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House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
    The subcommittee met, pursuant to notice, at 9:30 a.m., in room 334, Cannon House Office Building, Hon. Cliff Stearns (chairman of the subcommittee) presiding.
    Present: Representatives Bilirakis; Cooksey; Hutchinson; Peterson; Gutierrez; Evans; and Brown.


    Mr. STEARNS. Good morning. The House Committee on Veterans' Affairs, Subcommittee on Health, will come to order.
    This morning's hearing brings to mind a question which critics and interested parties raise from time to time. Namely, they ask us why Congress continues to provide service to veterans through a government-run healthcare system.
    In my view, an effective response to that question must include a discussion of VA specialized treatment and rehabilitation programs. VA's expertise in the care and rehabilitation of veterans disabled by spinal cord injury, chronic mental illnesses, blindness, and post-traumatic stress disorder are at the core of what makes VA a unique healthcare provider, one which Congress continues to support. Not surprisingly, therefore, when VA proposed a major restructuring of its healthcare system several years ago—one of the important concerns this committee raised was the future of its special disability programs.
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    At a hearing before this subcommittee in April 1995, Members asked what steps the VA's Under Secretary of Health, Dr. Kizer, would take to insulate these programs from cost-cutting. Dr. Kizer offered no specifics. His general assurance did little to allay the widespread concern that reorganization and restructuring would result in downsizing or even eliminating these important, but often costly programs.
    Accordingly, 2 years ago, this committee adopted legislation to require the VA at least to maintain its capacity, to provide for disabled veterans' needs through distinct specialized programs and facilities. That legislation enacted in October 1996, also required consultation with two consumer-focused committees and annual reporting to Congress to monitor compliance. This legislation was hailed by disabled veterans and their advocates. But its enactment has not quelled their concerns. I, too, am concerned that vital programs are being eroded. I called this hearing to ensure that these key programs get the priority, funding, and staffing required by law.
    I've reviewed VA's most recent report to Congress on maintaining the service delivery capacity of these special programs. Let me underscore my deep concerns.
    I'm concerned that one of the expert committees with which VA was to work in implementing this law questions the validity of the data VA has provided Congress.
    I'm concerned that 2 years after enactment of this law which was viewed as critical to safeguard these vulnerable programs, VA's data does not provide a reliable basis to determine whether there's been compliance with the law or not.
    I'm concerned that in giving the VISN Directors flexibility in meeting the law's requirement, VA's top leadership has done a lot of trusting, but not a lot of verifying.
    I'm concerned that too many of those charged with carrying out the law may be looking too closely at the bottom line and not carefully enough at the well-being of those who depend on these unique programs.
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    I'm concerned that the clear intent of Congress to insulate vital programs from cost-cutting may have been ignored or at least variably applied in some of the VA's 22 networks.
    The VA has certainly made impressive strides in healthcare delivery in recent years. But these special programs are what make VA unique and are critical to vulnerable, disabled veterans. VA leadership must work a lot harder, in my view, to ensure that they are preserved.
    I look forward to this morning's testimony. But before going further, I'd like to call on the ranking member, Representative Gutierrez, for any opening comments he may have.

    Mr. GUTIERREZ. Thank you, Chairman Stearns. Our Constitution established the framework for government that has served our Nation well for more than two centuries. In that esteemed document, roles for the three branches of government were defined. Under the Constitution, Congress is given the responsibility to make our laws and the Executive Branch was charged with administering their implementation. Today, I believe we are examining a case where the long-held relationship has broken down.
    In 1996, Congress approved, and President Clinton signed, the Veterans' Healthcare Eligibility Reform Act. Contained in this legislation is section 1706(b)(1) of title 38. This provision mandated that the Secretary of Veterans Affairs ensure that the VA maintains its capacity to provide for specialized treatment and rehabilitative needs of disabled veterans, including veterans with spinal cord dysfunctions, blindness, amputation, and mental illness.
    After carefully reviewing the available information regarding the specialized and rehabilitative services, and after hearing from members of the veterans' community—both here and in my district—I have concluded that the VA is currently failing to properly adhere to the stipulations mandated by Congress in section 1706. The VA's specialized and rehabilitative programs have been detrimentally affected by the VA decentralized structure, budget constraints and resource allocation formulas. The specialized and rehab programs have not been adequately protected by the VA. This is not to say that reform of the VA system is altogether damaging to the future of the veterans' healthcare. It is not. Reform is critical to the VA's future. The VA's recent reforms have led to greater efficiencies and savings in many areas of the veterans' health care system.
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    Nevertheless, what Congress feared in passing section 1706 was that the VA reform would threaten the more expensive inpatient base in long-term care specialized services that provide vital care to the most vulnerable veteran population. Congress' fears have come true despite our best intentions in 1996. Its spinal cord centers, geriatric research centers, substance abuse wards throughout all the specialized services—cutbacks have worsened the quality of care. Much of this stems from individual decisions made at the VISN (Veterans Integrated Service Networks) division level. Expensive costs of providing spinal cord care or to address the healthcare needs of blind veterans makes these programs particularly difficult to maintain in business where budget restrictions force major streamlining.
    VISN Directors, with salary bonuses based on how much they have saved annually, are provided with incentive to neglect specialized programs under their administration. Doctor and nurse positions go unfilled. Waits for treatment are extended and quality of care declines. This situation that has occurred throughout our Nation requires the immediate attention of the VA and this committee.
    I believe that we need a greater direct oversight of the administration of specialized programs, including the hiring of full-time coordinators in each division and on Vermont Avenue. Consolidating program budgets and taking the specialized services out of the model division funding pool should also be contemplated. If not, I believe, that Congress will have to take further legislative steps to ensure that section 1706 is being implemented.
    I have two final points. First, the VA exists primarily to ensure that our most vulnerable veterans receive the healthcare and compensation they have earned in risking their lives for our Nation. Whether the VA adopts private sector models or not, reforms or fails to, seeks out a new patient base of non-category aid veterans or structures its services around current eligibility standards should not affect this basic mission of the VA.
    Second, I have focused this morning on the inability of the VA to ensure that specialized services are being maintained as Congress charged. But I would be passing the buck if we did not point out that Congress is responsible for the problems we are discussing today. This Congress, the 105th, has underfunded the VA by more than $500 million. This Congress and the administration have pushed VA funding downward for nearly 5 years. Common sense dictates that when spending is tightly constrained, budget oversight is decentralized and cutbacks are forced at VA medical centers, the most vulnerable veteran will be the first to suffer.
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    When we in Congress disparage VA administrators and directors for the declining level of care veterans receive in various parts of our Nation—which we are prone to do—let us remember that we, Congress, have created this climate. That we, Congress, have slashed budgets that affect the specialized services. We, Congress, should look first to what we can do to adequately fund veterans' healthcare before we blame the VA.
    Mr. Chairman, my mother explained to me when I was young in life that you reap what you sow. We should all heed this wisdom when considering our responsibility to America's veterans. Thank you.
    Mr. STEARNS. I thank the ranking member.
    Now the first panel will come forward.

    Mr. BILIRAKIS. Mr. Chairman, we do not have the——
    Mr. STEARNS. Oh, I'm sorry. My good colleague from Florida, Mr. Bilirakis.
    Mr. BILIRAKIS. Thank you, sir. Mr. Chairman, first I, too, want to commend you for scheduling today's hearing on the VA's efforts to maintain specialized healthcare services. With the enactment of the Eligibility Reform Act of 1996 and the other major changes taking place within the VA healthcare system, this is an important issue that deserves our attention.
    Over the years, I've had a very strong interest in the VA's specialized services, particularly the services for veterans with spinal cord injury or dysfunction. I don't think that's too much of a surprise to anyone. When Congress approved the Veterans' Healthcare Eligibility Reform Act, we included language mandating that the VA maintain its capacity to provide specialized healthcare services to veterans. I'm very concerned, as others have already said, that the VA may be ignoring—and if not ignoring—certainly not living up to our directives. In reviewing the testimony of our witnesses, it's clear that I'm not alone.
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    In part, my concerns also stem from my continuing frustration over the construction of a SCI Center at the James Haley VA Medical Center in Tampa, FL. The VA first proposed expanding the current SCI Center in 1971. The existing center has one of the highest demands for SCI services in the VA system, but it suffers from major space deficiencies and safety violations. It's been over 25 years, Mr. Chairman, and Florida's veterans are still waiting for the new SCI Center to be constructed. I might add the current SCI Center was originally intended to be a psychiatric ward. It was certainly not designed for SCI purposes.
    Given the VA's continuing reluctance to fund this much needed facility and the other issues raised by some of today's witnesses, I, unfortunately, have to question the VA's commitment to maintain these specialized services. In my opinion, Mr. Chairman, the VA's specialized services are the heart of its healthcare mission. In fact, constantly in these hearings, we get VA witnesses using that as a reason to continue the need for separate veterans' healthcare, rather than mainstreaming. So it's incumbent upon us as Members of Congress to make sure that these services are available to the brave men and women who have served our country. Like you and the others, I look forward to hearing from our witnesses and look forward to working with you and other Members on this very important issue. Thank you, Mr. Chairman.
    Mr. STEARNS. That was excellent. Thank you. My colleague, Mr. Hutchinson.

    Mr. HUTCHINSON. Thank you, Mr. Chairman. I appreciate you showing leadership to hold this hearing. I am looking forward to the testimony of the witnesses. I think there is one simple question that has to be addressed. That is, whenever the VA is serving more veterans with special disability problems and in those categories, and yet we are spending less—is that a reflection of good management or is that possibly an indication of the lack of good care going to these special disability groups? So that's a very critical question that has to be answered. I look forward to hearing the testimony of the witnesses as they address that question. So I yield back, Mr. Chairman, and look forward to this testimony today.
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    Mr. STEARNS. I thank my colleague. I guess there's no more opening statements; we'll have the first panel come forward.
    We have Stephen Backhus, the Director of Veterans' Affairs and Military Health Care Issues, Health, Education, and Human Services Division of the U.S. General Accounting Office; Richard McCormick, Ph.D., co-chairman, Committee on Care of Severely Chronically Mentally Ill Veterans, and Mr. Thomas Miller, Chairman of the VA Advisory Committee on Prosthetics and Special Disabilities Programs.
    Let me welcome you folks here. I appreciate your taking the time this morning. We'll open with Mr. Backhus. Your opening statement.


    Mr. BACKHUS. Good morning, Mr. Chairman and members of the subcommittee.
    I'm pleased to be here today to discuss our ongoing evaluation of VA's efforts to ensure systemwide capacity and reasonable access to specialized treatment and rehabilitative services. You asked that I focus my remarks on two issues—whether VA is maintaining capacity with reasonable access to specialized care and whether VA has data that is sufficiently reliable to monitor and report on compliance.
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    My comments are based on meetings we've had with VA, VSO and advisory committee officials, as well as a review of VA and advisory committee reports. We will be continuing our work over the next several months and expect to issue a report next spring.
    In summary, our work to date suggests that much more information and analysis is needed to support VA's conclusion that it is maintaining its national capacity to treat special disability groups. While VA's data indicate that overall the number of veterans served has increased by 6,000, or 2 percent, between 1996 and 1997, the data also show the total spending for specialized disability programs decreased by $52 million. The number of veterans treated systemwide for conditions such as amputations and substance abuse has decreased, as have expenditures for veterans with amputations, serious mental illness, PTSD, and substance abuse.
    VA attributes decreased spending to reducing duplicative services and replacing more expensive hospital inpatient care with outpatient care. It is too early for VA to assert that capacity has been maintained without knowing how effectively these dollars have been spent. Similarly, positive indicators of improved access for five of the six special disability programs also warrant more review. For example, the proportion of veterans receiving psychiatric outpatient care within 30 days of hospital discharge increased by a negligible .6 of 1 percent in 1997. The monthly waiting time for admission to the inpatient blind rehabilitation program increased by 1 to 8 weeks for 11 months of the year.
    Consistent with the Government Performance and Results Act of 1993, VA plans to develop outcome measures over the next 2 to 3 years to track whether the care provided to disabled veterans is effective as a result of its shift to outpatient care. VA intends to replace expenditure data with outcome measures when they become available. While we fully support the addition of outcome measures to evaluate the effectiveness of physical, psychological, and social services, we also believe that current measures such as dollars spent serving veterans' special needs are also important to gauge legislative compliance.
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    Moreover, other data, not now used by VA, such as the number and type of specialist providers, and the number of beds may also be useful indicators of capacity. Additional analysis is also needed to fully explain the large regional variations in the number of patients served. Beyond the issue of capacity measurement, however, we also have questions regarding the reliability of VA's data. VA's reduction of its reported 1996 baseline expenditure data, without explanation, is a critical issue for us to review. In all six programs and services, VA reduced the baseline. In one program, by as much as 50 percent in each VISN facility and in another by $56.5 million. VA's two advisory committees have also raised questions that you'll hear about today, I think, regarding anomalies in the capacity data identifying—for example, a questionable increase in expenditures at one facility of 3,500 percent over one year. VA has acknowledged the need to improve its data systems and has several efforts underway to do so.
    In conclusion, Mr. Chairman, the VA strives to measure compliance with the requirements of the Eligibility Reform Act. It needs to develop more comprehensive data and improve the reliability of existing information. We will continue to assess VA's efforts as we complete our study. Mr. Chairman, this concludes my remarks. I'll be happy to answer any questions you or other members of the subcommittee may have.
    Mr. STEARNS. Thank you. Dr. McCormick.
    [The prepared statement of Mr. Backhus appears on p. 50.]


    Mr. MCCORMICK. Yes, thank you, Mr. Chairman. Approximately 1.7 million veterans meet the consensual definition for seriously mentally ill. About 300,000 of these use VA services. It is most appropriate that the capacity report monitor the care of veterans with serious mental illness and post-traumatic disorder. Over 450,000 veterans have been adjudicated to have mental disorders related to their military service. Over 100,000 were combat-related post-traumatic stress disorder—a disease which goes to the very core of the primary mission of VHA.
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    This is a tumultuous time in healthcare. Services for the seriously mentally ill are at risk during such times of change. These patients have disorders which are complex, disabling and chronic in nature. The data presented in the report on the number of services show the national increase of 1 percent for veterans with serious mental illness and PTSD and a decrease of 2 percent for seriously mentally ill substances abusers. This contrasts with a 3.8 percent overall increase in all veterans served by VA. This relative slower growth and in the case of substance abuse decline, can't be simply attributed to lack of opportunity to provide such care.
    In 1997, VA provided mental healthcare to only 38 percent of those who are service-connected for a mental health disorder, and only 8 percent of the total of low-income service-connected veterans. Local rates of variation and local rates of utilization vary widely and we related very much to the distance that a veteran lives from an access point. The capacity report shows declines in expenditures of 3 percent for the seriously mentally ill; 7 percent for post-traumatic stress disorder; and 20 percent for seriously mentally ill substance abusers.
    This decline must be compared to a 5 percent overall increase in funding for VHA services during the same period of time. Decreased expenditures are, in all cases, the result of decreases in inpatient care. The Committee on the Care of Severely Chronically Mentally Ill Veterans is supportive of de-institutionalization of the chronically mentally ill and the movement towards outpatient care for substance abusers. If accomplished appropriately, such efforts can increase the value of mental health services. The available data, however, caused grave concern as to whether such a transition is being consistently managed throughout VA. It would be expected that the transition for more expensive inpatient care would result in the ability to treat significantly greater numbers of seriously mentally ill, non-users of VA services.
    Of equal concern to the committee is the large variation among networks. We consider that true access implies reasonable access across the country; where a veteran lives shouldn't determine the availability of services. Decreases in specific networks in the numbers of patients served was as high as 35 percent for post-traumatic stress disorder; 28 percent for homeless seriously mentally ill; and 13 percent for seriously mentally ill substance abusers.
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    The current available data are inadequate to comprehensively monitor VHA's efforts to maintain capacity. For example, existing administrative databases do not indicate whether an adequate array of services are in place to successfully reintegrate the institutionalized, seriously mentally ill patients into the community. The rapid de-institutionalization needs to be accompanied by the development and deployment of intensive community-based services. There has, unfortunately, been little growth in the number of these programs in VA. Over two-thirds of VA facilities still do not have intensive community case management services for the seriously mentally ill.
    Furthermore, VA has begun the rapid development of a large array of community-based outpatient clinics. Most of these clinics are actually targeted for geographic areas where the utilization of VA services by high-priority seriously mentally ill veterans is low. As of January, 144 community-based outpatient clinics had been approved by Congress. Unfortunately, less than 40 percent of these included basic mental health services. These clinics could afford an ideal opportunity for VA to maintain its commitment to the care of the seriously mentally ill by utilizing at least a portion of the funds saved through inpatient reductions to provide outpatient care for seriously mentally ill veterans near where they leave.
    In summary, the number of seriously mentally ill served has not kept pace with the overall growth of VA; fewer dollars are being spent on their care. There is unacceptable variation across the system. There is no evidence, that nationally the expected growth and intensive community and outpatient programs has accompanied the closure of inpatient programs. Most VA new access points do not address the unmet demand for services for even the highest priority seriously mentally ill.
    The committee feels that continued vigilance supported by better data is required to assure that VA does not decrease its commitment to the seriously mentally ill and to veterans with combat-related post-traumatic stress disorders. Thank you, Mr. Chairman.
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    [The prepared statement of Mr. McCormick appears on p. 61.]

    Mr. STEARNS. Thank you. Mr. Miller.


    Mr. MILLER. Okay. I thought my hearing aid battery——
    Mr. STEARNS. No, no. Let me apologize. I just didn't have my microphone on—it's my fault.
    Mr. MILLER. In fact, audiology is one of those programs under our advisory committee's jurisdiction. I'll have to get new batteries, but——
    Mr. Chairman, I want to thank you on behalf of the Secretary's Advisory Committee on Prosthetics and Special Disabilities Programs for inviting us to participate in this extremely important hearing this morning. It's a real honor for me to represent our committee—both the current members and those who have served over the past 7 years. We've had a very distinguished number of individuals that have served on our committee, and have a great deal of expertise and experience in the treatment of special disabilities and in the rehabilitation field generally.
    We've had a rather diverse membership in our committee—individuals from the private sector, individuals from the VA, from the academic community, as well. As you are aware, we have three veteran service organizations—the Paralyzed Veterans of America, Disabled American Veterans, and Blinded Veterans Association—who are permanent members of that committee. I've had the pleasure of serving on that committee since its inception. Our first meeting was held in July—7 years ago.
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    I think it might be helpful to review a little bit the history of the committee, at least in terms of the problems that led to the establishment of our advisory committee. As I believe you're all aware, the Senate Committee on Veterans' Affairs conducted an oversight hearing in 1990 focusing on prosthetics and special disabilities programs. Many, many very serious problems were uncovered in that hearing, principally in the area of timely, high-quality delivery of prosthetics services. Many other problems were identified in terms of rehabilitation, research, and development service within VA, blind rehabilitation service, specifically unconscionably long waiting times and waiting lists for admission to rehabilitative services, and an assortment of other issues.
    As a result of that oversight hearing, our committee was established. There were a number of very positive outcomes or gains that were realized as a result of that hearing in the following several years. Principally, centralized funding was established to fund the prosthetics service program. Prior to that time, the funding of prosthetics services had been decentralized to the region and to the local levels. There was a good deal of evidence to suggest that dollars that were being allocated for prosthetic services were being utilized at the local level to provide services other than the provision of quality and timely prosthetics.
    In addition to the centralization of the funding, there was a significant increase in professional staff added across the system; namely, in the form of prosthetic representatives or prosthetic chiefs. New services were established in a number of VA facilities that did not have a full prosthetic service up until that time. Additional staffing was provided for headquarters. The staff in headquarters in conjunction with VA management and in the Congress established what they called the prosthetic improvement implementation plan. It defined a number of very specific goals that needed to be achieved within specific timeframes. We were very pleased on the committee that—and we receive reports on a regular basis regarding their compliance with the PIIP—they made great strides. Many of the problems that existed in prosthetic service diminished almost completely. They were very effective in managing the money, applying it to the purchase of prosthetic services in a timely way.
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    We, also, were pleased to note that problems in rehabilitation research and development service were similarly resolved and demonstrated significant improvement. Some improvement was also noted in blind rehabilitation service with the provision of additional resources across the system to bring all the blind rehab centers up to their full staffing levels. Therefore, they were able to operate all their authorized beds and reduce the length of wait for veterans who had applied for training because they were able to operate much more efficiently.
    I present that background to put into perspective our current view of the status of all of these programs following the transition—the new VHA, if you will—from a hospital-based system to an ambulatory managed primary care model of delivery. Unfortunately, the committee is quite concerned that we've seen some erosion in the gains that have been achieved as a result of the 1990 oversight hearing. Most notably, prosthetic service and blind rehabilitation service have taken the biggest hits, if you will. We have noted that in prosthetic service and they've realized—since 1995—they've experienced a 67 percent increase in workload, while at the same time, they've experienced significant loss in staffing levels.
    Their ability to provide timely, quality service has been severely compromised. One of the measures for that was a delayed order report that facilities submit to headquarters on a monthly basis. Since this time last year, there's been a 74 percent increase in the delayed orders being reported. There's over 8,300 delayed orders as of the end of the second quarter of this fiscal year. Clearly, there's a fiscal problem in that there aren't adequate dollars to support the prosthetics program. Medical centers are finding themselves in a very difficult position identifying sufficient funding to support these programs. Until this final quarter, the way they were doing that was borrowing from their—against their—next quarter allocation. Now that we're in the fourth quarter, there is not another quarter to borrow against. So we expect delayed orders to increase dramatically and the veterans to go without the necessary prosthetics appliances.
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    Prosthetic service is also experiencing extreme difficulties in the field in retaining highly qualified professionals and their services. Their grade structure is not adequate to recruit and retain folks. The organizational realignment that's occurred as a result of the transition to 22 networks with decentralized management has resulted in a great deal of inconsistency throughout the system with how prosthetic services and other services are organizationally aligned and treated within their facilities and/or networks.
    Just as an example, the Director, the Chief of the prosthetic service at the VA Medical Center in Denver, following a national training center went back home and was so frustrated, he resigned and took a purchasing agent position, six grade levels below. He felt that he couldn't get the support from this facility, he couldn't get adequate staffing. The staff that he was able to retain were burned out. This is not an isolated incident. It's occurring more and more frequently across the system. Clearly, there needs to be greater sensitivity, recognition, of a problem and the willingness to try and do something about it. We feel that that has been lacking to this point.
    The other two witnesses refer specifically to the capacity report and the data included therein. Our committee, as you know, did not endorse the capacity report that was sent to Congress. We felt the data was flawed, it was confusing, it was disorganized, and unreliable. We believe the VA—the VHA—is moving in the proper direction with regard to data collection, but the information management systems are not there yet. However, they're basing decisions on inadequate and inaccurate data. Dr. Kizer repeatedly has emphasized that this new system would be one that would be a data-driven management system and decisions would be driven by data. Inaccurate or invalid data is not going to help the decisions that are being made in the field.
    Blind rehabilitation service is experiencing some difficulties as a result of the reorganization and the allocation methodology. I will be coming back on another panel and we'll focus more in-depth on those specialized services for blinded veterans, but it is a problem that our committee has been intensely following. It's been a chronic problem. The erosion of resources and the involvement of our program managers at headquarters with a field leaves an awful lot to be desired. These are national programs, Mr. Chairman, especially prosthetic services which cuts across all the disability groups.
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    My final comments are related to the impact, I guess, of the Eligibility Reform Act and we appreciate the efforts of your subcommittee and the full committee in getting that legislation crafted and moved through the Congress—one of the unfortunate, I guess if you will, from VA's standpoint, effects of that is the increased demand for prosthetics and the increased budgetary implications that has had, particularly in the area of ophthalmology and audiology, speech pathology, their workloads have increased dramatically. Without any appreciable increase of staff to provide service, the workloads have just become incredibly large. Without relief from a resource standpoint, veterans are going to wait longer and longer for those services and for the necessary prosthetic appliances and aids to help them overcome their disabilities.
    Mr. Chairman, that concludes my statement and I'd be more than happy to answer any questions that I can.
    [The prepared statement of Mr. Miller, with attachment, appears on p. 66.]

    Mr. STEARNS. Thank you, Mr. Miller. What we're trying to do is understand whether it's management here or budget reductions. I think all of you have mentioned sort of the inconsistency from each VISN to VISN. Before I go further, Mr. Backhus, how far are you into your GAO report?
    Mr. BACKHUS. We began 2 months ago. I would say about one-fourth of the way through.
    Mr. STEARNS. About 25 percent?
    Mr. BACKHUS. Yes.
    Mr. STEARNS. When do you think it will be complete?
    Mr. BACKHUS. We're estimating that next Spring we'll have a final report, but really we'll have most of the analysis done late Winter.
    Mr. STEARNS. In the first part of your report, are you finding, from VISN to VISN, the inconsistency in delivery servicing of veterans in the disability group?
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    Mr. BACKHUS. Tremendous variation.
    Mr. STEARNS. Is this variation management-driven or is it, for example, that the delivery of services with outpatient clinics—as you say in your statement—has impacted some of the VISNs. Isn't that true?
    Mr. BACKHUS. Absolutely.
    Mr. STEARNS. Yes.
    Mr. BACKHUS. That's consistent with the nationwide shift toward more outpatient care. It's both. It's not just in the way care is delivered, but it's the management and the emphasis that's placed on particular programs. That's where variability seems to be less explainable and what we're really going to try to understand better.
    Mr. STEARNS. Dr. McCormick, how would you explain the marked differences that appear in this consistency of delivery of services from VISN to VISN? How should the VA respond to these regional differences and how can we be sure that we're maintaining the program consistently?
    Mr. MCCORMICK. Well, we start, of course, from a point of considerable variability. Some networks clearly do have budgetary reductions. Although again in a given year's period, those are capped and are nowhere near the 20 to 30 percent range of reduction in patients served that we see in some networks. The networks also vary very much initially in how many patients they have in inpatient settings. Nevertheless, we on the committee don't necessarily expect that even dollars will remain constant in every VISN. We recognize that as facilities go from inpatient to outpatient modes, they should be able to operate more efficiently. What we find very difficult to understand is that in some of those very networks where the dollars go down, the expected increase in numbers don't go up.
    To answer your question as to why there's variability. I think one thing that needs to be borne in mind is that the networks, perhaps understandably, have very different systems on how they manage mental healthcare. Some of them have a much more centralized network system where there is a single person or single body who oversees mental health services. Others continue to rely more on individual facilities. Again, one of the things we're very concerned about is that the growth to outpatient access points is, again, inconsistently including mental health services. There are some networks where every community-based outpatient clinic has mental health services and there are some where almost none of them do. These are clearly management decisions—that particular example is clearly a management decision.
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    Mr. STEARNS. So I think what you're saying is that the variability between the different VISNs is primarily a management problem.
    Mr. MCCORMICK. Well, I understand that part of it is driven given a VISN that's losing money. It's more complicated. If you're in a VISN that perhaps starts with a very heavily institutionalized population, it is more problematic. But I think, in my opinion, there is a lot of the variability that is due to management decisions.
    Mr. STEARNS. How would you grade the VA compliance, both at the VISN level and the national level? Is there any way you can do that?
    Mr. MCCORMICK. Well, again, the numbers, when you look at the numbers in the report and again these numbers are administrative data and don't tell the full story. The committee was glad to see that there weren't huge decreases in the number of patients seen. As a system, I think that based on the available data and taking very much into account what we still haven't seen in terms of movement towards community-based and intensive community outpatient approaches, I guess I would give the whole VA maybe a ''C''. But there are networks that probably deserve an ''A'' and there are those that probably deserve a ''D.''
    Mr. STEARNS. No one's flunking?
    Mr. MCCORMICK. Well, I don't have enough data to—when I teach I'm very careful only to flunk people if I really have good data.
    Mr. STEARNS. Well, this might be a little tougher question. Should we continue to require the VA to maintain the ''capacity'' of these programs from VISN to VISN?
    Mr. MCCORMICK. I absolutely think we should. Again, my view and the view of the committee is that these are populations who often don't have a voice especially the chronically and severely mentally ill—the psychotics. There are over a 136,000 veterans who are service-connected just for psychosis, which is the most disabling of the mental disorders. They have no voice. I don't think they often have a voice even within the networks. There needs to be vigilance to make sure that they don't get lost in the sweep towards making the system more of a healthcare system, which I think again, in my view, is a good move. I think the VA does need to move from being a hospital system to a healthcare system. We just need to make sure that as we do so we develop a healthcare system for the seriously mentally ill, as well.
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    Mr. STEARNS. Would you repeat that last part? You believe it should be moved from a hospital care system to a what?
    Mr. MCCORMICK. A healthcare system. I mean, I really do support going away from a series of hospitals to really looking at a population of patients who need care and trying to increase access to further impact a larger number of patients. Again, the figures that only 38 percent of those who are service-connected for a mental illness receive VA care shows that we have a long way to go to bring care closer to where patients live to take a healthcare system approach. So again, I'm very supportive of VA's move to become a healthcare system, rather than just a set of hospitals. I think the committee is also concerned that as we get out there and develop new access points, get into the community, the resources we save on the hospitals for the seriously mentally ill need to be redeployed out to these new access points.
    Mr. STEARNS. Mr. Miller, would you agree with Dr. McCormick on what he said, moving from a healthcare hospital system to healthcare delivery system?
    Mr. MILLER. Yes, sir. I think, there was no question that the VA needed to change the way they were providing healthcare. That a hospital-based system is not the most efficient or economically sound way of providing comprehensive quality healthcare to our Nation's veterans. I would have one caveat. However, there are certain programs that do need, and are very effective as inpatient, residential programs that need to be maintained. Not everything can be placed out in community-based outpatient clinics who are in some kind of an ambulatory care setting. Very careful decisions need to be made regarding what programs are suitable and appropriate and will result in desired outcomes in an ambulatory setting as opposed to an inpatient setting, and to ensure that those that require inpatient services, those services are there for those veterans who require that type of service.
    Mr. STEARNS. Thank you, Mr. Miller. That concludes my questions. Now the ranking member, Mr. Gutierrez.
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    Mr. GUTIERREZ. Thank you, Mr. Chairman. Mr. Backhus, in your judgment and given the information you have at this time, do you think that the VA is ensuring its capacity to provide specialized services to veterans? Do you think it's at the same level as it was in October 1996?
    Mr. BACKHUS. I suspect it's mixed, varying by program and, of course, by region. Overall, it's impossible to say. It's impossible to know at this time. I don't think that this Congress has the assurances that they expected to have from VA through this legislation. There clearly is additional information that I think is available, that ought to be made part of the reporting requirements of VA, that would give you those answers. But I haven't seen that information yet. We're focusing on that over the next several months and hopefully we'll have that answer, ultimately.
    Mr. GUTIERREZ. Following up on information and where we should be getting our information—pools of information—the GAO questions the reliability of the VA's data. But you're going to use it. If the VA's data is faulty or at least questionable, could you just share with us what other sources of information you're going to search out to get to this—to get the answers we need.
    Mr. BACKHUS. That's always a difficult thing for us. I think there's other—the comment I made about the reliability of the VA data refers to the information that we have gotten thus far out of the reports to the Congress—the capacity reports. I think there are other sources in VA; a number of them that, when combined with this data, provide a better look. There are ways to take data—and differing data—ask questions and explain the differences. There are multiple sources of data that you can trace back to original documentation. That's the kind of process we go through. We'll take data from NEPEC and from PRAC and these other resource groups in VA, piece it together and eventually come up with something that seems to make the most sense.
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    So there's not one database in VA that you can go to but there are several sources within. In talking with people who run the programs there—dealing with the veterans on a day-to-day basis, you begin to be able to construct a picture. But it takes a lot of work. It's not a simple thing to do.
    Mr. GUTIERREZ. Mr. Backhus, in your testimony, you state the VA's data and assertions thus far may—and I'll quote you ''mask potential adverse effects on specific programs and locations.'' In conducting your research, have you found this occurring in certain localities? Can you share with us examples of adverse effects?
    Mr. BACKHUS. No, I don't have any specific adverse effects. I really put the word potential in there to represent what it is we're going to be on the lookout for here. But at this time, I can't identify to you any particular instance of someone being adversely affected.
    Mr. GUTIERREZ. Okay. Let me just quickly—to Mr. McCormick, I'm going to ask you the same question I asked Mr. Backhus. In your opinion, the VA maintaining its ability to provide services at the October 1996 level in specialized care?
    Mr. MCCORMICK. I can really only speak for the seriously mentally ill. I have to start off with a copy of our administrative databases which most of the report is based on are limited. They don't tell anywhere near the whole picture. It isn't even that the data is necessarily unreliable, it just isn't full and complete. I feel that the gauge that I would use looking at the total growth of VA and the direction of VA that special programs for the seriously mentally ill are not totally keeping up. That is, we are not—VA isn't maintaining its commensurate commitment that it had a year ago. Although the changes are relatively small, nationwide they are very large someplace.
    Mr. GUTIERREZ. Mr. Miller, the same question. What do you think? Do they have the capacity, the VA, that they had in October 1996 to provide specialized services?
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    Mr. MILLER. I would kind of concur that it's somewhat mixed, but I would submit that, particularly in the area of prosthetics, their capacity has been significantly reduced. Staffing levels in the field and headquarters have been decimated severely impairing their ability to maintain capacity. Some of the other programs, if they are, it's very, very marginally. They're on the edge of the loss of ability to maintain capacity. But again, there's a lot of inconsistency from program-to-program across the system.
    In response, if I might, to your earlier question to Mr. Backhus, data, one of the fundamental problems I think our committee has identified is inconsistency across the system as to how data is entered; how it is coded; how services are costed from one facility to another, from one network to another. If there are not national standards established and someone held accountable for those standards to be adhered to, we're not going to have good, solid data. They won't be able to roll-up national data because everybody's recording things differently—reporting in a different way, in a different format that just is not conducive to rolling up good, solid, accurate data.
    Mr. GUTIERREZ. Thank you, Mr. Miller. Thank you, Mr. Chairman.
    Mr. STEARNS. Mr. Bilirakis.
    Mr. BILIRAKIS. Thank you, Mr. Chairman. Of course, the question offered by Mr. Gutierrez is the bottomline question and the reason for this hearing. We know that specialized services are the most expensive. So I guess common sense would dictate they might be considered the most vulnerable to cuts to the budgetary constraints. So that's why it's just so very necessary to be even more diligent than we are being. Tom, Mr. Miller, we got to know you real well.
    Mr. MILLER. Now, I'm in trouble. (Laughter.)
    Mr. BILIRAKIS. I've been here for 16 years—and I think you've probably been in that audience and testifying for at least that period of time—or close to it anyhow. Now, you're chairman of this advisory committee and I do want to commend the VA for its efforts in the creation of that committee. You gave us a history of it. Now you're an advisory committee of the VA—you're all volunteers, right?
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    Mr. MILLER. Yes, sir.
    Mr. BILIRAKIS. You're an advisory committee of the VA. Have you been given the opportunity for input on this particular problem—specialized services—particularly prosthetics and, you know, the special disabilities?
    Mr. MILLER. Yes, sir. Over the history of the committee—whenever we met, and we meet twice yearly usually in the March-April timeframe and then again in September of each fiscal year. Following each meeting, we submit detailed minutes of those meetings with a list of recommendation the committee wants to send forward to management. Normally throughout all of those meetings, we receive briefings from VHA management officials——
    Mr. BILIRAKIS. I don't want to use up all my 5 minutes now——
    Mr. MILLER. Oh, okay.
    Mr. BILIRAKIS (continuing). On that, Tom. Forgive me for interrupting you, but I think I know you well enough that you'd be willing to do that. So you're not ignored. In other words, you do have inputs and do you feel that your inputs are creative and, you know, at least addressed and considered?
    Mr. MILLER. In the last few years, we've had serious questions regarding whether or not they were read, and if so whether the responses have been less forthcoming in some situations. We've had some serious problems with the methods in which those reports were handled within VHA. We addressed those with Deputy Secretary Gober in our last meeting in March. He suggested some changes and we're hopeful that VHA will be more responsive in the future.
    Mr. BILIRAKIS. All right now, so basically you've testified that there's been a drop in this maintaining of specialized services. That has happened since the Eligibility Reform Act of 1996. Is this any unintended consequence of that particular piece of legislation that maybe we should have taken into consideration? Any comments from any one of you in that regard?
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    Mr. MCCORMICK. Well, let me say I think that it was something to be concerned about when the VA attempts, as it is, to increase the number of users and to move to more outpatient delivery modes, the needs of special patients can be left behind. So I think the capacity section was a very well thought out portion. I guess my own view is that we need to continue to be vigilant. We need more data. It's very difficult to really make any final decision right now, but I think that it certainly was a good thing to highlight.
    Mr. BILIRAKIS. Mr. Backhus, you have any opinion in that regard?
    Mr. BACKHUS. Well, I think the incentives these days and in the field or divisions are to try to make the best out of limited resources, and to keep the cost of those patients down. When they're finding efficiencies, or ways to become more efficient, there is sometimes that tendency to seek out those patients who are less costly. It makes the special population somewhat vulnerable. There are protections that are in the system, such as this legislation to prevent that, and I think they are very important.
    Mr. BILIRAKIS. But that protection is just basically a mandate, a rhetorical mandate, on our part. Isn't that true? I don't know when you say protection?
    Mr. BACKHUS. That carries weight. I mean the legislation certainly does carry weight. I don't disagree with Mr. Miller at all. But from where I sit, there just isn't enough data yet to conclude that the capacity has been reduced. But there certainly is the need to find out.
    Mr. BILIRAKIS. Yes, but the trouble is that by the time we get enough data, another year or so has gone by. That's much of the problem.
    Mr. BACKHUS. Correct.
    Mr. BILIRAKIS. You have a new Secretary of Veterans Affairs, I suppose coming aboard and I don't know, all sorts of different policies will change. But Tom, very quickly, I don't have more than a few seconds if you have anything to add to all that.
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    Mr. MILLER. Yes. I would indicate that I think the eligibility format was—has been a contributing factor and that it's increased the cost of prosthetic services, and increased workload for a number of these special programs. But I think even more importantly is the totally inadequate funding level for VA healthcare in general. To be fair to the network directors, facility directors, and the headquarters management, they have very, very difficult and a wide range of programs that they must fund and provide. There just aren't the sufficient resources for them to do everything they need to do and want to do.
    Mr. BILIRAKIS. Thank you. Thank you so much. Thanks, Mr. Chairman.
    Mr. STEARNS. Thank you, Ms. Brown.
    Ms. BROWN. Thank you, Mr. Chairman. To Dr. McCormick—my question is—I guess it's nothing more disturbing to me, and probably most Americans, is that one-third of the homeless people are veterans. They're veterans with mental health problems or substance abuse problems. I think it's a direct relationship to us closing hospitals and putting them in the community and the services not following them to the community. In your testimony, you mentioned that we—you're serving more mental health veterans, but there have been a drop in serious mental ill, substance abuse and its treatment. Well, that's disturbing.
    Mr. MCCORMICK. Certainly, as you accurately said, most homeless veterans that the VA treats—and there are estimates that there are as many as 200,000 to 250,000 homeless veterans. Most of them do have some mental disorder, including substance abuse that require care. VA's homeless programs actually have been among the best programs to get out into the community—use community resources, use residential resources in the community as well as the VA in an attempt to rehabilitate and take the homeless back to independent living. Again, this is a program I think that the Congress very much pushed and the Congress can be very proud of. And, overall, nationwide, it is still a program that is very viable and vital. My committee's main concern is that, of all the subclasses that had the largest decrease in any network, it was homeless that showed a 38 percent decrease in one network. So again, it perhaps highlights the variability issue more than any other portion of what we do.
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    Ms. BROWN. Well, following up—I note that you say that you have a drop in the amount of services that you're providing to these veterans.
    Mr. MCCORMICK. Well, again, nationally, you've got to remember that this particular report kind of breaks the homeless into two parts, like it breaks every population. The seriously mentally ill homeless versus the total population of homeless patients. The seriously mentally ill being those that are the lowest functioning of the homeless, if you will. Nationwide, there was not actually a decrease in the number of seriously mentally ill homeless treated. There was, however, the concern of the committee that there was really tremendous variations across networks; that the growth of the homeless that we actually served—and again, we only make a dent on that population—didn't grow at the same rate that our overall penetrance into the treatment of veterans in the Nation grew.
    Ms. BROWN. Well, what would be some of your recommendations as to how can we have more aggressive outreach of forces to where it would be homeless veterans?
    Mr. MCCORMICK. Again, I think our homeless programs are, again, particularly vulnerable. Because the VA's healthcare system, much to its credit, goes much beyond the benefits that a private healthcare plan offers, you know. Services for homeless are more than just health services, they're also psycho-social and rehabilitation services to get them back into the community and producing revenue—actually producing dollars that can be taxed. Those programs need to be constantly highlighted and need to be constantly watched over. There needs to be vigilance to see that we don't lose our way to becoming a more narrow healthcare system that doesn't provide that broad range of benefits. The committee and myself were very happy to hear Dr. Kizer actually at a recent hearing talk about homeless being the fifth mission of the VA. We just need to make sure that that message filters down all the way to the levels where operational decisions are made in VA.
    Ms. BROWN. Thank you. I have one other question. I have a little bit more time, I guess. Mr. Miller, do you think providing a performance measure in the Veterans Integrated Service Network performance contracts to address each of the protective specialization service would give Congress better assurances that the programs will receive adequate attention?
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    Mr. MILLER. Yes, I think that would be very helpful. I think accountability is crucial. I know I've heard Dr. Kizer and Dr. Garthwaite on many, many occasions in headquarters and their philosophy and what they expect. What we find in the field is often not consistent with their policy and how they conceptualize the system. I think if requirements were included in their performance standards making network directors and facility directors accountable would be very helpful in terms of monitoring, in placing the appropriate emphasis on these specialized services.
    Ms. BROWN. Okay. Thank you, Mr. Chairman.
    Mr. STEARNS. I thank my colleague. Are there any additional questions?
    I want to thank the panel very much for their time and efforts. We will now have the second panel.
    Dr. Thomas Garthwaite, Deputy Under Secretary for Health, Department of Veterans Affairs; Dr. Fitzgerald, Director of VISN 1; and Dr. Leroy Gross, VISN 6.
    We want to welcome you folks this morning and appreciate your taking time in your busy schedule to come by and talk to us. Why don't we start with Dr. Garthwaite? Doctor, you have an opening statement.


    Dr. GARTHWAITE. Thank you. Mr. Chairman, I'm pleased to be here to reaffirm VHA's commitment to maintain and where feasible, enhance the scope and quality of our specialized treatment and rehabilitation of disabled veterans. VHA's programs that meet the specialized needs of veterans help define the VA as a unique healthcare system. VA has developed strong expertise in specialized services for veterans with spinal cord dysfunction, blindness, traumatic brain injury, amputation, serious mental illness, and post-traumatic stress disorder. These services are not widely available in the private sector and we are committed to meeting the needs of veterans who rely on VA for these specialized services.
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    Public Law 104–262 requires that we maintain capacity to provide for the specialized treatment and rehabilitative needs of disabled veterans. The legislation requires ongoing monitoring of the capacity of these special programs. We have submitted two reports to Congress—one in May 1997 and one in June 1998—detailing our efforts to measure capacity. In the process, we have consulted extensively with and will continue to work with service organizations, advisory committees and others in implementing monitors of the performance of these specialized programs.
    While we have developed various working definitions for terms identified in the law, we appreciate the complexities and the realities underlying the concepts of capacity and access. We seek practical solutions for measuring these today as we work collaboratively to find enhanced measures for the future.
    Our June 1998 report reflects that nationally the numbers of veterans treated in the six programs was maintained or increased for all categories, except amputation which declined by 2 percent. We do believe that the decline in amputations was due to greater emphasis on preserving limbs and better management of veterans at risk for amputation. My formal statement discusses our performance reached in specialized programs as reported in our June report.
    Several issues have been raised about the data presented in or underlying our report. We are, and we will continue to be completely open with our data and our methods of analysis. We welcome questions from and discussion with all interested parties. We look forward to providing this committee with specific responses to data concerns raised during this hearing and at any time in the future. While we believe that our data systems have many strengths, we also believe that we have much work to do to accomplish their continued evolution. In addition to the myriad of data enhancements currently underway, we will have a data summit later this year and will seek broad participation from those outside VA who depend on our data to track quality and system improvements.
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    We continue to listen and communicate with our VSO colleagues and we continue to ask critical questions of ourselves regarding how we might enhance, not just preserve these outstanding programs. Recently, Drs. Kizer, Holahan, and I spent 2 hours with PVA's top leadership discussing their concerns. We continue to work on various issues raised during that and other meetings. I think PVA and VHA are making good progress in developing outcome measures for patients with spinal cord dysfunction. An effort which will once again have that partnership leading the way in the advancement of care in spinal cord disease.
    In mental health, we have examples of outstanding leadership and creativity in network service lines. As we learn from those leaders, we will aggressively teach the best practices for others to follow. We believe that other initiatives such as our mental health report card, the recently funded mental health research and education centers, the recent funding of our quality enhancement research initiatives in mental health, and expanded funding of our homeless grant and per diem program, voted by VISN Directors for inclusion in our budget, reflect our commitment to these patients. Early detection of illness, outreach to enroll patients, and coordination of care are fundamental issues which underlie all we've been doing to reinvent the Veterans' Health Administration—these issues are especially important in mental health and in special programs.
    In blind rehabilitation, we are proud of our service and our history, but we are not content. We are chartering a gold ribbon panel, in honor of the 50th anniversary of the blind rehabilitation service, to help us visualize the best integration of blind rehab with our decentralized network structure and to suggest ways that we might effectively serve additional visually-impaired veterans.
    In prosthetics, we are concerned that an increase in workload has resulted in gradual increase in delayed orders. We are aware of problems and have taken specific actions to address them, including staffing adjustments, central earmarking of funding, and continued careful monitoring of delays. Dr. Kizer has charged our prosthetics and sensory aids service to develop additional performance measures that will address quality, access and satisfaction in prosthetics in addition to the historical tracking of timeliness.
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    In conclusion, I'm pleased to report that VHA has maintained its national capacity to provide for the treatment and rehabilitation of the broad groupings of specially disabled veterans. While some sub-group and some network variation exists, we continue to monitor and work to understand these variations and take action to assure these patients are not adversely impacted by the needed changes in the Veterans' Health Administration.
    The veterans we are discussing here today, to a great degree, are the reason there is a VA health system. We've made many changes in the VA in the past 3 years. Change is not easy. It has been said that people don't resist change, they resist change for which they see no reason. Our reasons for change are clear—better service, better access, better quality, and better outcome. We thank you for the opportunity to discuss these issues and look forward to your questions.
    Mr. STEARNS. Thank you. Dr. Fitzgerald.
    [The prepared statement of Dr. Garthwaite, with attachment, appears on p. 78.]


    Dr. FITZGERALD. Thank you very much. Mr. Chairman and members of the committee, I appreciate the opportunity to appear before you today to discuss the management of and support for our special programs. VISN 1, VA New England Healthcare System includes nine medical centers located in the sixth New England State. We provide the full spectrum of healthcare services, including most special programs.
    The importance of the special programs has been recognized in VISN 1 and appropriate support has been shown throughout the network. Our strategic plan is linked to our financial and human resource plans to ensure that these programs will receive appropriate attention and the necessary resources to operate effectively now and in the future. The patient focus inherent in the implementation of service lines will further enhance the quality and assessibility of these special programs. Network 1 West Haven has maintained capacity to provide veterans a full-range of blind rehabilitation services. A 100 percent of veterans referred to inpatient blind rehabilitation have access to the program within 6 months of their application.
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    The SCI program capacity at Brockton, West Roxbury is more than adequate to meet the current and anticipated demand. The number of patients treated has remained about the same during the past 2 years and the total dollars allocated to the SCI program has increased. Access to care is excellent and performance on national customer service standards placed the Brockton, West Roxbury SCI program number 1 among all VA SCI centers in the areas of access, information, emotional support, overall coordination of care, and continuity of care.
    VISN 1 provides a comprehensive list of inpatient and outpatient services for the mentally ill veteran. Seventy-six percent of our veterans are seen within 30 days of discharge compared with the national average of 68 percent. According to a report card furnished by the Northeastern Program Evaluation Center, Network 1 was ranked 7th over all the mental health services. VISN 1 was a pioneer in developing intensive psychiatric community care programs and support 2 of 9 programs for the treatment of veterans with co-morbidities of PTSD and substance abuse. Facilities in our network have been home to many national mental health programs—two of the three national schizophrenia centers; four of the six divisions of the National Center for PTSD, and national mental illness research education and clinical center—to name a few.
    I am very proud of the efforts of the employees of VISN 1 to continue to improve the excellent service they provide to the veterans of New England. We have come a long way, but much more needs to be done. I have the privilege to work with staff who are dedicated to providing the best care possible to all our patients. The close ties we have with many excellent medical schools and universities enhance the care we offer, as well as the education and research opportunities available to our staff. These four special programs are of prime importance in carrying out our assigned mission. They will continue to receive appropriate attention and the support of Network 1.
    Thank you for inviting me to speak before you today. I appreciate you support for our efforts to provide the best possible care to our Nation's veterans. I would be please to answer any questions you might have.
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    Mr. STEARNS. Thank you. Dr. Gross.
    [The prepared statement of Dr. Fitzgerald appears on p. 85.]


    Dr. GROSS. Mr. Chairman and members of the committee, I'm privileged to testify about the implementation and management of specialized treatment and rehabilitative needs for veterans that are disabled and Veterans Integrated Service Network 6.
    VISN 6, or the Mid-Atlantic Network is comprised of eight healthcare facilities and other VA medical programs in Virginia, North Carolina, and Beckley, West Virginia. We have strong academic affiliations with six major universities and other teaching facilities. We serve a growing veteran population in this area that has increased over the past 2 years. A good percentage of these veterans do require the support of our specialized programs. The leadership of VISN 6 has recognized early on the need to give priority to specialized programs in this era of declining resources. We're now in the third year of refining our structures, processes and outcomes to maintain and even expand the capacity to meet our commitments to disabled veterans.
    The hallmark of our structural changes is characterized by the formation of multi-disciplinary teams that are patient-focused and that place authority and responsibility and accountability at the lowest level where care is provided. This concept is known as service-line management. VISN 6 has established service-line for spinal cord injury, mental health, primary care preventive health, and geriatrics and extended care. SCI, mental health and primary care will have independent budgets in 1999—this coming fiscal year—and this will enable VISN to improve the monitoring of our resources to more accurately reflect our outcomes to increase access and even to positively affect patient satisfaction.
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    I would like to comment on a selected specialized programs as follows and the blind rehabilitation program. VISN 6 continues to support our VIST or Visual Impairment Service Team coordinators at each medical center. In March 1997, a network coordinator was appointed to insure consistency in programs for the visually impaired veteran population throughout the VISN. We refer our visually impaired patients to West Haven, CT and Augusta, GA for residential rehabilitation support. We estimate that the population of the legally blind veterans in VISN 6 is anticipated to increase by 122 percent by the year 2005.
    In the area of prosthetics, VISN 6 has redirected a portion of its workforce between 1996 and 1998 to generate a 9 percent increase in personnel to support our prosthetics programs. Our delayed orders for VISN 6 continues to be below the benchmark of 2 percent threshold for fiscal year 1998, notwithstanding the fact that we have increased our workload 19.8 percent over the same period.
    In providing care for veterans with amputations, our preservation and amputation clinic and treatment programs are operational at each facility. The amputation workload in this network is projected to decrease which is according to the national trend.
    In mental health, from April 1997 to March 1998, mental health patients treated in our outpatient programs increased by 13.4 percent over the number in 1996. For this same period, inpatient episodes of care decreased by 17.4 percent. We at VISN 6 have a broad menu of health services at each facility in mental health. These are augmented by specialized programs at selected medical centers.
    As noted previously, spinal cord injury and disease is one of our service lines. This program provides 164 beds for our inpatient, acute, and long-term care spinal cord patients. These centers are located in Richmond and Hampton. Our centers also support three contiguous VISNs. The remainder of our facilities—the other six—have qualified as the primary care teams that have been formed and trained to provide ambulatory support services for veterans closer to their homes. We've noted in VISN 6 that there's been a 10 percent increase in our patient workload since 1996 for SCI.
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    At this time, I would like to take the opportunity to thank members of the PVA, DAV, and VFW American Legion and other VSO's for their input and participation on our Management Assistance Council, or MAC, and my planning boards. I rely heavily on stakeholders that the VSOs provide me the input I need to help in managing specialized programs. Although we may not always agree, their input and assistance as I indicated is invaluable in the change process.
    I would like to pay special tribute to PVA members, Mr. John Malone, who was our VISN 6 PVA liaison officer; and Mr. John Devine, and Randy Pleva in West Virginia for their outstanding support to the MAC. I cite them because their progressive disease processes have lately not allowed them to continue to support us in the recent months. While they were there, they were very, very helpful.
    Mr. Chairman and members of the committee, I want to assure you that VISN 6 will continue our efforts to fully comply with the spirit and intent of section 1706, title 38, USC. Treating more veterans with specialized needs over the past years, I think in my network has demonstrated the ability to maintain the scope and availability of these programs even while expanding them.
    I thank you for your support and I remain available to answer your questions.
    [The prepared statement of Dr. Gross appears on p. 94.]

    Mr. STEARNS. Thank you, Dr. Gross.
    I guess I might start out with you, Dr. Garthwaite. You've heard the criticism from two expert panels before. Would you acknowledge this morning that there's more than just a problem? Differing perceptions here? Do you think there is a problem, or how would you characterize a problem? Perhaps do you have any solutions? What is your reaction here? Mr. Thomas Miller, you've heard his comments. I'm just curious what's your perception of this?
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    Dr. GARTHWAITE. I think there have been tremendous changes made in the VA. Many of them are positive. I also think there are, always have been, and always will continue to be issues that we will need to address. When you try to deal with a system that has 173 hospitals and when you try to operate a hospital system that has hospitals in every area of the country, there will continue to be variation and some immediate areas of concern. I've not had time to review the PVA's concerns, but they have some specific concerns at specific medical centers and I'm very anxious to find out more about them.
    But I think, overall, if you ask the question, have we seen the same number, total number of veterans in these categories across the VA system, I think we can answer yes. If you ask the question is there variability in healthcare across the United States and in specialized programs—my answer is yes, there is. Dr. Wennberg, at Dartmouth, has shown—in the Medicare population—dramatic differences in healthcare in the private sector. Do we notice differences in healthcare and therefore differences in all parts of our healthcare across the VA system? Yes, we do and we're trying very hard to understand whether those differences are related to funding, to staffing, to local variation and employee availability or to policies or things that we can affect nationally.
    Mr. STEARNS. Well, I understand your answer. I understand it's a little bit circumspect. But we've heard from experts here that say it's a problem; there is a definite problem. Yet, I hear from you, you don't know if there's a problem yet. You need to look at it further. You're saying that from VISN to VISN, it can explain the problem. Do you think there's a problem? Just yes or no. I mean, it just seems like if I were in your position, I would——
    Dr. GARTHWAITE. Well, I would think there's a problem.
    Mr. STEARNS. Yes, I would say that you're telling me that you just think it can be explained by just saying from VISN to VISN, the predictability, and probability and things like that. I think we've heard from experts—got a GAO audit that's starting. The question is for you, is there a problem or not?
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    Dr. GARTHWAITE. I hesitate to give you a simple yes or no.
    Mr. STEARNS. Well, obviously, then you don't think there's a problem?
    Dr. GARTHWAITE. No, no I don't. I think there are multiple problems at multiple levels.
    Mr. STEARNS. So, there's a problem?
    Dr. GARTHWAITE. There's certainly a problem that veterans' service organizations have perceptions of loss of capacity. There are specific local issues, as I said in all healthcare systems that will have specific local issues and we can call those problems. So there are specific local problems. Are they different because there's legislation? Are they different in relation to what they were before we started all the change or are they better compared to what they were before we started all the change?
    Mr. STEARNS. Do you think the problem——
    Dr. GARTHWAITE. I think it's hard to answer that with a simple yes/no.
    Mr. STEARNS. Do you think the problems are more a function of management or lack of money? Either one. I mean can't you just give an answer to that? Or both—there's a third answer.
    Dr. GARTHWAITE. I think there are some management problems that we attempt to deal with. I think we can give you examples of where we've done that specifically. I think there are, have been, continue to be, and will always be a tension on our ability to meet all the demand. So we will always have the tension and we will try to give as much quality care with the dollars that we're given. So we're always fighting that tension of treating additional veterans, who would not get care if not for VA, and treating as many patients as we can without wasting any dollars. So there's always that tension.
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    Mr. STEARNS. Part of my question is, obviously if you don't think there's a problem, you're not going to do anything. But if you think there's a problem, then the question is what do you propose to do to solve it? I really haven't felt that you think there's a problem and that you are really clearly going to map out a program to solve it with alacrity. That's just what's coming across to me. Now, I don't know if you want to correct that impression or not.
    Dr. GARTHWAITE. No, I think in my oral testimony I hit on several specific issues that I think we will do to try to address some of the concerns that have been raised in other testimony.
    Mr. STEARNS. Okay. Dr. Fitzgerald, your VISN I understand is up in Boston, the New England area?
    Dr. FITZGERALD. Yes, sir.
    Mr. STEARNS. VA's capacity report indicates that in your VISN the number of patients seen for serious mental illnesses, substance abuse, and PTSD are all declining substantially. Now, I just heard that the demand in this area is increasing. How do you explain that? In the area of mental health, the VA's capacity reports shows that your VISN workload actually is declining substantially—not just, incrementally. A substantial decline. How do you explain that? What specific plan for providing mental health services do you have? How do you explain the statistics?
    Dr. FITZGERALD. With the chronic mentally ill volume that we're seeing, I would look at those statistics very carefully. I believe that in the area of substance abuse, for the first two quarters of 1998, there was a decrease in the number of patients seen in the ambulatory environment. But other than that, I'm not aware of a significant decrease in the area of chronic mental illness.
    What we have devised in VISN 1 to handle the mentally ill services—we've developed a VISN-wide council on mental health. We have developed special programs and actually have an over-capacity in terms of inpatient beds versus the rest of the Nation. We have over 550 beds in mental illness; some 235 of them are for chronic mental illness. We have in addition to that, 111 beds in outpatient PTSD rehabilitation and residential care for the homeless veterans who are, as you know, in large part have dual diagnosis. Our team is leading the way in how we deliver mental health services across the VISN. So I think that our capacity has been maintained according to the information except in the area of substance abuse. We are looking into that as to the reason to first of all validate whether that reason is true. Second of all to look at the root causes of that difference and we will be moving to correct that as appropriate.
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    Mr. STEARNS. Dr. Garthwaite, you heard earlier in the first panel when we asked them about the management practices and the data from VISN to VISN. It was implied that the regional inconsistencies between the VISNs dealing with the special disability programs exist. How do you react to that concern that we have now had experts saying that from VISN to VISN the consistency is not there. Are you concerned about that? How do you reconcile this inconsistency with a system whose funding is based upon the principle of equity of access?
    Dr. GARTHWAITE. I think we're very much concerned with any inconsistency that's unexplainable. We're interested in the explanations and whether they're reasonable or not. So the answer is yes, we're very concerned. We're looking at variability in many programs across networks moving from a single system to a network system, which has allowed us the opportunity to explore those differences and care patterns. We're pleased to work with people in our mental health programs and with our committees to explore why those exist and what significance they might have.
    Mr. STEARNS. Dr. Gross, anything you might want to add to some of the questions I've asked?
    Dr. GROSS. Yes, sir. I think as an individual in the field with perspectives as a manager of this healthcare system in Virginia, North Carolina, and West Virginia, I have a need for data. I find that the decisions I need to make and that the service line managers need for their specialized programs—are better databases. So I certainly will be working as best I can to support that. Because as I reviewed the written testimony of the organizations before I arrived—the GAO, PVA, et cetera, there's a wide variability in the numbers for the same issue. My numbers are different from theirs. So that's one problem that I think I need resolved.
    The other, as I look at the capacity issue, in my network—and I'll use spinal cord as an example. As long as I can see all the patients that want to receive spinal cord services in my network, I feel that I've maintained the capacity. In my network, to the best of my knowledge, that is true. It is not equated to the number of beds, or the staff, or the dollars which is something that, it appears, is the measurement of capacity. So I would hope that we would take a look at access and quality. Because quality is there, the access is there in my network, and cost of course we have to monitor.
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    Mr. STEARNS. Thank you. Mr. Bilirakis.
    Mr. BILIRAKIS. Thank you very much, Mr. Chairman. Dr. Garthwaite, I'm going to take a few seconds just as a reminder and then I'll go maybe into some questions, but not in connection with this reminder, if you will. You're smiling, so you probably have a pretty good idea of what I'm going to say.
    Several months ago, you sat in on a meeting that I had with Deputy Secretary Gober.
    Dr. GARTHWAITE. Correct.
    Mr. BILIRAKIS. To discuss the Tampa SCI construction project. At that meeting, Secretary Gober—and if you disagree with this comment, you certainly can tell me so—but at that meeting, Secretary Gober gave me his personal assurances that the Department would include funding for the SCI center in its Fiscal Year 2000 budget. Now I know that the Department is in the process of compiling this budget; I'm just reminding you.
    All right, let me ask you, sir. You're not under oath. You're an honorable man. I know this committee has had a lot to do with you and I don't think any of us have any ill feelings towards you or any of your good people. I've always thought frankly that veterans healthcare services are a pretty darn good services. Sure there are problems there. God knows in every hospital in the land there are. This is not to excuse now some of these things that we've talked about, not trying to whitewash us. But can you tell this committee that, as far as you know, even though the specialized services are the most expensive and even though they are the most vulnerable to cuts to the budgetary constraints, that there has not been any directive from on high or any directive from any of the directors of the VISNs to basically curtail, or to cut any of those as a result of the fact that they are much more expensive.
    Dr. GARTHWAITE. To the contrary, it was clearly the message from on high, if you will, doesn't feel that way most days. But from headquarters, it is very clear that we're not to diminish our capacity to treat veterans. In preparing for this testimony, I reviewed that with the two network directors that are sitting here who can remember their first day on the job hearing that from Secretary Brown. It's been a consistent message that we've put forward.
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    Mr. BILIRAKIS. Well, but things apparently have happened. We've had testimony here. Some of the veterans' service organizations will be testifying. PVA has conducted their own surveys, and we can get into that if we have time. So, you know, there has been apparently an impression at least, if not anything else, of the curtailing of those services and not having lived up to the directive in the 1996 Act. Of course, we don't have the centralization to the point that we had previously. Isn't that correct? Could that be a problem?
    Dr. GARTHWAITE. Yes, certainly the changes with decentralization could be a problem. But I think if you look overall at patient satisfaction, survival, morbidity, mortality, and surgery, the number of patients treated, preventive health measures, and so forth. Most measure are on a good trend. What we have to do is dissect out whether there have been specific instances and specific specialty programs where we failed to meet our expectations.
    Mr. BILIRAKIS. You indicated—I think it was you during your testimony—that you have sat down with PVA and spent an awful lot of time with that particular organization.
    Dr. GARTHWAITE. All of them.
    Mr. BILIRAKIS. All right, but the veterans groups have told us—and they'll testify to this—that they've taken their own counts. Those counts do not square with basically the data that's been furnished by the VA. Have you discussed that in your conversations with the PVA?
    Dr. GARTHWAITE. We've had some discussions. We clearly need to have more discussions about the specific data issues. Because data is very definitional. There's a lot of difference between an operating bed and a staffed bed. We staff based on current demand. It's a very complex and hard-to-do process. I would say that's where we fail, that's often a place we fail. I think that's true in every hospital I've ever worked in. As they're getting the right staff for the right number of patients on any given day is a very difficult process. Because people don't sick on cue and there are a lot of other factors about our employees that relate to that. So I would just say that staffing is exceptionally challenging in any medical facility having——
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    Mr. BILIRAKIS. I complimented the chairman for calling this hearing initially because there are perceived problems out there. Perception sometimes can be even stronger than fact. I frankly think there are probably some factual problems out there. I think you all would admit that.
    Dr. GARTHWAITE. I'd agree to that.
    Mr. BILIRAKIS. PVA has recommended that the maintenance of capacity for our specialized services be made a part of performance measures for management personnel—from the level of the VISN Director on down. Do you agree with them?
    Dr. GARTHWAITE. We're working on trying to get valid measures that we can use for that purpose. We'd like to put together an index similar to our prevention index for chronic care and disease that reflects our overall performance in those areas.
    Mr. BILIRAKIS. In those areas—so you do agree with them?
    Dr. GARTHWAITE. Correct. Yes, not a problem.
    Mr. BILIRAKIS. Have you implemented any safeguards to ensure that specialized services are maintained since the 1996 Act? We don't have decentralization anymore and you're talking about more expensive services here. Human nature might dictate that a Director might say ''Hey, I'll borrow a little bit from here in order to take care of this.'' Knowing all that, have you implemented any safeguards to keep that from happening?
    Dr. GARTHWAITE. Yes, I believe we have. We certainly made it high priority to the network directors. They can testify as to our consistent admonishments to them at various meetings. In addition, we've continued to maintain centralized control of prosthetics funding simply because we don't believe that we have adequate tracking mechanisms yet. When we get those we might reconsider that, but we think that's a key piece. We've put a lot of money into the monitoring of mental health programs. We have like 80 FTE in the NEPEC (northeast evaluation program evaluation center). We have, as I mentioned in my oral testimony, moved forward to understand the quality of care we're giving in mental health. Our quality enhancement research initiative which is a major new initiative to put data behind these decisions and to make sure we can assure you, our patients and veterans' service organizations that we're giving the best care possible. I'm sure there are more that I can give you for the record.
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    Mr. BILIRAKIS. Well, all right, Mr. Chairman, my time is up. I guess, you know, I get concerned we talk about data. Only 25 percent of the investigation by the GAO has been completed. It seems like we can do better than just—not that the data is not significant, Dr. Gross, you're right, but it seems like we could really do a heck of a lot better than just depend on data and that sort of thing.
    Dr. GROSS. Talk to the veterans.
    Mr. BILIRAKIS. I think that's basically——
    Mr. STEARNS. Mr. Miller.
    Mr. BILIRAKIS. Thank you, sir.
    Mr. STEARNS. Yes. Ms. Brown.
    Ms. BROWN. Yes, before I get into my couple of questions. Will someone just take a minute—one of the three—and explain to me the Veterans Integrated Service Networks. Just explain to me how that's working.
    Dr. GROSS. Yes, ma'am. Veterans Integrated Service Networks—there are 22 of these. They are regionally based and were established according to the patient referral patterns. In my network, like I said, I have Virginia, North Carolina, and Beckley, West Virginia. So these are essentially regions that have been carved up and the authority and responsibility has been decentralized to the directors of these respective networks or VISNs.
    Dr. GARTHWAITE. I'd just add one amplification of that from a central perspective. That is, that we used to be hospitals that competed with each other for funding and services and so forth. The goal has been to think of ourselves, not as a collection of hospitals, but as entities that are responsible for a population of people and their overall care. I think it's had a profoundly positive effect on the coordination of care within a geographic area.
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    Ms. BROWN. Yes, and my understanding, yes, you do have 22 and only 1 African-American.
    Dr. Gross, nice meeting you.
    Dr. GROSS. Two.
    Ms. BROWN. Two?
    Dr. GARTHWAITE. We recently hired a Mr. Danridge, yes.
    Ms. BROWN. Yes. You have two now?
    Dr. GARTHWAITE. Yes, correct.
    Ms. BROWN. How many women?
    Dr. GROSS. I think there's six.
    Dr. GARTHWAITE. Let me count them out.
    Ms. BROWN. [Laughter.] Okay.
    Dr. FITZGERALD. I think we have four.
    Dr. GARTHWAITE. More than that, I think. I'll have it in a minute.
    Ms. BROWN. Well, we're working on the problem. (Laughter.)
    Let me go to my question. VA has a variety of performance measures that's supposed to ensure that these network directors make certain things happen for the VA. Directors are rewarded for recruiting new veterans, patients, for shifting care from inpatient to outpatient settings, and for saving money. How can we ensure that these programs are working for the veterans and that we have high standards? Is there something in the performance contracts to this effect? If not, how can we put it in the contract to these different providers?
    Dr. GROSS. Yes, as part of the establishment of the networks, we started initially—and have even expanded what we call performance measures. There are like 24 of these measures. They are very numerous. We have quarterly report cards, if you will, of how well we're doing. Some of these are stretch goals. Some are very difficult to attain. It spans the spectrum from MCCF or collecting money from third-party billers to ensuring that we have clinical practice guidelines, et cetera. So they're broad in scope and they're reviewed annually. So we're held accountable for that. So my report card, my assessment, is based on how well I do. There are other measures that Dr. Garthwaite also even adds as objectives. Now, these are objective measures, but there's some subjective components that he may be able to address.
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    Dr. GARTHWAITE. Yes. I would just add that initially what data was available to push performance and what some of the major issues facing VA were related, in part, to structure and to providing care for inpatient versus outpatient. We're evolving away from those measures and evolving to outcome measures for patient's health. I think that's really the essence of your question. We want everyone in the whole system to be focused on improving outcomes for patients. So that's really the goal the performance measures.
    Ms. BROWN. My next question pertains to VA is going through downsizing of the institutions. You know, we had that in this country in the 1970's and 1980's. The homeless, in my opinion, is the result of it. What kind off assurances do we have that VA, as they go through this, are not going to repeat those same mistakes? Dr. Fitzgerald?
    Dr. FITZGERALD. We have initiated, nationally, four pilot studies, one of which is in New England. Essentially, what it is is a homeless program where the VA and its resources reach out to the community and its resources so that we avoid duplication. We come together in a cooperative manner across the entire network. This has resulted in a 15 percent increase in the identification of homeless veterans within New England in the short 12-to-15-month period that this has been in operation. We're continuing this with the appointment, not only of a network coordinator of the homeless program, but also local coordinators at each one of the facilities. Homelessness is as different in Maine as it is in Boston. I mean, it's a very, very different problem depending upon the different areas. It requires a local approach, using local community resources. That's what we're attempting to do. So far in the 12 to 15 months, it's been working. It's been very successful.
    Ms. BROWN. Thank you. Thank you, Mr. Chairman.
    Mr. STEARNS. I thank the gentlelady. Dr. Cooksey?
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    Mr. COOKSEY. Well, it's good to see you again, Dr. Garthwaite, Dr. Fitzgerald, and Dr. Gross. I'm always glad to have physicians here. I'm encouraged and feel very good to know that there are areas of expertise that the veterans' hospitals have that other hospitals don't have, particularly in spinal cord injuries. It's obvious that the reason that you do have that expertise. I think there's some other areas. We have a VA hospital in my district that is really a well-run hospital. I would make an overall comment.
    I think this patient protection legislation that is on the front burner—on everybody's mind now—is there's some need for a lot of it is politics driven by the election coming up in November, and does not really address the overall problems, but that we're working on them. But we really need to be thinking in terms of moving to a system where we can go to areas that, where there's the top expertise on spinal cord injuries, for example, and put enormous resources in there. If it's in the VA hospital, that's where it should go. I, personally, have a heavy bias toward veterans, being a veteran. I feel that veterans that have war injuries, or training injuries, should have unlimited resources for their injuries and long-term care. But there is some duplication in this country, not so much in the veterans' hospitals, but in a lot of other hospitals and probably to some extent there. But we still need to think in terms of an overall restructuring. I want the veterans' hospitals to be big players in this. I want the veterans to benefit from some restructuring. We ultimately need to move to a more of a system that is a market-driven system for the non-Medicare patients. Then we won't be worried about patient protection. But always on the front burner for me will be the veterans that have some injury that they got in combat.
    I, quite frankly, am not as sympathetic. We, in my congressional office, 35 percent of our constituent services is for veterans, and 35 percent is for social security. All of which are related to disability. I just feel that there are too many people that are looking for disability that did not get their disability as a result of a war injury. They got it as a result of falling off the back of a pickup truck at Fort Pope in Louisiana. It bothers me when I see people that really got war injuries that don't get what I think are adequate resources. So I really think we need to start thinking in those terms. You do a good job and I want to assure you that you will have support from those of us on this committee, and me on this committee. But we still need to look at the big picture. Thank you.
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    Dr. GARTHWAITE. Thank you, Mr. Chairman.
    Mr. STEARNS. We'll take the next panel. I thank you folks for coming here. I know how busy you are, too. I appreciate your time very much.
    Panel three is Mr. Gordon Mansfield, Executive Director of Paralyzed Veterans of America; Mr. Thomas Miller, again, Executive Director of Blinded Veterans Association; Ms. Jacqueline Garrick, Deputy Director, National Veterans Affairs and Rehabilitation of the American Legion; Mr. Richard A. Wannemacher, Jr., Association National Legislative Director, Disabled American Veterans; and Mr. William Warfield, Deputy Director of Government Relations, Vietnam Veterans of America. It's a honor for the subcommittee to have you here this morning. Appreciate your taking the time. We look forward to hearing your testimony. We'll start with Mr. Gordon Mansfield, Executive Director of Paralyzed Veterans of America.


    Mr. MANSFIELD. Thank you, Mr. Chairman. We're still getting arranged down here.
    Mr. STEARNS. That's okay. Take your time.
    Mr. MANSFIELD. Mr. Chairman, first of all, I'd like to introduce myself. I am Gordon Mansfield, Executive Director of Paralyzed Veterans of America. I'd like to request that my full statement be submitted for the record.
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    Mr. STEARNS. Without objection, so ordered.
    Mr. MANSFIELD. In light of what we've heard here, I'd like to make some selected comments based on the testimony that's been presented.
    First of all, I want to say that the people involved here from the Department of Veterans Affairs—Dr. Garthwaite; VISN Directors—Dr. Gross and Dr. Fitzgerald; and Dr. Margaret Hammond who's in charge of SCI; other VISN Directors, and others in this system are good people. They're caring people. I think they want to work to take care of veterans. But what's been going on here is a health care system where we've had massive change. In the process of that change, I believe that what we're seeing is that the management of the VA is attempting to track the civilian managed care HMO models. In my mind that means that they are looking at dollars, dollars, dollars, and dollars. They ought to be looking at patients, patients, patients. They ought to be looking at veterans, veterans, veterans.
    We're in a situation now where the last time I heard Dr. Kizer speak, he indicated that 25,000 beds are gone—closed, out of the system. In addition to that, we have limited resources. The congressional appropriation has been set at a certain level. I'll just slip by a reminder that we recently had a deal with some highway robbery down here where veterans benefits were cut to pay for road construction. Next there are management issues. We now have a situation where we have 22 VISN Directors. To some degree I think we've got a situation with the decentralization of the system, that those 22 separate VISN Directors believe that they can do whatever they want to do in their own VISN. This is a concern for spinal cord injury programs because we view, as I believe the doctor indicated, spinal cord injury in the VA as the only national spinal cord injury care program. Also it's the only care program that covers care from onset of injury all the way through long-term care. It's the only national program that does that.
    We're concerned also as it's been indicated here by both the VA and the GAO, about the VA's ability to count, to know what its capacity is. I will tell you that the SCI system has been in the VA for more than 30 years. There are 22 centers. Patients are supposed to be kept track of at these centers. PVA put at least $.5 million of our own funds into implementing an SCI Registry of Patients. But apart from our efforts I bet the VA would not be able to tell you how many SCI patients they have.
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    Another area of concern deals with what's going on with decentralization and with the changeover to an area that Mr. Bilirakis referred to, construction.
    There are two things going on there. One is construction that's now being handled at the local level under minor construction rules, regulations. We find the VA is going forward without any compliance with accessibility regulations or other requirements of construction law. In addition to that, as indicated in Mr. Bilirakis' concern about the new Tampa SCI Center, which PVA shares and has shared for 18 years, there's a lack of construction of new SCI facilities. This leads you to wonder where the future of the system is going to be if they're not going to take care of the needs that have been expressed and as the member presented.
    Then we come to what, I believe and PVA believes, is the biggest concern that we have, which is staffing. In all this change—and getting rid of 25,000 beds and other changes going on—we find that the biggest problem we have in the SCI centers, and in other places that are taking care of SCI patients—SCI or special cord dysfunction—is staffing. It's one of these cat chasing its tail deals. Because if you ask the VA what the problem is, they'll tell you the reason staffing is down is because patients are down. We do not believe that is true. The reason staffing is down is because they don't have the resources. People are paying attention to the dollars rather than the needed care. They're making decisions based on dollars and resource allocation, rather than the patient needs.
    When you get into a situation where, as we've indicated in our testimony, you have 80 beds but you can only staff 60 of them, then the medical professionals have got to make a decision ethically that they won't put the next person in that bed. So it's a staffing question related to resources.
    Then I think you folks here in Congress have got a problem. Because if you pass a law for VA to maintain it specialized services capacity, I think you ought to expect that it would be followed. We're saying that the law and capacity have not been followed and maintained. Examples of our concern include vets being moved out to community nursing homes and then coming back with pressure sores. We're saying that's something new that's happened in the last few years across the system.
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    We're seeing vets not being transferred to SCI centers from other VAMCs because the people at that other VAMC want to keep the dollars with that patient there. We're also seeing patients not being treated responsibly in a medical sense because of the lack of staffing—people not being bathed; people missing meals; people missing appointments; people not being taken care of the way they should.
    The solutions, we believe, are to provide the dollars as needed. We think that we need a centralized management responsibility for national programs. We think the VA needs to get accurate data. We have to understand, again, that the reason we have a VA is to take care of the specialized needs of veteran patients. I see the red light, Mr. Chairman, and I'll await further questions.
    Mr. STEARNS. Let's go from left to right. Ms. Garrick.
    [The prepared statement of Mr. Mansfield, with attachments, appears on p. 99.]


    Ms. GARRICK. Jacqueline Garrick from the American Legion.
    Mr. STEARNS. Okay.
    Ms. GARRICK. Mr. Chairman and members of the committee, good morning.
    Mr. STEARNS. Good morning.
    Ms. GARRICK. The American Legion is grateful for the opportunity to comment on the Department of Veterans Affairs report on maintaining capacity to provide for the specialized treatment and rehabilitative needs of disabled veterans since The American Legion does have several concerns.
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    Public Law 104–262, section 104 mandates VA to protect its capacity to meet the specialized treatment and rehabilitative needs of disabled veterans within existing appropriations. The law is aimed at maintaining capacity in a manner that provides access to care for spinal cord dysfunction, blindness, TBI, amputations, seriously mentally ill, including substance abuse, homelessness, and PTSD. However, the Balanced Budget Agreement requires VA to meet this challenge with no significant increase to its buying power.
    The American Legion questions VA's ability to do more with less in these highly technical and complicated treatment arenas. The American Legion commends Congress for its foresight to ensure that the scope and quality of these specialized programs are maintained. VA is often the only local provider, and is the unparalleled national leader in providing these services. Monitoring these programs is particularly important in light of VA's challenge to maintain capacity with a budget that will not keep up with medical inflation. It is hoped that, by monitoring these programs, any problematic circumstances such as inaccessibility can be identified, and corrected by VA.
    The challenge to maintain capacity begins in defining capacity and how to effectively measure it. Preliminary monitors have included the number of unique individuals treated and dollars expended with consideration being given to bed levels and FTE. There is consensus that outcome measures should be used in determining the capacity in the future. While The American Legion concurs with the importance of outcome measures in assessing capacity, it also believes there is merit in continuing to monitor within the current parameters. The American Legion recommends measuring capacity by evaluating resources expended with patients treated, and then documenting outcome. According to VA's report, capacity as measured by the number of unique individuals served nationally in the programs has been maintained. Capacity, as measured by resource expended, has dropped in some cases. While the American Legion recognizes VA's ongoing commitment to these programs, there have been gaps in maintaining capacity.
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    In two networks—8, headquartered in Bay Pines, FL, and 18, headquartered in Phoenix, AZ—there are no long-term mental health services available at all. The American Legion views this as an inequitable distribution of capacity, in spite of the overall national average being maintained. This does not seem to be a logical conclusion, nor does it seem to be in keeping with the spirit of the law.
    The American Legion is also concerned with the definition of access used by VA as being limited to timeliness. The American Legion VA Local User Evaluation workbook—or V.A.L.U.E. book, as we call it—defines access by ''the key characteristics of market penetration broken down into both medical groups under VERA, as well as by the seven priority groups and the quantifiable measures aimed at providing the most accurate picture of the availability of healthcare services, such as timeliness of appointments and availability of diagnostic services.'' If VA only measures timeliness, it does not get a full perspective of veterans' access to VA's specialized programs.
    The main criticism of this year's capacity report to Congress is the unreliability of the data. Both advisory committees and the Paralyzed Veterans of America have noticed serious shortcomings with the data collection. Obviously VA's efforts to monitor these specialized services are contingent upon its ability to garner accurate data. In our written statement, The American Legion outlines in detail discrepancies in data found during a February 1998 site visit to Cleveland, OH and the response to that report from the network director. This experience, also, leads us to question the final report.
    The American Legion sits on the VA's Consumer Council for the Committee on the Care of the Severely, Chronically Mentally Ill Veterans. It was involved in the development of a second annual report to the Under Secretary for Health in February. The American Legion praises the SMI committee for all its work on behalf of veterans with disabling psychiatric disorders, and refers Congress to its comments on capacity. In addition, the SMI committee report also included the fiscal year 1997 report from Dr. Robert Rosenheck on the mental health performance monitoring system. The American Legion finds this to be a significant reporting mechanism and has referred to it several times when conducting its own site visits. A mental health report card is a valuable tool in assessing quality of care which is a crucial element in assessing capacity. Capacity becomes meaningless without incorporating quality and patient satisfaction.
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    In sum, the American Legion finds the VA report on maintaining capacity to be flawed in its methodologies and conclusions. It is incomplete since it is unable to report on outcomes. Capacity cannot be defined without understanding quality. The American Legion urges VA to utilize the expertise it has within its own resources like the National Center for PTSD and develop appropriate outcome measures. These measures should be instituted in conjuncture with existing input measures and not replace them. Yet, the overarching concern for capacity begins with the Balanced Budget Agreement, and VA's ability to continue to provide specialized care to all veterans who will need it in the 21st century.
    Mr. Chairman, that concludes this statement and I will be happy to answer questions.
    Mr. STEARNS. Thank you. Mr. Wannemacher.
    [The prepared statement of Ms. Garrick appears on p. 125.]


    Mr. WANNEMACHER. Good afternoon—or good morning, I guess. Thank you very much for allowing us to present—I brought Mr. Jerry Stillman to the table with us because he heads up and supervises 195 different hospital service offices throughout the Nation. He may have some insight although he's not here for testimony.
    I'm pleased on behalf of the Disabled American Veterans, our over 1 million members of the men and women who served this country and became disabled. The DAV, AMVETS, Paralyzed Veterans of America, and Veterans of Foreign Wars, as you know, have joined together for 12 consecutive years to present the independent budget. In the independent budget, we've addressed under the medical care section, specialized services. Some specialized services are special because of the population they serve, while others are special under section 1706 of 38 United States Code. Because our four organizations work closely together each year, we have agreed to limit our testimony today to specific areas which we're most familiar. You've already heard from Paralyzed Veterans of America and their insight as to the problems in the SCI units.
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    The DAV has been honored with the opportunity to serve on both the Advisory Committee on Prosthetics and Special Disabilities and on the Consumer Council for the Committee on the Care for the Severely Mentally Ill. In the past, prosthetics funding has been centrally based as you heard earlier. As you've heard Mr. Miller mention, this centralized funding base is allowing for an increase in the delayed orders. The delayed orders have increased since 1996 when section 1706 38 U.S.C. was enacted. The increase in delays are unacceptable.
    We're also concerned that with the flat-line appropriation, staffing shortages within prosthetics and sensory aid services are contributing to the increase in. Additionally, funding shortages do not allow for local site visitation, staff training, and monitoring of services delivered. Internal pressures are being placed on clinicians and managers who provide prosthetic sensory aids and the delayed prosthetic order report is unacceptable.
    Mr. Chairman, this dilemma cannot be allowed to continue. Veterans whose orders are delayed and those who cannot timely obtain artificial limbs, supplies and devices, wheelchairs, eyeglasses, hearing aids—are being further delayed in their rehabilitation and return to gainful and competitive employment. In an attempt to fill vacant prosthetic service personnel positions, local VA medical centers are transferring other personnel within facilities who are untrained and unable to fulfill VA's commitment to these men and women who rely on VA healthcare to improve their functional abilities. We recommend that VHA centrally retain sufficient prosthetics and sensory aids funds and allocate those funds—or excess funds—to other VISNs in order to insure that there are no delayed orders.
    VHA also must add at least three full-time equivalents in the strategic healthcare group on prosthetics and sensory aids at VA headquarters. VHA clinicians must be allowed to prescribe prosthetic devices and sensory aids based on medical need and not on cost. VISN Directors must ensure that prosthetics and sensory aids departments are fully staffed by appropriately trained teams and directors. Under seriously mentally ill, and as a member of the Consumer Advisory Committee, the full committee presented its first report in September 1997, making 17 recommendations.
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    As part of this most timely hearing, just want to note a few here this morning. The Committee was asked to review the proposed bed program closures and policy proposals and reinvestment of savings in providing a continuum of care for the seriously mentally ill. The Committee utilized data from the Northeast Program Evaluation Center, NPEC. The Committee has publicized successful consumer programs, both at VA and non-VA. They also asked for the promotion of anti-stigma training related to mental illness for VA medical centers to include personnel from areas other than mental health programs. They also asked for the reviewed policy such as pharmacy protocols and confidentiality guidelines that affect persons with mental illness. They also ask to have an input into the development of measures of customer satisfaction. They want to have mental health measures within the VISN Directors' performance evaluations. The Committee cares for veteran mental health consumer council formation at every VA facility as well as at VISN level. They also want to help develop a nationwide network of VISNs of mental health consumer councils.
    Many of these questions were asked last year and accomplished. But there are a few were not accomplished. In the second report, the Committee continued to ask that VHA staff CBOCs with mental healthcare providers who can meet the special healthcare needs of this specialized service population. They also ask that the Under Secretary authorize a survey of clinical management at all psychiatric facilities that have been consolidated within the last 3 years in order to determine where that money has been spent. Has it gone to mental health? Has it gone to outpatient services? Where has it gone? They also ask that each VISN prepare a brief addendum to their business plan that addresses their achievements and transformation in implementing mental health services.
    The DAV and other service organizations feel that the Medication Formulary is part of access and capacity. As you well know, we asked for a moratorium on the Formulary and a study of its implementation. We're continuing to ask that that the study address questions such as quality devices are being given to persons with specialized disability needs. Are catheters going to leak on a veteran whose confined to a wheelchair. Is the wheelchair going to be delivered in a timely manner. That's something the veterans' organizations are asking that someone address and look into.
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    You also heard today there are many new problems with delivery of specialized services. We're asking that this committee continue to enforce 1706 and not allow the Veterans' Administration to diminish services to specialized veterans. Thank you.
    [The prepared statement of Mr. Wannemacher appears on p. 129.]

    Mr. STEARNS. We have a vote here. We have several things we could do. If you folks would be willing to wait until we've come back. Another possibility is that Mr. Miller and Mr. Warfield could put their opening statements as part of the record and perhaps give an abridged version in the next couple of minutes; we could let each of you have your opening statement. I think from what I see the opening statements are pretty powerful and compelling in themselves. I'm sort of receptive to what you want to do. We have a vote which would be 15 minutes. Then we have another vote after that which would be anywhere from 10 to 15 for those two. So you're looking at 30 minutes before we would reconvene. Now we could adjourn this and come back at 1 o'clock,. I'm very receptive. I would say——
    Mr. MANSFIELD. Mr. Chairman, after a quick review here at the table I think the two folks that haven't testified have the bigger vote. We'd like to come back.
    Mr. STEARNS. Okay. This is a little bit—I think the testimony is just so compelling—it's a little unusual, but I would like Dr. Garthwaite to perhaps stay to listen to this testimony. If in fact he still feels that this is a problem, I'd like to know what he's going to do about it. Because I think this is, the bottomline is, you're giving these compelling arguments. We want to hear from him how he feels and what he's going to do because then Congress obviously has an obligation after hearing this to do something. I mean, that's my take on this. So I think if that's what we'll do, then would you rather wait and get your full opening statements after we come back. Then perhaps why don't we do this so everybody can get some lunch and we can all get things done. We'll be a half-hour voting and then we'll take some lunch. Why don't we reconvene then at 1 o'clock and continue? Will that be satisfactory?
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    Mr. MANSFIELD. Thank you, Mr. Chairman.
    Mr. STEARNS. Okay. Thanks.
    Mr. STEARNS. Perfect. I want to thank the third panel for continuing to stay with us. I appreciate their indulgence and we welcome continuation of the testimony. At this point, Mr. Warfield, your opening statement.

    Mr. WARFIELD. Thank you, Mr. Chairman. I appreciate your patience for allowing us to appear. My name is Bill Warfield. I'm here to represent Vietnam Veterans of America. I will try not to be redundant and duplicative of the excellent testimony you've heard today from my colleagues. I'm honored to be up here with them. We work in these trenches together day in, day out on behalf of veterans.
    On the data testimony, I strongly support and conclude that there are problems with this data. Management systems—I think there are deficiencies there. I agree with my colleagues. There are a couple of other things that I'd like to mention in my statement. Our moral and legal responsibilities are now and always should be to provide the highest and best standards of care in treatment for veterans who gave so much in defense of America. That obligation must not be eliminated nor shirked by those who make our laws at the Federal level and those whose duty it is to enforce those laws.
    A strong perception and reality has surrounded this government like a deadly fog as part of the general lowering of government's priorities and ranking of care and concern about our veterans. This sad decline became a reality when the majority of the Congress and the President this year took scarce budgetary resources from VA—estimated to be $15 billion for payment of disabled veterans, widows and orphans. They used it to payoff high-rolling transportation interest group projects. Those of us who work everyday to protect those who were wounded in line of duty must make our voices heard loud and clear by the Americans who vote in November. We need to elect members who will support veterans.
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    The ongoing trend of reductions in VA budget resources continues. As we speak, there's a Kasich budget plan that will have adverse effects on future 5-year budget projections for VA. These trends are especially troublesome for special needs programs, such as medical care for seriously mentally ill and PTSD treatment. What will happen when the supply and quality of medical services for people who suffer from serious mental illness, veterans, and related chronic conditions and reduced disability ratings are imposed by VA?
    I would like to move away from the data because you've had adequate testimony on the data. Really sort of conclude by saying that we could not disagree more forcefully with a policy which is totally driven in the wrong direction. This is a dollar-driven policy. Such bottomline policies will produce adverse consequences nationally for special care needs. They are shortchanging veterans everywhere, in every category. But they are especially harmful for veterans who are poor and who suffer multiple health problems related to mental illness. VA is not solely responsible for this retreat from our 200-year Federal commitment to care for veterans.
    Other players like OMB, and CBO has forced the VA budget into near starvation. All in the name of deficit reduction, but at what cost? Should the health and well-being of veterans be transferred to Blue Cross/Blue Shield, Kaiser Permanente—there are many on the Hill who have told me that they should be—or even State and local government? We say a resounding no. But the end results of consolidations, decentralization, and cost reduction is by default shifting the burden and responsibility for the care of veterans who earned that care to non-VA programs.
    Worse yet, those hardest hit are veterans who once got good care and needed at least some inpatient support to receive therapy. We've heard today that in many VA VISNs and facilities, inpatient treatment and care for residential PTSD and the seriously mentally ill is a vanishing commodity. We certainly regret that. We have confirmed the numbers of homeless veterans is growing. In fact, more than 275,000 veterans are estimated to be homeless on any given night of the year. Despite this shocking fact, less than 3 percent of all of the more than $1 billion spent every year by HUD is allocated for veterans who are homeless. The myth that the VA is meeting all of the needs for all of America's veterans is still pervasive, but it's very wrong. Only 10 percent of the veterans receive even moderate care now.
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    We urge this committee to work with us and other VSOs to do more in-depth, impact field and case management studies to find out the true impact of these changes. The best way to get the truth is for you, as representatives which you've done, to go to your districts to visit first-hand VA hospitals, clinics, vet centers. In your home areas, talk to veterans who use the VA healthcare system. Talk to the local healthcare providers who care for veterans, and talk to VSO service reps who have great insight. Make your own studies, conclusions, and fact-finding missions. Listen to the real people back home and discount most of the inside the beltway, bureaucratic, mumbo-jumbo and academic nonsense.
    That concludes my statement. I'll be glad to answer questions. Thank you, sir.
    Mr. STEARNS. Thank you, Mr. Warfield. Would staff just take his name tag and just put it up if you would. Mr. Miller, we welcome you again with your opening statement.
    [The prepared statement of Mr. Warfield appears on p. 134.]


    Mr. MILLER. Thank you very much, Mr. Chairman. I don't know what Bill had for lunch, but I don't think I had the same thing. We try to get him excited. Mr. Chairman, I would like to thank you from the Blinded Veterans Association for holding this very, very, very important hearing. We're very concerned about the specialized program and services VA offers for our Nation's blinded veterans the impact the new VHA—and reorganization—is having on those programs.
    I was very gratified this morning to hear Dr. Garthwaite acknowledge—at least in the sense that there may be problems—by announcing the establishment of a special panel to look into the blind rehabilitation programs and services. We certainly pledge to work closely with that group and hopefully we'll be a part of that and can come up with some solutions to determine just how the specialized programs can fit into the veterans' integrated network concept.
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    In my written statement that request be submitted for the record, I went into some detail regarding the three distinct programs the VA offers for blinded veterans. I think in some of the data collection, problems that were identified earlier and that we discussed—it's difficult when you look at their data to distinguish between programs and programs within programs which is very important when it comes to capacity. The three distinct programs of blind rehabilitation centers which are residential or inpatient comprehensive blind rehab programs.
    The visual impairment service team program, which you heard Dr. Gross refer to, those are managed care, case-managed ambulatory care programs to ensure the comprehensive delivery of service to blinded veterans. In a new program, the blind rehabilitation outpatient specialist is also an outpatient program. Some of the data that VA collects rolls all those numbers together so it's impossible to determine whether there's been a negative impact on the inpatient residential program because of other numbers that are folded in with that. So we feel that it's imperative that data collection and data management problems be identified, clarified, and worked out on a national basis. There needs to be consistency across the system.
    One of the most frustrating things for us has been with the organization of the VA system and the 22 integrated service networks is that the differences that have occurred, the level of understanding from network to network about our programs, what they do, and what the expected outcome should be. Some network directors have stated openly they don't understand why blind rehabilitation can't be done on an outpatient basis. It's too costly to put a blinded veteran into a hospital and keep him in a residential program for 4, 6, 8, 10 weeks—whatever the length of the program may be.
    As a consequence, there are a couple who are in fact discouraging referral to the residential programs and insisting that the coordinator's refer blind veterans to local resources which are totally inadequate to meet the comprehensive needs and are certainly not comparable to those of the VA. Others have mentioned the decisions that are being made are cost-driven. Our concern with the blind rehabilitation program—the inpatient services—in an effort to increase capacity, they're reducing—increasing pressure to reduce the length of stay. The length of stay of the program is critical as to whether the veteran is going to optimize benefit from that program.
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    This is an example. I went through VA's blind rehab program 30 years ago—I know I don't look that young—but the average length of stay at that time was 18 weeks. Now, we're looking at around 8 weeks. That's a substantial reduction in length of stay. For the most part, that's happened naturally because of the change in the veteran population that they're dealing with in the blind centers and they've modified and adjusted programs to address the current needs of—excuse me—being served. Unfortunately, local managers are increasing pressure to reduce those length of stays even further.
    Our vets coordinator positions are absolutely crucial to identify blinded veterans, plugging them into the system, and assuring that they're getting the services that they need to overcome the handicap of blindness. When some of those positions become vacant, the first thing local managers are looking at is eliminating them altogether or reducing them to half-time. We've got 30 years of experience with that program. The first six were with those coordinators functioning part-time. We learned very quickly that part-time was not adequate.
    Back to the blind center, Dr. Garthwaite we're celebrating the 50th anniversary of the VA blind rehabilitation service and the first blind rehab center that was opened in Hines, Illinois. We have 50 years of experience. We have a program that's been the premier provider of residential blind rehabilitation in the world. The VA has served as a model around the world for other countries to develop their services for their blind citizens. We know it works; we know, once outcome data is available that will validate the anecdotal information and what we all know, those of us who've had the opportunity to go through those programs can tell you about the quality.
    Finally, I think I'd like to conclude by reinforcing that these are national programs. There needs to be national standards and national guidelines, and some mechanism to monitor the funding of these programs on a national level. It's unfortunate that as a national program the full burden falls on the local medical center. When they have to take reductions in their FTE, they do it across the board so that a blind rehab center will have to take its share of the cuts. Well that center doesn't serve only that local hospital, it serves the entire network, multiple networks and maybe up to 30 or 40 medical centers in their geographic catchment area. So that burden needs to be shared.
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    I don't believe the funding mechanisms at this point are adequately compensating, reimbursing the local facility so they can take a heavy responsibility fiscally to maintain these specialized programs. If not central funding, some other mechanism has to be developed in order to relieve them of that burden to enable them to allow these programs to function with optimum staffing levels and resources so that they can maximize the number of veterans that go through the program without compromising the quality of the service. That concludes my statement, Mr. Stearns. I'd be glad to answer any questions.
    [The prepared statement of Mr. Miller appears on p. 145.]

    Mr. STEARNS. I thank you, Mr. Miller. As you know before we broke, I mentioned that we would like Dr. Garthwaite to come back. He has indicated he cannot come back and I didn't push it. But he has said he is committed to providing a response to some of what I believe is compelling arguments that you make here this afternoon. Myself and staff are going to follow-up with him with some questions, and ask him for specific steps that the VA should take to solve the problems we've heard about today. So I think your testimony has been very helpful. We appreciate you coming.
    (See p. 159.)
    Mr. STEARNS. I have a few questions. I'll just give you my thought on an overview here. We have another vote in less than 15 minutes. What I'd like to do is go around shortly with some of my questions. Then my colleague from Florida, Mr. Bilirakis, let him ask some questions. But we're sort of moving towards the idea of adding legislatively some appropriate performance measures for the VISN Directors and hospital directors' performance contracts. I guess the question I would have, Mr. Mansfield, is do you think possibly legislative measures regarding appropriate performance measures for VISN Directors' and hospital directors' performance contracts would make a difference?
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    Mr. MANSFIELD. Mr. Chairman, I think it would. There are some concerns, you know, about how far down the management ladder you can go, and what you can do in legislation—how would you make that work. But I think that Congress has to make sure that managers in the VA understand all the way down as far as you can go that they've got to take care of veterans with specialized needs. That's what their mission is. If performance measures are what they're paying attention to, and unfortunately, I think in the new system that's what they are paying attention to, then we probably need to affect the things that affect them. I would say yes, let's go ahead.
    Mr. STEARNS. I came from the private sector. Whenever large corporations or small corporations ran into problems that they could not get sufficient objectivity, they would go to Price Waterhouse. Or they would go to MacKenzie Consulting Companies and ask them to come in to do something. Now we have the GAO doing a report. A lot of people would argue that the GAO would do a good job. But others will argue that maybe we might even need a more objective outside professional accounting firm. The GAO is going to point out the problems, but they're not necessarily going to come up with the solutions.
    So, frankly I see the problem as a little bit of consistency of performance standards bearing management ability here. I'm very sympathetic to the fact that the balanced budget put a constraint on the cost here. I'm not sure what I can do about the latter. But I would suggest that we need some more information and perhaps legislatively, the performance measures would be good. But perhaps even having an outside consultant come in and tell us from a management standpoint what could be done. Let me switch to Ms. Garrick. How would you grade VA compliance with the ''maintain capacity'' requirement at the VISN level?
    Ms. GARRICK. How would I grade it?
    Mr. STEARNS. Yes. How would you grade the VA's compliance? In other words, in your opinion is it an F or an A or C?
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    Ms. GARRICK. Well, it sounds like it's hovering somewhere just above an F.
    Mr. STEARNS. I mean, that's—from our testimony, we just wanted to help you quantify your feelings.
    Ms. GARRICK. Well, obviously, the American Legion is disappointed in that we do see capacity as not being equitable. With equity being such an influence in the budget under VERA—VERA is supposed to be about equity—well, so should capacity and access and timeliness and quality. Those things should also be about equitable distribution. If there are veterans and VISNs, like 8 and 18, Florida and Arizona where there's no long-term mental health, that's not equity. That's not equity in capacity and it certainly isn't equity in quality.
    Mr. STEARNS. Let me just ask each of you. If I recommended that the VA obtain an independent management review to corroborate the information, would any of you have an objection to that? Going outside? Yes, sir, Mr. Warfield.
    Mr. WARFIELD. Yes, sir. If I may, with all due respect. There have been probably 15 or 20 outside consultant firms, including Price Waterhouse, NAPA studies—the Appropriations Committee frequently does this. VSOs have done this. There have been internal studies. There's voluminous documentations——
    Mr. STEARNS. On this subject?
    Mr. WARFIELD. Yes, sir. Sir, I think we know the problem. We've identified the problem here. I think it can be documented. I think that we also have touched on the solutions to the problem today. I think that going down to the—as I recommended in my testimony—go down to the local level and talk to the people who are using the services and practitioners who are delivering this service. You can find out pretty easily what's gone wrong.
    Mr. STEARNS. You think the idea of us legislating performance standards with both the VISN Directors and also the administrators of the hospitals would help?
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    Mr. WARFIELD. No, sir. It's already being done. There are 24 different standards. As an example to those performance standards, the VISN Directors will administer certain diagnostic tests on mental illness; put it in the file, and have a 97 percent compliance rate for performance and receive perhaps a bonus award for doing that. So follow up of mandatory or statutory performance standards, is well-intentioned, reasonable, but it's not really going to be implemented by a bureaucratic, uncaring agency.
    Mr. STEARNS. So you're saying we have to go down to the grass root level.
    Mr. WARFIELD. That's my recommendation. Yes, sir. Field hearings——
    Mr. STEARNS. Implement it?
    Mr. WARFIELD. Yes, I do.
    Mr. STEARNS. That's how you sum it up. Okay, Mr. Bilirakis.
    Mr. MANSFIELD. Mr. Chairman, I think you indicated you're going to ask each one of us to respond to that question.
    Mr. STEARNS. That's fine. Okay. We have probably about 7 minutes to vote.
    Mr. MANSFIELD. Real quickly, I would say this. I understand where my colleague's coming from. But I would suggest we work on two fronts. Number one, I think you know what you need to move this Congress to act and if you think mandating performance measures is part of it, then it might be a plus. The second thing is, rather than just talking about the capacity issue here, by itself here it might be time for the Congress to study this whole change that's going on within the VA, including the move to VISNs. In the context of that, if you did it, I think if you looked at the programs we're talking about here as national programs and examined what happened to them in this change, it might be important.
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    Mr. STEARNS. Okay, Mr. Bilirakis.
    Mr. BILIRAKIS. Well, Mr. Chairman, I guess the big problem as I see it is veterans' healthcare and veterans' programs getting caught up in the political picture where you have changes every so often in administrations which means changes in terms of the Secretary. But you know, when we talking about maintaining and meeting the requirement for specialized services. Let me go to the SCI Center in Tampa, for instance. I understand that VA has at least one representative in the audience taking all this in, which is good.
    I have visited that center many times over the years. They have so many beds for SCI patients. The beds are not enough because of the wide area they cover. Someone would say, well it has 70 beds. We've been maintaining those 70 beds, et cetera, et cetera. Yet those beds are scattered over many floors—not all on the first floor where there should be. If there is a fire or something like that, God forbid, at Haley, I don't know, Gordon, if we could ever evacuate those people. I know they've been up to as high as the 5th floor. We're talking about SCI patients being evacuated from the 5th floor of the hospital. Now I think they're only going up about two floors right now. This expansion that we're talking about would have the SCI center on the first floor where it should be. So, you know, again if we take a look at, or we talk about data, we take a look at statistics and things of that nature that data or the statistics might meet the requirement. But really in practice in the real world, is the requirement being met when they're scattered throughout all these areas. I think it's probably what Mr. Warfield is saying and the rest of you that it's got to be down at that particular level.
    Mr. STEARNS. Yes, sir.
    Mr. BILIRAKIS. Well, we're going to do the best that we can here. But you know, the trouble is we change all the time, too. You have a chairman of the subcommittee—who knows next session whether he would be the chairman or there might be a change. I guess that's really what makes the job so darn difficult for everybody, including the people in the VA and the fact that there are changes that constantly take place.
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    Mr. STEARNS. Well, I didn't get to hear all your testimony because it's a heck of day for me, as it is for all of us but we thank you. It's obviously been very helpful.
    Mr. WANNEMACHER. Could I just say one thing?
    Mr. STEARNS. Yes, sir.
    Mr. WANNEMACHER. If you are going to do performance measures, make sure that performance measures also address seriously mentally ill. I mean, how they're treating seriously mentally ill veterans. What I think Bill was talking about, though—going to the grassroots—we don't hear a lot, the DAV doesn't hear a lot from our veterans as far as improper care problems. Only because at the front door, they are told this is the way it's going to be and this is what you're going to get. They've accepted that. They go outside for other services.
    But if you—well, like what Bill was saying—if you went to the grassroots. I have physicians that are calling me from throughout the Nation, VA physicians, telling me the horror stories out in the State of Washington, down in the State of Florida, out in Utah. There is a real problem out there about morale within the system. These people, because they're short-staffed, just don't feel that they're being provided the tools and the time to provide quality healthcare. You've got to go to the grassroots. Not from some analysis from here—what you read in the directives from Dr. Kizer, read real well. But the implementation of these directions in and there impact in the field is eye opening.
    Mr. STEARNS. I had a hearing out in Boise, ID.
    Mr. WANNEMACHER. You know what you heard there.
    Mr. STEARNS. That was an eye-opener. So I understand it. Again, thank you for staying over for the reconvening. We have to rush to a vote. I appreciate your testimony. We'll stay in touch here.
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    Mr. MILLER. Thank you, Mr. Chairman.
    Mr. WARFIELD. Thank you, Mr. Chairman.
    [Whereupon, at 1:26 p.m., the subcommittee adjourned subject to the call of the chair.]