. But that's the way VA has always
done it. So again I'm not trying to come down on you. But I'm
just telling you, do you have any idea on how many physicians
work for VA that don't see patients?
Dr. Robbins. I don't, sir.
Dr. Highberger. I would like to respond to that. It's my
impression, this is just my impression, that it's about 50/50
with people continuing to see patients when they take on a full
administrative load.
I do still see patients, I am credentialed and privileged.
I have tried to keep even just a half day every other week. And
I can tell you that the administrative duties have wiped that
out nearly completely.
Our business was downsized, I don't have support staff.
It's not as simple as just dropping my duties. If I'm not there
as the acting chief medical officer to review those applicants
for the Phoenix facility, for Albuquerque, for El Paso who have
issues with their credentialing, that person can't get hired
until I do it. I'm the only one that can do it.
So there's a real trade-off there. Now, I do still want to
see patients. I was assisting El Paso by telehealth. I can tell
you that that pull for me to do that is very strong. But when I
go over to Phoenix or I go to a CBOC that I'm privileged to see
patients in, there isn't the space for me.
The Chairman. Part of the bill is we have billions of
dollars for space. But, you know, one thing the VA is not good
at doing is thinking outside the box. Instead of extending the
hours of a facility, they want to build a whole new facility.
It's like why not extend appointment times that just happen
to be when a veteran probably could come so they don't have to
take off work to go to VA.
But because VA wants to do fairly normal working hours,
we've got to build a whole other facility because we don't have
the space. So we're going to have to crack this nut. And it
ain't going to be easy.
Dr. Highberger. I agree. And I did work extra evenings even
to support that CBOC to do that.
The Chairman. You said the key. You said the key. Support
is important. I mean I don't know how many veterans have told
me their doc never looks them in the eye because they're
staring at a stupid computer screen.
Why? Because they have to fill out all kinds of garbage to
CYA VA 20 years down the road if we ask did you do this, did
you do that.
Look, that's not what a highly skilled, highly paid
physician should be doing. They don't do that in the private
sector. But VA does it. We've got to fix that.
Dr. Highberger. I agree. I think one of the most important
things that I see in that bill, at least specifically speaking
to VISN 18, is space. So I've had times where I've scheduled
patients.
And I literally had to take a patient over into my VISN
office that is not set up for seeing patients. People open up
my door and interrupt. And I had to stop because it wasn't
right, it wasn't right.
And so, you know, I think with additional space, you're
going to see a lot more patient care occurring from
administrative physicians. It is a desire of mine to definitely
do that.
The Chairman. I'll bet you don't. I'll bet you don't.
Because that's not what they're accustomed to doing. But I hope
you're right.
Mr. Lamborn.
Mr. Lamborn. Thank you. Let me build on this really
important line of thought that the chairman has been pursuing.
I know VA has a lot of metrics. So many that that consumes
a good part of your working day. Do you think that we could
really reduce the number of--I know probably every single one
of those is well-intentioned. But can we do a drastic job of
reducing that so that more patients can be seen during a given
day, any one of you?
Ms. Freeman. So I really appreciate the question, because
there used to be something called a performance measure work
group nationally. And I was one of the few field members as a
facility director on that group.
Every time a new measure got added, you know, if it wasn't
myself personally or my physicians, my nurses or my staff would
be impacted by those additional metrics.
And so I completely agree with you that my observation in
the community where I live and my regular job, they have a
corporate scorecard that has ten or less. And even the board
pushes back and says it should be seven or less corporate
goals.
And that's what community healthcare systems, at least what
I've seen, operate under. So we have a very clear goal
deployment.
I'm not saying there are lots and lots of things we have to
do in the background because we are healthcare and there's lots
of outside entities that audit us. And it's very important to
ensure the quality of our care.
But we need to be able to articulate that to everyone, from
the front-line employee to the head administrators, so that
everybody is working toward the same direction.
Mr. Lamborn. I really--I hope that this is one of the
things that the Congressional CARES Commission--I hope I
pronounced that correctly. But one of the commissions that the
bill sets up, Mr. Chairman, that's going to look at VA from the
ground up.
I really know we need to get into this so that highly
trained care providers can get back to the basics of what they
are trained to do and do not have to have their face glued to
the computer screen like the chairman just said.
Dr. Highberger, what do you say about that?
Dr. Highberger. I think what I see is that you throw so
many metrics at people--it becomes a blur. I think sometimes
it's easy to get lost in the real message that's supposed to be
there. I know for VISN 18, what we've been preaching for years
is that it is not about the metric. The metric reflects the
care.
I don't know how well we get that message communicated all
the way down to every employee. But I know that's what we
believe. I think, if you look at it that way, having more
metrics perhaps is okay. It's just different reflections of the
care.
I think that the way we've done it, though, we've had too
many splittings off in too many directions and then losing the
real focus, which is the veteran and what is the care like for
them, how are they experiencing it. It doesn't matter what the
metric says.
Mr. Lamborn. And lastly, and maybe this is a metric. But
what is the average waiting time in New Mexico for primary,
specialty, and mental healthcare?
Dr. Robbins. Sorry. Give me just a minute. The average
primary care wait is 47 days. The average specialty care wait
is 64 days. And the average mental health wait is 41 days.
Those are new patient wait times.
Mr. Lamborn. New patient. If someone calls in for ongoing
care, it could be different, higher, lower? Do you have those
numbers?
Ms. Freeman. The VA is reporting wait times in two
different ways. He just gave you the prospective wait times.
And the completed new patient primary care average wait time is
the end of June; is that correct?
Dr. Highberger. Correct. It's appointments that were
completed at the end of June.
Ms. Freeman. So for appointments it's the end of June. For
primary care for new patients the time they actually wait----
The Chairman. Wait, wait, wait. What the hell is a--what
did you just call it, a primary prospective new patient? What
kind of--you guys, quit. You keep changing the rules.
The Chairman. All we want to know is how long does it take
a veteran to see a doc, period?
Dr. Highberger. Sir, I agree.
The Chairman. Don't give me three different ways to do it.
This has gone real well up until this last little bit.
Dr. Highberger. So these are the data that are published on
the website for transparency purposes.
The Chairman. That doesn't mean anything. I don't care
where it's published.
Dr. Highberger. I understand. This is what we're----
The Chairman. Anybody in here get a primary care
appointment within 40 days?
There ain't a hand up. None. When did we start this new
measuring?
Dr. Highberger. The data is the same.
The Chairman. No, no, no, no. When did we start this new
process? Because it's something that I've never heard of
before.
Dr. Highberger. So this is the new process.
The Chairman. No. My question is when did you start it?
Dr. Highberger. It was in May.
The Chairman. That's all I need to know. When the crap hit
the fan, you changed the metric again. Stop. Stop it. These
veterans deserve better.
Dr. Highberger. I agree. We have no control over these
metrics, sir.
The Chairman. Yes, you do. Raise your voice. Tell your
leaders it's not working, your veterans aren't being served.
Don't tell me you can't do it.
Dr. Highberger. We are and we have.
Ms. Freeman. And we will.
Dr. Highberger. And we will continue.
The Chairman. Good. Steve.
Mr. Pearce. Thank you, Mr. Chairman. One of the things that
I hear literally from providers from VA and from veterans alike
is fear of reprisal.
So many people did not want their names used as I talked
about their items. Are you all addressing the fact that we
can't cure the problems when people can't talk about it inside
the system?
Ms. Freeman. Absolutely. And one of the things at my home
facility that we promulgate and that I have shared with some of
the executives in VISN 18 to see if they're interested in
trying to hear is we really want a healthcare system where
every employee that comes to work every day sees themselves as
a problem solver.
So they're all contributing to continuous improvement and
improving the quality of care we provide to veterans. And it's
been stated, you know, over 30 percent of our employees are
veterans. We are veterans serving veterans.
Mr. Pearce. But there's still fear of reprisal.
Ms. Freeman: Absolutely. And as the chairman mentioned at
the very opening of this hearing, a culture is our habit, it's
the way we do things. And it won't change overnight.
But we have to start. We have to engage every employee
every day and continuously improve. And raising their hand
saying the issues that they think need to be addressed and have
a system of closing that loop and addressing those.
Mr. Pearce. Dr. Robbins, we have discussed in one of the
previous meetings a practice where you have the physician
leave. You assign his patients over to a doctor that didn't see
patients in order to make the system sort of look like it's
working on paper or the computer. Has that situation been
resolved?
Dr. Robbins. Yes, sir.
Mr. Pearce. That's all I want to know. Just it's been
solved. What is the scope, Dr. Robbins, of the nine people
being seen here today and in the future, do we have any PTSD,
anybody seeing mental health providers here as part of that?
Dr. Robbins. So the nine folks today and tomorrow, those
are all primary care. Those are primary care appointments.
Mr. Pearce. So you are open to people seeing mental health
professionals here?
Dr. Robbins. Absolutely.
Mr. Pearce. So you were there for a fairly energetic
exchange between your staff member and myself over the fact
that people--doctors, hospitals, will not see people for
basically the cost of gasoline.
I suspect that's the reason that we've never moved any
further towards letting veterans see local providers, because
of that internal belief that the system doesn't need to change
and will never need to change.
Is there any more clarity inside your staff there in
Albuquerque about the willingness of local doctors, local
hospitals to see patients and the reasonableness of the
service?
I mean you heard one guy say--you heard Mr. Moncrief say
his appointment was 75 bucks. And you've got to pay him $160
for gasoline. Is that sinking in, especially the gentleman that
we had the discussion with?
Dr. Robbins. Yes, sir. We clarified that shortly after you
left.
Mr. Pearce. Okay. I think my last--that was my last
question. No, no. I have one more. What level did you have to
go to to get this pilot project approved, were you able to do
it or did you have to go to a higher chain of command, did you
have to go to the Secretary level?
Dr. Robbins. Sir, we spent some effort and some time trying
to figure that out. But as it turned out, these were actions
that were within our existing authority at the facility level.
Mr. Pearce. So you all were able to make the decision in
Albuquerque, you did not have to get an approval to run this
project here?
Dr. Robbins. That's correct, sir.
Mr. Pearce. Mr. Chairman, I yield back. And thank you very
much for having this committee hearing here in Roswell, New
Mexico.
The Chairman. I want to thank everybody for attending. And
I do want to say thank you, VA, because you are the tip of the
spear. And don't think that, because you're way out in
Albuquerque and the central office is way over in Washington,
that you can't make a difference, because you can. You can.
Your veterans are telling you what they need. The system
has got to change. As a mental health provider, you know you
have to listen. And unfortunately that's not been the case at
VA for a long time.
We have a golden opportunity to help VA become the very
agency that they should be. And I have said it a dozen times in
the last week.
Thank you for being here. We truly appreciate what you do
on a daily, weekly, and nightly basis because I know you work
hours that many don't think you do.
I would ask unanimous consent that all members have five
legislative days in which to revise and extend their remarks.
The Chairman. Again, thank you, everybody, for being here.
This hearing is adjourned.
[Whereupon, at 1:00 p.m., the committee was adjourned.]
APPENDIX
Prepared Statement of the Chairman Jeff Miller
Good morning and thank you for joining us today.
I am Jeff Miller--Chairman of the Committee on Veterans' Affairs
for the United States House of Representatives and Congressman from the
First District of Florida, where--as we like to say--thousands live
like millions wish they could.
I am joined here today by senior Committee Member and the
Congressman from the Fifth District of Colorado, Doug Lamborn, and by
our friend and colleague and your Congressman, Steve Pearce.
I know I speak for Rep. Lamborn (Doug) as well when I say that I am
grateful to Rep. Pearce (Steve) for his hard work, leadership, and
advocacy efforts on behalf of New Mexico's servicemembers and veterans.
I am grateful to him for inviting us to New Mexico today and am
honored to be here in Roswell with all of you.
Before I go any further, I would ask all of the veterans in our
audience today to please stand, if you are able, or raise your hand and
be recognized?
Thank you so much for your service.
Ensuring that you and your veteran friends, neighbors, and
colleagues in New Mexico and across the country have timely access to
high-quality healthcare through the Department of Veterans Affairs (VA)
is why we are here today and I am grateful to you for joining us this
morning.
As you all know, in April, a Committee investigation and
whistleblower revelations exposed widespread corruption and systemic
access delays and accountability failures across the VA healthcare
system that left thousands of veterans--including some right here in
New Mexico--waiting for weeks, months, and even years for the
healthcare they earned through honorable service to our nation.
In the four months since, the Committee has held multiple hearings
to get to the bottom of the Department's deficiencies; VA senior
leaders have resigned and been replaced; and, nationwide initiatives
have been undertaken.
Just last week, Congress passed a bipartisan Conference agreement
that will improve accountability for VA employees; increase access to
care for veteran patients facing lengthy waiting times or residing far
from the nearest VA facility; and pave the way for long-term reforms
that will dramatically improve the Department for veterans today and
for generations to come.
Needless to say, it has been a busy summer.
However, our work is just beginning.
During today's hearing, we will discuss the challenges Roswell
veterans experience accessing care--particularly mental healthcare--
through Veterans Integrated Service Network (VISN) eighteen and the New
Mexico VA healthcare System.
In short, things could certainly be better.
VA's nationwide access audit found troubling scheduling practices
were in place at the Albuquerque VA Medical Center and I want to hear
from our witnesses-- local veterans and local VA officials--how those
practices have impacted the care veterans receive here and what actions
have been taken and still need to be taken to improve access to care
for New Mexico veterans.
I look forward to our discussion this morning and to taking your
thoughts and ideas back to Washington when we leave.
I thank you all once again for being here this morning.
Prepared Statement of John Taylor, Sergeant, U.S. Army (100% Combat
Disabled Ret.)
Chairman Miller and Members of the House Committee on Veterans
Affairs, it is an honor to provide testimony before you today.
My active duty combat military experience was with the 101st
Airborne Rangers in Vietnam. After seeing many of my brothers die in
heated combat situations within the infamous A Shau Valley area of Thua
Thien/Hue, and being shot twice and bayoneted on the same day, dying on
the MASH unit surgery table (and obviously returned to life), I never
imagined any of us would come back home to die directly related to post
combat medical care in our VA hospitals. Sadly, as you are now aware,
that has become a painful reality.
After being combat disabled retired from the military, I completed
my degree in Business Administration, with a Pre-Med Biology minor.
Half of my career was spent in corporate management for Dun &
Bradstreet. More important to this hearing, I spent the last half of my
career (12 years) in medical administration; hospital director, nursing
home administrator, medical hospital-satellite manager, urgent care
center director, substance abuse center director and psychiatric center
director.
In the interest of saving this Committee time with respect to my
evaluations and solution recommendations, please let me refer you to a
previous field hearing you had on 10 July 2014, ``Service should not
lead to suicide: Access to VA's mental healthcare.'' One of my younger
brothers'-at-arms, U.S. Army (RET.) Sgt. Josh Renschler's gave an
excellent testimony before this Committee. Even though we came from
different wars, basic problems, observations, and suggested resolutions
are essentially the same. I can, however, give you a significant
variation I would term ``acute rural'ality''. Being in a rural, desert
community, systemic problems encountered throughout the country are
greatly intensified in southeastern New Mexico. As a quick example;
Following the Cares Commission findings during President Bush's last
term in office, a Director of Rural Administration was created to help
eliminate our acute problem of rural access in our area. As it turned
out, that rural administrator responsible for resolving our problems
was none other than our Administrator of the Albuquerque VA Hospital,--
the very person, historically, refusing our request for local fee-base
services. Ineffectual outcomes are obvious.
For the last nine years, I have published a weekly ``Veterans
Advocate'' column in our local newspaper, the Roswell Daily Record. The
column is a volunteered, non-compensated, freelance work, having no
allegiance to any person or group, except to my brother and sister
veterans. Over the years, I've made members of both sides of the aisle
uncomfortable to say the least. However, the majority of my rants have
now shown to be true. Like so many other public-forum veterans'
advocates are asking, ``Why did it take the recent deaths of so many of
us to prove what we advocates have been claiming for so many years was
true?''
It is important to note, our deaths were majorly not due to medical
care provided by our VA medical professionals (physicians, nurses and
medical support personnel), but from administrative ``games'' played by
VA administrative leaders and by system oversight groups. I've made
that statement publicly, several times over the last nine years, only
to be ignored or politely told either ``were working on a resolution''
or ``you're not correct in your accusations''. Finally, saddest of all,
my claims have been validated with the many deaths recently
``uncovered'' (and still being uncovered) thanks to courageous
whistleblowers. The retaliation they received, as you all have been
made aware, is the perfect example of the VA's response to anyone
questioning the VA's activities. Veterans, families and friends have
not, and continue to not, come forward due fear of reprisal. The VA has
historically denied this to be true, but as you yourself have recently
seen, the VA seems to have a problem with the truth. I personally can
offer proof this has occurred long before the recent ``awakening''.
I have respectfully submitted a few of my VET ADVO columns in
support of my testimony today, most of which are 6 to 9 years old. This
illustrates real-life catastrophes I have encountered over my nine
years as advocate, which were literally ignored or denied as being
accurate by our State VA administrators and Government officials. We
all now know how invalid the VA denials were, and still are. Two
specific sets of columns illustrate factually the problems and battles
we have faced with the Albuquerque VA Hospital administrators,
consistently denied by the VA as being accurate.
1. The first was a series of columns I did on a chronic PTSD
veteran who over the space of more than one year threatened to commit
suicide due to his Desert Storm nightmares. His wife approached Col.
Ron McKay (USMC Retired) and me with horror stories of her lack of
effective treatment for her husband by the VA. Apache (my column name
for my brother to respect his privacy) had undergone several
``treatment modalities'' lasting from three days to three months in-
patient sessions. More than once, he was sent home in a cab (for a two
and one half hour drive), before which he would ask the driver to
``swing by'' the nearest Albuquerque liquor store to make his journey
easier. His primary substance abuse/dependency directly related to his
PTSD was alcohol. Knowing this, his treatment team and or patient
discharge planner should have known this was a perfect storm doomed to
failure. Each time, Apache return home totally inebriated, once again
threatening suicide. He was instructed by his Albuquerque VA treatment
clinician to report to a local VA social worker for ``after-care''.
During the first visit (Apache and his wife), as reported by his wife,
the counselor asked, ``So what is it you want me to do? You know, you
could go to AA and get some help.'' A furious Apache and his wife got
up and left. In my experience as a director of a psychiatric center and
an inpatient substance abuse center, after-care for either malady
requires, at a minimum, the services of a certified psychiatric
counselor or certified substance abuse counselor (for facility
licensure by Texas and New Mexico), not a social worker. Eventually,
Apache was found dead one night outside his house, in spite of repeated
request to the VA for help keeping him alive. The VA response? He was
non-compliant. In other words, they gave up!
2. The second set of columns dealt with several cases I followed
involving the unacceptable six-plus hour round-trip drive to the
Albuquerque VA Hospital from Roswell. One involved an 86-year-old
veteran with stomach cancer (with an active drainage catheter) who had
to be driven to Albuquerque 2 to 3 times a month by his 87-year-old
wife, who was in failing health herself. His primary care physician at
the VA Artesia clinic had requested approval for him to be seen
locally, in Roswell. That approval never came. To this day, I have the
uneasy feeling Mr. Borum died prematurely due to the stress this put on
his system.
3. Additionally, in one column I actually reported a conference
call I had with VA Albuquerque Administrative Staff concerning fee-
based (local contract) dental care for 100% service-connected veterans
in Roswell. The assurances and ``promises'' of local contract dental
care by administrative heads in Albuquerque were later found to be
lies, subsequent to my telephone visit with a staff dentist at the
Albuquerque hospital. When I approached the VA Hospital Administrator
at that time, he refused to review the incontrovertible evidence I
offered him. His response to me (several times) was, ``My people don't
lie!'' I have reliable witnesses to that encounter. To the point of
ineligibility for local care (fee-based services) in Roswell, Roswell
has been denied local access to fee-based services because it was
``determined'' by the VA to be less than 40 miles from the nearest
CBOC. That also has been a lie each and every time it was offered by
the VA. Last week, I measured the actual distance from our nearest CBOC
(Artesia, New Mexico), and found it to be (exactly) 45.6 miles to my
front door, and 43.8 miles from the center of town, accurately showing
half of Roswell is at least 44 miles from the Artesia VA CBOC (greater
than the ``less than 40 mile'' rule). This certainly was not the 38
mile VA calculated distance given in our several denials for local
contract services. Additionally, when Taos, New Mexico received a
``shadow clinic'' which we were also promised, we were denied due to
the 38 mile determination. I did a study finding that Taos was in fact
closer to its nearest CBOC than Roswell was to the Artesia VA clinic.
In fact, there were over 100 clinics built in our quad-state region in
violation of the ``40-mile'' rule.
I apologize for this lengthy testimony, but after nine years of
reporting on these issues and warning everyone of the obvious,
predictable outcomes, I hope this report does not, once again, fall on
deaf ears. Simply stated; (1) Systems monitored by its own department
members (no matter the claims of independent watchdog status) do not
and will not work. (2) Paying bonuses to upper echelon administration
is a crafty mechanism created by ``upper management'' to milk the
system. I know! I've been there. In my many years as a medical
administrator, my reward (bonus if you please) was continued employment
next year. The contrived reason for VA bonuses (reported in other House
and Senate committee hearings) is to entice and retain competent
administrators. That, Hon. Committee members, is a fallacy perpetrated
on those who have not worked in the medical arena. Competence in our
current VA administration (based on this bonus rule) has been proven
grossly lacking among our current VA ``hand-pick'' wonder kids! In my
experience, it's safe to say you would find a sufficient queue of
qualified applicants for each VA administrator position you currently
find ``not up to par''. Current doctors and medical administrators
being RIF'ed (Reductions in Force) in the Administration's military
drawdown could easily and effectively be placed in certain comparable
positions recently found ``lacking'' within the VA administrator
network.
I sincerely hope my testimony and attached resource materials will
help you with your enormous task of keeping my brother and sister
veterans alive once they return home, after surviving death on the
battlefield.
I would be pleased and honored to answer any questions you may
have. God bless you in your efforts, God bless my brother and sister
veterans, and God bless our Nation. Thank you.
Prepared Statement of Richard Moncrief
I would like to thank the committee for giving me the chance to
speak out about the lack of Mental healthcare in the Southeast corner
of the state.
I have been using the Mental Health services in the Artesia Clinic
for several years now. With the loss of Dr. Peter K. Hochla we now are
going to be forced to use the telemed system which is a very impersonal
way of conducting mental health. The men and women who suffer from PTSD
and TBI need to have a live physical being to talk to. Better yet to
have Group Therapy with a skilled group leader and a Psychologist would
even be better.
Having a warm body to talk to, in person is better than a Flat
Screen for the patient. The talk is more personal and you can see the
body movements and make better eye contact with the person doing the
counseling.
When Dr. Peter K. Hochla was here every 3-6 months, I still needed
to talk to someone to be able to let my hair down and be relaxed. I
ended up hiring a MA, LPCC (Licensed Professional Clinical Counselor).
I tried to use TRICARE, but they did not pay the going Medicare rate so
I ended up paying for the Counselor out of my pocket.
There is a very great need for some kind of skilled counselor in
this part of the Country.
Prepared Statement of Ms. Elizabeth Freeman
Good morning, Chairman Miller, Congressman Pearce, and Congressman
Lamborn. Thank you for the opportunity to discuss the New Mexico VA
Healthcare System's (NMVAHCS) commitment and accomplishments in
providing Veterans accessible, high quality, patient-centered care and
to specifically address rural healthcare and access to mental
healthcare in New Mexico. I am accompanied today by James Robbins, MD,
Interim Medical Center Director for NMVAHCS, and Lori Highberger, MD,
Deputy Chief Medical Officer and Mental Health Lead for the VA
Southwest Healthcare Network.
New Mexico VA healthcare System Overview
The NMVAHCS serves Veterans in New Mexico, southern Colorado
(Durango area), and west Texas. NMVAHCS is comprised of the Raymond G.
Murphy VA Medical Center (VAMC) with 13 Community-Based Outpatient
Clinics (CBOC). The Raymond G. Murphy VAMC is a Joint Commission-
accredited, VHA complexity level 1a, tertiary care referral center
located in the heart of Albuquerque, New Mexico. It provides a full
range of patient care services with state-of-the-art technology as well
as education and research. It is the only VAMC in New Mexico.
The Raymond G. Murphy VAMC is a teaching hospital, affiliated with
the University of New Mexico School of Medicine and College of Nursing.
It has an active partnership with Kirtland Air Force Base 377th Medical
Group and collaborates with Indian Health Service and Tribal healthcare
organizations. The facility has an active Community Living Center, a
26-bed Spinal Cord Injury Center, and a strong commitment to
psychosocial rehabilitation and vocational rehabilitation. VA-staffed
CBOCs are located in Artesia, Farmington, Gallup, Silver City, Raton,
Santa Fe, and Northwest Metro (Rio Rancho), New Mexico. Contract CBOCs
are located in Alamogordo, Truth or Consequences, Espanola, Las Vegas,
and Taos, New Mexico, and Durango, Colorado. The VAMC is a tertiary
referral facility for Veterans from the VA facilities in Big Spring, El
Paso, and Amarillo, Texas.
Rural Health in New Mexico
The VHA Office of Rural Health (ORH) supports programs and
initiatives in the areas of Veteran transportation, telehealth,
resident and allied health student rural clinical training and
education, and care closer to home via primary care and mental
healthcare extension teams that leave the VA facility and treat
Veterans in their remote communities. Over 45 percent (77,493) of New
Mexico's 170,799 Veterans live in rural areas of the state.
Approximately 74,713 New Mexico Veterans are enrolled in VHA
healthcare, and 47 percent (34,982) of those enrolled Veterans live in
rural areas. NMVAHCS serves a geographic area that is 121,826 square
miles. ORH currently supports nine projects for a total of nearly $1.9
million in the state of New Mexico. These projects increase rural
Veteran access to mental healthcare, women's healthcare, primary care,
pharmacy services, and neurology services. Five of these nine projects
use telehealth to deliver healthcare closer to Veterans' homes.
One currently-funded ORH initiative is Home Based Primary Care
(HBPC) for Veterans residing in rural areas near Santa Fe and Artesia.
The HBPC program provides primary care services for frail, chronically-
ill Veterans in their own homes. HBPC is available in the Gallup CBOC
and is being expanded to the Santa Fe and Artesia CBOCs. Another ORH-
supported initiative focuses on diabetes education and overall health
and wellness for Southern Ute American Indian Veterans. NMVAHCS
continues to work with ORH to develop innovative project ideas to
increase rural Veteran access to care and services.
In the recent past, Farmington, Silver City, Raton, and Artesia
CBOCs were relocated to new clinics with increased space. New clinics
for Gallup and Santa Fe CBOC relocations will be activating in calendar
year 2014. The Truth or Consequences Contract CBOC will have a new
contractor in approximately one year.
Telehealth in New Mexico
The VA healthcare system offers expanded access to mental health
services with longer clinic hours, telemental health capability to
deliver services, and standards that mandate rapid access to mental
health services. Telemental health allows VA to leverage technology to
provide Veterans quicker and more efficient access to mental healthcare
by reducing the distance they have to travel, increasing the
flexibility of the system they use, and improving their overall quality
of life. This technology improves access to general and specialty
services in geographically remote areas where it can be difficult to
recruit mental health professionals. In areas where CBOCs do not have a
mental healthcare provider available, VA uses secure video
teleconferencing technology to connect the Veteran to a provider within
VA's nationwide system of care. The program is also expanding directly
into the home of the Veteran using Internet Protocol (IP) video on
Veterans' personal computers.
There is increased support for group specialty care through the
expanded use of Clinical Video Telehealth (CVT) technology. The use of
this technology in homes is on the rise, especially aiming to assist
American Indian Veterans, who are the most rural, isolated, and
transportation challenged. Other initiatives include expansion of
telehealth specialty service, which includes anticoagulation
monitoring; dedicated space for telehealth education for staff and
Veterans of rural health service; and health fairs at NMVAHCS CBOCs.
In Fiscal Year (FY) 2013, NMVAHCS served 5,168 Veterans through
telehealth, and 59 percent (3,031) of these Veterans lived in rural
areas. Of these, 1,002 Veterans accessed mental health services through
CVT in FY 2013, 90 percent (897) of whom lived in rural areas.
Mental Health Services Engagement Initiatives
VA is working closely with its Federal partners to implement
President Barack Obama's Executive Order 13625, ``Improve Access to
Mental Health Services for Veterans, Service Members, and Military
Families,'' signed on August 31, 2012. The Executive Order affirmed the
President's commitment to preventing suicide, increasing access to
mental health services, and supporting innovative research on relevant
mental health conditions.
On February 1, 2013, VA released a report on Veteran suicides, a
result of the most comprehensive review of Veteran suicide rates ever
undertaken by the VA. With assistance from state partners providing
real-time data, VA is now better able to assess the effectiveness of
its suicide prevention programs and identify specific populations, such
as Veterans living in rural areas, who may need targeted interventions.
This new information will assist VA to identify where at risk Veterans
may be located and improve the Department's ability to target specific
suicide interventions and outreach activities in order to reach
Veterans early and proactively. The data will also help VA continue to
examine the effectiveness of suicide prevention programs being
implemented in specific geographic locations as well as care settings,
such as primary care, in order to replicate effective programs in other
areas.
In an effort to increase access to mental healthcare and reduce the
stigma of seeking such care, VA has integrated mental health into
primary care settings. The ongoing development of Patient Aligned Care
Teams to deliver primary care will facilitate the delivery of
integrated primary care and mental health services. It is VA policy to
screen patients seen in primary care in VA medical settings for PTSD,
MST, depression, and problem drinking. The screening takes place during
a patient's first appointment, and screenings for depression and
problem drinking are repeated annually for as long as the Veteran uses
VA services. Furthermore, PTSD screening is repeated annually for the
first five years after the most recent separation from service and
every five years thereafter. Systematic screening of Veterans for
conditions such as depression, PTSD, problem drinking, and MST has
helped VA identify more Veterans at risk for these conditions and
provided opportunities to refer them to specially trained experts.
VA operates the National Center for PTSD which guides a national
PTSD Mentoring program, working with every specialty PTSD program
across the VA system to improve care. The Center has also begun to
operate a PTSD Consultation Program open to any VA practitioner
(including primary care practitioners and Homeless Program coordinators
from every location) who requests expert consultation regarding a
Veteran in treatment with PTSD. So far, 500 VA practitioners have
utilized this service. The Center further supports clinicians by
sending subscribers updates on the latest clinically relevant trauma
and PTSD research, including the Clinician's Trauma Update Online, PTSD
Research Quarterly, and the PTSD Monthly Update.
To support Veterans who use VHA mental health services and build on
the work of the 2012 Executive Order from the President, VHA has hired
and deployed over 950 peer support staff to mental health programs
across the country. Peer Specialists are Veterans who have been
successfully and actively engaged in their own mental health recovery
for a minimum of one year and who are trained and certified to provide
peer support services. Peer Specialists work as members of mental
health treatment teams and help Veterans achieve their treatment and
personal goals, and they demonstrate that recovery is achievable.
No Veteran should have to wait for the care and services that they
have earned and deserve. NMVAHCS intends to continue to work to meet
Veterans' needs using the following initiatives:
Recruit and fill mental health vacancies.
Explore recruitment incentives to entice psychiatrists
to relocate to NMVAHCS. There is an industry shortage of
psychiatrists.
Increase the number of Albuquerque-based mental health
clinicians trained in and certified to deliver telehealth and
other virtual care modalities such as CVT in the home to
provide increased access for rural patients.
Realign all outpatient mental health programs under
one outpatient Mental Health Division to increase patient
access to specialized mental health services.
Conclusion
NMVAHCS is committed to providing high-quality, safe, and
accessible care for our Veterans. We will continue to focus on
improving Veterans' access to care. Our location presents unique
challenges with regard to distance, culture, and constrained healthcare
markets. Our rural health programs are robust, and we will continue to
strive to serve Veterans in rural areas.
Mr. Chairman, this concludes my statement. Thank you for the
opportunity to appear before you today. I would be pleased to respond
to questions you or the other Members of Congress may have.
[all]