[Senate Hearing 107-791]
[From the U.S. Government Publishing Office]
S. Hrg. 107-791
OVERSIGHT HEARING ON THE INTEGRATION OF VETERANS INTEGRATED SERVICE
NETWORKS 13 AND 14
=======================================================================
FIELD HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
MAY 13, 2002
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JOHN D. ROCKEFELLER IV, West Virginia, Chairman
BOB GRAHAM, Florida ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska KAY BAILEY HUTCHISON, Texas
William E. Brew, Chief Counsel
William F. Tuerk, Minority Chief Counsel and Staff Director
(ii)
C O N T E N T S
----------
May 13, 2002
SENATORS
Page
Nelson, Hon. E. Benjamin, U.S. Senator from Nebraska, prepared
statement...................................................... 3
WITNESSES
Bereuter, Hon. Doug, a U.S. Representative in Congress from the
State of Nebraska.............................................. 4
Prepared statement........................................... 6
Bernhardt, Elaine, President, AFGE Local 2601, Grand Island, NE.. 21
Prepared statement........................................... 22
Bove, Jerry P., State Commander, The American Legion, Department
of Nebraska.................................................... 38
Braman, Howard, Commander, Disabled American Veterans............ 34
Cada, Jim, State Commander, Military Order of the Purple Heart,
Nebraska Department, Lincoln, NE............................... 29
Prepared statement........................................... 30
Crawford, Mike, Engineering Employee, Nebraska-Western Iowa
HealthCare System (NWIHC), Omaha, NE........................... 24
Enenbach, Craig F., National Director, Great Plains Paralyzed
Veterans of America............................................ 41
Fickenscher, Keith, Immediate Past Director, Veterans Affairs for
Nebraska....................................................... 26
Hilgert, John, Director of Veterans Affairs, State of Nebraska... 13
Kulm, Greg, on behalf of the Military Order of the Purple Heart.. 40
Martinez, Al, State President, Vietnam Veterans of America and
Legislative Coordinator........................................ 35
Prepared statement........................................... 36
Potter, Jane F., M.D., Harris Professor of Geriatric Medicine,
Chief, Section of Geriatrics and Gerontology, Department of
Internal Medicine, University of Nebraska Medical Center,
Omaha, NE...................................................... 31
Prepared statement........................................... 32
Principi, Hon. Anthony J., Secretary of Veterans Affairs......... 7
Prepared statement........................................... 10
(iii)
OVERSIGHT HEARING ON THE INTEGRATION OF VETERANS INTEGRATED SERVICE
NETWORKS 13 AND 14
----------
MONDAY, MAY 13, 2002
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to notice, at 10:12 a.m., the
Alumni Center Building, University of Nebraska at Omaha, 6500
Dodge Street, Omaha, NE, Hon. E. Ben Nelson presiding.
Present: Senator Nelson.
Senator Nelson. [Raps gavel.] I've always seen Chairman
Rockefeller do that and I always had the desire to do that and
now I have just done it and this morning I would like to thank
you all for being here and call to order this field hearing of
the Veterans' Affairs Committee of the U.S. Senate. I would
like to thank everyone for your attendance here today and for
the opportunity to learn and to discuss more about the services
our veterans have earned and receive here in Nebraska.
For the veterans in the room, I want to give you my
personal thanks and thanks on behalf of everyone for your
service and your sacrifice. Your service and sacrifice give us
the freedom to express our opinions as we will do here today.
I would also like to thank my friend Secretary Principi for
his attendance, and his staff as well, for taking the time out
of what is obviously a very busy schedule for being here today
to listen to Nebraska's veterans. Special word to Jim Cada, my
classmate from law school; he'll be testifying here with the
second panel, and I want to thank Jim for everything that he
has done to help make this possible today as well.
As a matter of housekeeping items, we'll hear testimony
from 14 witnesses on three panels today. That's an aggressive
effort. And although we couldn't accommodate everyone who
wanted to testify, we have tried to present a broad spectrum of
veterans experts and veterans affairs. I apologize to those
that we were unable to accommodate. We've got a signing
specialist here today, if I could see a show of hands today for
those who may need the services of a sign language interpreter?
Is there anyone who has a special challenge that would need
these services because she could come closer? I guess we're in
good shape, and we appreciate very much you being here today.
If you have cell phones with you, could you please switch
them off ring to vibrate, so that we don't have any unnecessary
interruptions as a result. I notice that if one of those
vibrates or one of those rings these days, everybody jumps for
theirs, they feel guilty, thinking maybe it's theirs. I'm
fortunate I haven't had mine ring in a hearing or anything like
that, but I have seen it happen to various other people. If you
would, please put them in the vibrator or off position.
Today we are holding a field hearing on the issues and
concerns relating to the integration of VISN's 13 and 14, and
for the benefit of us all, I want to review how it is that we
came to the decision to call for a field hearing.
On December 11rd, I received a letter from Secretary
Principi stating that he had asked for the Veterans Health
Administration to conduct a review of the possible merger of
VISN's 13 and 14 and I also received a draft copy of the
Administration findings.
Then on January 23th, I received another letter from the
Secretary stating that he had approved the integration and that
it should be conducted as rapidly as possible.
On the same day a press release was issued by the
Department of Veterans Affairs announcing the decision to
integrate the VISN's and that Dr. Petzel, who is here with us
today, was selected to be the interim network director of the
proposed VISN 23. In addition to the letter, Undersecretary
Laura Miller conducted a staff briefing in DC about the
consolidation.
On January 24th, I sent a letter to the Secretary and Dr.
Petzel addressing my concerns with merging both VISN's. At the
same time my colleague and my friend, Congressman Bereuter, was
also directing a letter raising concerns about the integration.
I didn't understand why speed was necessary in the process
before we could fully understand the ramifications of
integration and why there wasn't time to begin dialog on the
issue. There are over 450,000 veterans in VISN 14 with a vested
interest. We were not informed of how the merger would affect
their earned care, how it would affect the quality and quantity
of their care, or if there would be any effect at all. We also
felt that elected representatives weren't given the time or
evidence in order to adequately address these concerns.
So on February 14th, we held a Veterans' Affairs hearing in
the U.S. Senate. I thanked the Secretary for his help on the
Grand Island Veterans Nursing Home facility where he had been
very responsive. I invited him to Nebraska for a field hearing
to address Nebraska's concerns about VISN integration. The
Secretary at the time said he would be honored to come, and he
kept his word.
On March 25th, the Secretary assured me that the services
provided to Nebraska's veterans would not be affected by the
merger.
This brings us up to date, for the record, of what happened
and why we are all here today. It brings us up to date on the
issue, but unfortunately there's still lingering questions and
concerns about how care might be affected and if the decision
to integrate is warranted.
There have been at least two other studies prior to the
most recent one in late 2001 on whether or not VISN's 13 and 14
should be integrated. Both concluded that there was not a
substantial cost savings to warrant the merger and now we're
under the impression that somewhere between $650,000 and $1
million may be saved. Obviously, there's no guarantee that
there will be a savings in this situation, or at least, there
was no guarantee in the study. This adds up to about 1 percent
of the VISN's 13 and 14 combined budget, which leaves
speculation about what VISN 23's budget will actually be.
It appears that there are many sound arguments for not
integrating and as far as I can tell maybe three reasons to
integrate; cost savings, consolidated leadership, and
consolidating two large geographic but lightly populated areas.
Last year VISN 14 had a patient satisfaction rate of 64
percent, which is 2 percentage points above the national
average, yet it failed to meet the 45-day fully successful
standard in 3 out of 6 clinics. This leads me to believe that
Nebraska veterans are patient and pleased with their care, so I
am deeply concerned when I get letters from veterans in
Nebraska that say the veteran health care system in Nebraska
may not be as it should be. So I hope that these rates climb
this year because the quality of care and the time it takes a
veteran to receive care will be the true test of whether this
merger is the right decision.
VISN 23 would encompass 429 counties and 12 different
States serving over 1 million veterans. The decision to
integrate has, unfortunately, already been made. I know that
Secretary Principi has the best interests of veterans at heart,
but the process in making the decision, in my opinion, should
have included something similar to what we are doing today. But
better late than never, so we are here to help veterans, and
their representatives, become better informed about their care
givers on how and why this process is going to proceed as well
as soliciting opinions on if it is necessary. The good of our
veterans should always be our goal as public servants.
In order to allow everyone to voice their opinions to gain
more information, opening statements will be limited to 5
minutes and we have brought one of our verbal traffic lights
here from DC which has always mesmerized me. When the red light
is on, you've exhausted your 5 minutes.
[The prepared statement of Senator Nelson follows:]
Prepared Statement of Hon. E. Benjamin Nelson, U.S. Senator From
Nebraska
Good Morning. I would like to thank all of you for
appearing here today to discuss the services our veterans have
earned and receive here in Nebraska, For the veterans in the
room, it is thanks to your service and sacrifice that we have
the freedom to express our opinions, as we will do here today.
I would also like to thank Secretary Principi and his staff for
taking the time out of their busy schedule to visit with
Nebraska's veterans. Jim Cada is also here today, he will be
testifying here with the second panel, and I want to thank you
for everything you have done to make this hearing possible.
Today we hold a field hearing on the issues and concerns
relating to the integration of VISNS 13 and 14. For the benefit
of all of us, I want to review how it is that we came to the
decision to call for a field hearing.
On December 11th, I received a letter from Secretary
Principi stating that he had asked the Veteran's Health
Administration to conduct a review of the possible merger of
VISNs 13 and 14. I also received a draft copy of the
administrations findings.
On January 23rd, I received another letter from the
Secretary stating that he had approved the integration and that
it be conducted ``as rapidly as possible.''
On the same day a press release was issued by the
Department of Veterans Affairs announcing the decision to
integrate the VISNs and that Dr. Petzel, who is here with us
today, was selected to be the interim network director of the
proposed VISN 23. In addition to the letter, Undersecretary
Laura Miller conducted a staff briefing in D.C. about the
consolidation.
On January 24th, I sent a letter to the Secretary and Dr.
Petzel addressing my concerns with merging both VISNs, I did
not feel and did not understand why speed was essential in the
process before we could fully understand the ramifications of
integration. And why there was not time to begin dialogue on
the issue. There are over 450,000 veterans in VISN 14 with a
vested interest that were not informed of how the merger would
affect their earned care. Elected representatives were not
given enough time, discussion, nor evidence in order to
adequately address their concerns either.
On 14 February, we held a Veterans' Affairs hearing in the
United States Senate where I thanked the Secretary for his help
on the Grand Island Nebraska Veterans' Nursing Home facility
and invited him to Nebraska for a field hearing to address
Nebraska's concerns about VISN integration.
On 25 March, the Secretary assured me the merger would not
affect veterans' services in Nebraska.
This brings us up to date on this issue but unfortunately
there still exist many lingering concerns about how care will
be affected and if the decision to integrate is warranted.
There have been at least two other studies prior to the
most recent in late 2001 on whether or not VISN's 13 and 14
should be integrated. Both concluded that there was not a
substantial cost savings to warrant the merger. Now we are
under the impression that somewhere between $650,000 and
$1,000,000 may be saved but there is no guarantee of a savings
in this study either. This adds up to about 1 percent of the
VISN 13 and 14 combined budget. Which leaves speculation about
what VISN 23's budget will be.
It appears that there am many sound arguments for not
integrating and as far as I can tell maybe three reasons to
integrate; cost savings, consolidated leadership, and
consolidating two large geographical but lightly populated
areas.
Last year VISN 14 had a patient satisfaction rate of 64%,
which is 2 points above the national average, yet it failed to
meet the 45-day fully successful standard in 3 out of 6
clinics. This leads me to believe that Nebraska veterans are
patient and pleased with their care so I am deeply concerned
when I get letters from veterans that say the veteran health
care system in Nebraska is not as it should be. I hope those
rates climb this year, because the quality of care and the time
it takes a veteran to receive care will be the true test of
whether this merger is the right decision.
VISN 23 would encompass 429 counties and 12 different
states serving over 1 million veterans. The decision to
integrate has unfortunately already been made, and I know that
Secretary Principi has the best interests of veterans at heart,
but the process in making the decision should have included
something similar to what we are doing today. Informing
veterans, their care givers, and their representatives on how
and why this process is going to proceed as well as soliciting
opinions on if it is necessary and good for our veterans should
always be our goal as public servants.
In order to allow everyone to voice their opinions and for
us to be successful in gaining more information about today's
subject of integration from different experts, opening
statements will be limited to 5 minutes. We have brought one of
our verbal traffic lights here from D.C. Obviously when the red
light is on you have exhausted your five minutes.
Secretary Principi, again, welcome to Nebraska, and I look
forward to hearing your comments.
Senator Nelson. Before we begin, I would ask my friend and
colleague, Congressman Bereuter, if he would have an opening
statement to make? We appreciate very much his being here today
as well.
STATEMENT OF HON. DOUG BEREUTER, A U.S. REPRESENTATIVE IN
CONGRESS FROM THE STATE OF NEBRASKA
Mr. Bereuter. Senator Nelson, I appreciate the fact that
you are holding this hearing here and that you invited me to
participate when I expressed my concerns similar to your own. I
had a full day of meetings scheduled in Lincoln, but we have
rearranged things. I won't be able to stay for much of the
hearing, but I want to learn as much as I can in the brief time
available and also to share some thoughts about this subject.
Secretary Principi, we very much appreciate your attendance
here, you and your staff, all of the distinguished witnesses,
veterans leaders and the people that support them and their
families today. The subject, of course, is the proposed merger
of VISN, V-I-S-N, Veterans Integrated Service Network. I happen
to think that the primary problem underlying it however is the
VERA program, which is Veterans Equitable Resource Allocation
system which isn't equitable in my judgment and that's the
basic problem we're having today in this part of the country.
And so I wrote to Secretary Principi in January and I believe
that's about the same timing of your expressed concern,
Senator, and I do oppose the merger which was officially
announced.
I think unfortunately the VA simply has not presented a
strong case that the merger will improve the service for
Nebraska's veterans or that it will result in addressing the
ongoing funding shortfalls which have plagued both VISN's.
Indeed, VISN's 13 and 14 have a combined shortfall of $92.7
million for fiscal year 2001, but a consultant's study not too
long ago suggested that there is no cost effective efficiency
resulting from the proposed merger. That's not too long ago
that that statement was made. And, of course, the merger
savings are said to be or projected to be somewhere between $1
and $6 million now. That's in contrast to what was said
earlier.
Immediately upon receiving that information about the
merger, I sent a letter to the Secretary to protest the merger.
In the response which I received from the Secretary he stated
that the merger in and of itself will not bring financial
stability to the two VISN's, and I agree with that.
Subsequently, I therefore must ask two questions: (1) Why does
the VA plan to simply restructure the VISN system rather than
find a long-term solution to the continuing financial
shortfalls facing VA facilities in the midwest, especially the
Northern Great Plains, and (2) what value does the merger add
to the quality of service which veterans in our Heartland will
receive?
I would note that I believe the current VISN structure is
not the primary reason for the financial woes that VISN 14 and
VISN 13 face and which VISN 23, that's a new one, would now
face. Indeed, I have been a long-term outspoken opponent of the
badly misnamed Veterans Equitable Resource Allocation system,
or VERA. Through VERA, the VA distributes its health care
budget on the basis of a per capita veterans usage of
facilities, not basic health care facility needs or geographic
considerations. For sparsely populated States such as Nebraska,
this is simply unfair to veterans who are entitled to VA health
benefits and who are forced to drive many miles to receive this
care.
In a letter to the Secretary that I sent, I would like to
quote from it. When the Clinton administration constructed
these arbitrary regional divisions and subsequently instituted
the VERA system, I also strongly protested that these policies
would negatively impact health care services to veterans in
rural areas. Allocating veterans health care funds on a veteran
per capital basis is unbelievably discriminatory for sparsely
settled States like Nebraska. I and other representatives in
Congress from such States have tried unsuccessfully to alter
this formula since it was announced. Every veteran, no matter
where he or she lives, deserves equal access to VA medical
services, equal to those living in sun-belt States. As we see
this migration of veterans to the southland, we're left here
with less and less veterans and yet we have to provide the full
degree of veterans care that the Nation has promised its
veterans in these settled parts of the country. So we voted on
this issue on three or four occasions on the House floor, but
it runs into a strictly geographic kind of vote and the
veterans in New York or New England also have some of the same
concerns, but it is particularly acute for the people who live
in the Northern Great Plains. So I think that's the basic
problem that VISN's has today. You cannot simply provide
adequate health care to the veterans of the Northern Great
Plains on a per capital funding basis. That is just too
simplistic. It is not the way that we should do things in this
country.
So you can have a merger between VISN 13 and 14, but that
just is a little attempt to adjust numbers and to write a few
efficiencies if that and the basic problem is the VERA system,
it needs to be abandoned. It should have been abandoned by the
Clinton administration. It should be abandoned by the Bush
administration and something more equitable determined. So
those are my concerns. I feel very strongly about that because
my veterans are not receiving the same health care
opportunities that veterans in other parts of the country
receive and that is because of a discriminatory VERA system. So
we can look at VISN today and we know that's the primary focus,
but the basic problem is the VERA program.
Senator Nelson, thank you very much for giving me a chance
for me to speak and to listen on this subject. I think that you
do us a great service by giving this careful scrutiny today and
I thank you for your initiative and I would be pleased now to
hear from the Secretary and the other witnesses.
[The prepared statement of Mr. Bereuter follows:]
Prepared Statement of Hon. Doug Bereuter, a U.S. Representative in
Congress From the State of Nebraska
Mr. Chairman, I would like to express my appreciation to
the Senate Veterans' Affairs Committee for convening this field
hearing in Nebraska. Additionally, I would like to commend my
colleague in the Nebraska Congressional Delegation (Senator Ben
Nelson) for his efforts to highlight the issue before us today.
Indeed, the merger of Veterans Integrated Service Network
(VISN) 14, which includes Nebraska, Iowa, and western Illinois,
with VISN 13, which includes Minnesota, North Dakota, and South
Dakota, is a topic which certainly deserves greater examination
by Congress and more detailed explanation on the part of the
Veterans Administration (VA).
I strongly oppose the merger which was officially announced
by Department of Veterans Affairs (VA) Secretary Anthony
Principi on January 23, 2002. Unfortunately, the VA simply has
not presented a strong case that the merger will improve care
for Nebraska's veterans or that it will result in addressing
the ongoing funding shortfalls which have plagued both VISNs.
Indeed, VISNs 13 and 14 have a combined shortfall of $92.7
million for FY2001.
Immediately upon receiving information about the merger, I
sent a letter to VA Secretary Anthony J. Principi to protest
the merger. In the response, which I received from the VA,
Secretary Principi stated that ``the merger, in and of itself,
will not bring financial stability to the two VISNs.''
Subsequently, I must ask two questions? (1) why does the VA
plan to simply restructure the VISN system rather than find a
long-term solution to the continued financial shortfalls facing
VA facilities in the Midwest, and (2) what value does the
merger add to the quality of service which veterans in our
heartland will receive?
I would note that I believe that the current VISN structure
is not solely to blame for the financial woes which VISN 14 and
VISN 13 faced and which VISN 23 must now face. Indeed, I have
been a frequent and outspoken opponent of the Veterans
Equitable Resource Allocation (VERA) system. Through VERA, the
VA distributes its health care budget on the basis of a per
capita veterans usage of facilities, not basic health care
facilities needs or geographic considerations. For sparsely
populated states such as Nebraska, this is simply unfair to
veterans who are entitled to VA health benefits and who are
forced to drive many miles to receive care.
During the House Floor debate on the VA, Housing and Urban
Development (HUD), and Independent Agencies appropriations bill
for FY2002 (H.R. 2620), I spoke in favor of an amendment
offered by Representative Rodney P. Frelinghuysen (R-NJ) which
would have prohibited the use of funds in the bill for
implementing the VERA system. Unfortunately, and to my dismay,
the Frelinghuysen amendment was withdrawn, and, therefore, the
House did not vote on it. Such amendments have been defeated
during the past several years, and I suspect Mr. Frelinghuysen
wanted to avoid still another defeat on a recorded vote.
Mr. Chairman, the health care needs of our military
veterans must be met to the fullest extent possible. Veterans
fought to protect our freedom and way of life. As they served
our nation in a time of need, the Federal Government must
remember them in their time of need. The people of the U.S. owe
our veterans a great deal and should keep the promises made to
them. I look forward to hearing Secretary Principi's responses
to the questions I have raised and any other insights he might
provide on the future of the misbegotten VERA system now in
effect.
I am committed to ensuring that Nebraska's veterans receive
the benefits they deserve--benefits they have been promised and
which the American people support. The VERA system stands in
the way of meeting that commitment to the veterans of Nebraska
and other sparsely settled states of the Northern Great Plains
and the northern states in the Rocky Mountain region of our
country.
Thank you.
Senator Nelson. Thank you, Congressman Bereuter.
Our first panel is a very distinguished panel. First of
all, we have Secretary Anthony J. Principi, who is the
Secretary of the U.S. Department of Veterans Affairs; Dr.
Robert A. Petzel, the Acting Director, Veterans Integrated
Service Network No. 23; Gary Nugent, is the Chief Executive
Officer, VA Nebraska-Western Iowa Health Care System; and John
Hilgert, former State senator, Director of the Nebraska
Department of Veteran Affairs.
Once again, Secretary Principi, it's a real pleasure to
have you in Nebraska and we are very anxious to learn from you
and help you learn from us.
STATEMENT OF HON. ANTHONY J. PRINCIPI, SECRETARY, DEPARTMENT OF
VETERANS AFFAIRS
Mr. Principi. Thank you, Mr. Chairman, Mr. Bereuter. It is
certainly a pleasure to be with you. I thank you so much for
your kind invitation to visit Nebraska to attend this field
hearing. I'm pleased to be accompanied by Dr. Petzel, our
acting Network Director, Network VISN 23 and Mr. Gary Nugent,
the Director here in Omaha and I'm certainly pleased to be with
Mr. John Hilgert.
I'm also very honored to be in the company of so many
distinguished veteran leaders, members of veteran service
organizations, and my fellow VA employees who are here this
morning for this hearing.
I thank you for the opportunity to discuss the merger of
VISN 13 and 14 into VISN 23, the meaning of that merger and
perhaps to address some of the other issues that you
highlighted this morning, Mr. Bereuter, and Mr. Chairman as
well.
Let me begin by bringing a national perspective to this
regional issue. The Department of Veterans Affairs faces
extraordinary challenges in providing health care today. We are
reaching crisis levels, I'm afraid to say, and I want to talk a
little bit about the historical perspective for it.
In the mid-1990's a couple of very important decisions were
made that profoundly impacted and changed the face of the VA
today. The first I think was a very, very important decision,
and that was to transition the VA from a hospital centric
health care system to a more primary patient focused health
care system. The result of that is that today VA has some 800
outpatient clinics which are much closer to veterans homes.
Whereas in the past, of course, we had very, very few, if any,
community based outpatient clinics and that made it much more
difficult for veterans to access the VA health care system.
Also about the same time, around 1998, the decision was
made to go to enrollment so that any veteran whether they're
service-connected disabled by virtue of their military service,
poor, nonservice connected higher income, anyone can come to
the VA. Prior to that time, of course, the VA was considered to
be a health care system for men and women who were disabled by
virtue of their military service and/or poor. It was a safety
net for poor veterans. But with that change to open enrollment,
any of the 25 million veterans could come to the VA health care
system.
Those changes were premised on a couple of things
happening. One was that we would have Medicare subvention. The
VA would be able to tap into the Medicare trust fund because a
large percentage of our veterans are Medicare eligible. They
contribute to the trust fund. That never happened. Perhaps
there were a lot of reasons for it, and I certainly don't blame
the administration back then or the Congress, Medicare
subvention just never was realized.
Another factor was that the VA would do much better in
medical care cost recovery. We have the authority to bill the
insurance company for nonservice connected health care.
Congress gave us that authority back in 1998, to allow those
dollars to stay with the VA, the networks, the medical centers
where those dollars were collected. Our medical care cost
recovery program didn't reach the levels that everyone
anticipated back then, and, of course, appropriations--we're a
discretionary funded health care system. We are not an
entitlement program. Not one veteran under law, is entitled, so
we have to rely upon annual appropriations, and Congress has
been very, very generous with us. But the fact remains that as
a result of opening all of the outpatient clinics, and open
enrollment, veterans have come to us in significant numbers. Of
course, we have had a lot of Medicare HMO's close down around
the country. We have had fluctuations in the economy where
veterans have lost their jobs and lost their health care
coverage and have come to us. So as a result of these changes,
we now have over 6 million veterans enrolled in the VA health
care system. We have a million additional veterans who have
used the system who never used it before. The growth in
Priority 7's since 1996 has been dramatic. In 1996 they were 3
percent of VA's workload; today they comprise 33 percent and we
expect that Priority 7's will be almost 50 percent by the end
of this decade. They have grown 500 percent since 1996, and the
growth this year alone is 50 percent higher than it was last
year.
So the fact is, we have many veterans who are looking to
the VA, and, of course, VA's quality is much better. This is
not my father's VA. The VA health care system today is a truly
fine, high quality health care system. Our Nation should be
very, very proud of the health care system we have. But with
the increasing number of veterans who are turning to us
combined with the rising cost of health care, our
pharmaceutical budget is now $3.1 billion. It has grown from
$750 million to $3.1 billion and that's just for ingredients
only. That does not include the cost of managing this program,
which is about $600 million additional. You can see some of the
challenges facing us. So we have had to make some hard
decisions if we are going to continue to meet the ever growing
increases on a finite budget.
Our budget requests for fiscal year 2003, I am very, very
proud to say, is the largest increase ever requested by a
President, whether Republican or Democrat. It is $6.1 billion
more than 2002, about 7 percent for discretionary spending
health care, when most agencies of Government are being limited
to 2 percent. I am grateful to the Congress. I thank you for
your leadership, Mr. Chairman, Mr. Bereuter, Senator Hagel and
Congressman Osborne and for your tremendous support of VA in
trying to get us additional resources. But I think we all know
that unless we have something like Medicare subvention or
increased appropriations, it is going to be difficult to meet
the expanding need of health care.
So what we're trying to do, what I am trying to do as head
of the VA, an agency that I am very, very honored and humble to
lead, is the following: improve our procurement practices so
that the dollars we save can be put back into health care, by
reshaping our legacy infrastructure to meet the needs of 21st
century veterans, not the century gone by, by increasing
cooperation with the Department of Defense, health care system,
through more sharing, more partnership, by improving our
business practices.
I try to bring a business sense to what we do because we
have a bottom line. It may not be dividends, but it certainly
is more health care for veterans. Every dollar we save is a
dollar we can use to expend the reach of health care, by
increasing the effectiveness of our collections operations. You
told us we can keep the dollars we collect from insurance
companies. We need to do better because that is money that is
being left on the table. VA is making intelligent use of the
opportunities offered us by modern technology, telemedicine, so
that in rural areas we can in fact reach some of those veterans
that Congressman Bereuter talked about. VA is using
telemedicine and radiology and psychiatry and continuing to
look for ways to make our medical practices more cost effective
without sacrificing quality. We have worked very, very hard. My
predecessors have worked very, very hard to improve the VA's
quality. I certainly do not want to see it diminished. Under no
circumstances will I allow quality to be compromised.
Combining VISN 13 and 14 certainly as you both indicated
will not solve all of our problems. Our challenges are much
greater than the consolidation of these two networks. But I
believe it is a step in the right direction. It is a step that
will save us some dollars. Now, these are administrative
management overhead dollars. These are not clinical dollars,
and I really want to make sure that I separate the two. By
combining the networks, we are talking more in terms of
administrative overhead as opposed to clinical practice.
I believe it is a step that will improve the quality of
care for many veterans. It will allow us to better coordinate
health care among veterans in a larger area of Nebraska, the
Dakotas, Minnesota, and Iowa. It will affect veterans who
previously used facilities in both networks.
I hope it will help us to reduce waiting times for
appointments as we develop new strategies to make access to
care more equitable. So those are primarily some of the reasons
that we have undertaken this consolidation. I am told by Dr.
Petzel that we are already saving money on pharmaceutical
procurements through our widespread use of generic substitutes
and laboratory contracts in the two now combined networks. We
have already prepared a plan to expand psychiatric services in
rural midwestern areas through the use of the telepsychiatry
program. We will soon hire psychiatric regional care
coordinators in both Nebraska and Iowa to enhance our services
in this area and to ensure the project's success and we have
already authorized funding for temporary new staff to renew our
business procedures. This staff will prepare a plan so that we
can increase our third-party collection from insurance
companies.
But, Mr. Chairman, and Mr. Bereuter, let me be clear about
one thing. None of the 28 employees of either network directly
affected by this change provide direct patient care to
veterans. VISN staff performs staff support work for the VISN
Director and for the networks' facilities. Changing our network
configuration will not curtail service at any VA facility that
provides health care in Nebraska or anywhere else in either
network because Networks 13 and 14 have a continuous boundary,
have few facilities in metropolitan areas, and have large areas
where rural health care is an issue. It is my hope that
combining their management will enhance care while reducing
costs. I believe that's a win/win situation for veterans and
for the VA.
My time is well past the 5 minutes, Mr. Chairman, so at
that point I will stop and be pleased to answer whatever
questions you or Mr. Bereuter might have.
Thank you, sir.
[The prepared statement of Secretary Principi follows:]
Prepared Statement of Hon. Anthony J. Principi, Secretary of Veterans
Affairs
Mr. Chairman and Members of the Committee:
I am pleased to appear before the Committee to discuss the merger
of VISNs 13 and 14 into VISN 23 and what that merger means for the
future of VA health care for all affected veterans.
On January 23, 2002, the Department of Veterans Affairs (VA)
announced the merger of VISN 13 and 14 into new VISN 23. This merger
has placed under one structure two health care networks that provided
services to veterans in Iowa. Nebraska, Minnesota, South Dakota, North
Dakota, and portions of western Illinois, western Wisconsin, and
eastern Wyoming.
Combining these two Networks to improve health care delivery and
access makes good sense. The facilities within the two VISNs maintain
excellent Joint Commission for Accreditation of Health Care
Organizations (JCAHO) scores, rank high in patient satisfaction, and
are strong performers in quality measures. The change should have no
effect on the facilities or their scores, beyond what is expected to be
gained in administrative efficiencies. The two VISNs share many
commonalities. They are close geographically and both have few
metropolitan areas and large areas where rural health care is an issue.
VISN 23 provides services throughout a large region that includes
Iowa, Nebraska, Minnesota, South Dakota, North Dakota, western Illinois
and western Wisconsin. The Network operates nine medical centers,
thirty-five community-based outpatient clinics, four domiciliaries, and
seven VA nursing homes. Nearly one million veterans reside within the
Network service area, which represents 4.3 percent of the Nation's
veteran population. In 2001, Network medical facilities served a total
of 215,711 patients and provided 1.8 million outpatient visits.
When compared to the other networks, VISN 23 ranks fifth in the
number of patients served last year as compared to their rankings as
individual networks where VISN 13 ranked 18th, and VISN 14 was 22nd.
VISN 23's combined budget represents 4.87 percent of the national
budget and ranks 11th among the other networks. Prior to integration,
VISN 13's budget was 2.84 percent of the national budget and VISN 14's
budget was 2.03 percent. As you can see from these numbers, integrating
VISNs 13 and 14 into a larger VISN 23 has not created for the VISN
leadership any extraordinary budgetary or workload challenges beyond
those currently faced by other VA health care Networks. More
importantly, integration has in no way diminished the VA's health care
presence in Nebraska or any other area of the new VISN 23. A VISN is
simply the administrative structure. Reorganizing that structure will
not affect provision of care.
I would now like to highlight several of the benefits to be gained
from this merger.
Improved Coordination of care
The two networks share many patients between Nebraska and South
Dakota, and Minnesota and Iowa. For those patients that move between
the borders, coordination of care will be improved.
Economies of Scale
The merger is expected to generate cost savings through economies
of scales. Joint purchasing across the Midwest will bring lower prices
for high cost medical equipment and supplies.
Budget Flexibility
Combining the budgets of former VISN 13 and 14 will give VISN 23
greater flexibility in allocating the estimated one billion dollars on
VA programs and services. The merger is expected to generate cost
savings, and the estimated savings ($1-6 million), over a period of
time, will be redirected into expanding access and enhancing services
for veterans throughout the Midwest.
Consolidation of Administration Functions
There will be opportunities to implement management efficiencies by
integrating fiscal services, consolidating business offices, and
materiel service functions, such as contracting, logistics, supply, and
warehouse functions. Combining the talents of the staffs of the two
former Network Offices (13 and 14) will bring greater efficiency and
effectiveness and eliminate duplication. Of the more than 8,000
employees in VISN 23, less than four tenths of a percent (approximately
28 network office employees) will be directly impacted by the initial
phases of this merger, although all VISN 23 employees will ultimately
benefit from the improved, more viable organization created by the
integration.
Clinical Benefits
Access to specialty care in rural areas such as those served by
VISN 23 is often limited and traveling long distances to access health
care can be a burden to the elderly. The Department of Veterans Affairs
recognizes the importance of healthcare providers working
collaboratively with veterans and their families in developing
effective ways for delivering accessible, high quality health care in
rural areas. A fully integrated senior clinical leadership team will
seek to understand the veterans perspective and work cooperatively to
eliminate or reduce long distance travel for veterans by developing
health care delivery systems that will assure equitable access to VA
health care across the Midwest.
When a veteran must travel to access care not available at the
local VA medical facility, VA considers all available options and
discusses with the veterans and family the most appropriate referral
site for accessing the level of care needed. Referral patterns in
Nebraska have remained the same in recent years and the reorganization
of VISN 23 has not impacted on how or where veterans are referred for
care. Currently, elective open-heart surgery is provided at the
Minneapolis VA Medical Center through a contract that was established
prior to the merger of VISNs 13 and 14. An integrated VISN 23 Cardiac
Services Task Force is reviewing this current arrangement and is
considering contracting for open-heart surgery in the Omaha, Nebraska
area.
Overall, the now VISN 23 will build on the successes of VISNs 13
and 14 and seize opportunities for enhancing quality, expanding access,
gaining efficiencies. and improving veteran satisfaction in areas that
need improvement. Both Networks 13 and 14 have done excellent clinical
work, and we expect that, in combination, the clinical staffs will
learn from each other, creating a better and improved health care
delivery system.
Today, I am also pleased to report some of the early successes of
integration.
Pharmacy and Purchasing Efficiencies
The new Network has been able to identity savings as a result of
the joint pharmacy and therapeutics committee's implementation of the
use of generic substitutes and laboratory contracting.
Enhanced Mental Health Services
The Network has approved plans to expand psychiatry services in
rural areas through the use of Tele-Psychiatry. Included in the plan is
the hiring of Psychiatric Regional Care Coordinators in Nebraska and
Iowa to enhance coordination of care and Tele-psychiatry services at
CBOCs throughout Nebraska.
Improved Business Practices
Recently the Network identified problems within the Nebraska and
Iowa MCCF Collections and Fee Basis Units. The Interim Network Director
authorized funding for additional temporary staff and combined the
resources and expertise of the Business Managers to review business
practices and develop a plan for eliminating backlogs and improve
business practices. Within the next six months, the Network expects to
have the backlog eliminated and plans in place to prevent problems from
recurring in the future.
closing comments
The merger of the two networks should be transparent to veterans.
Each medical facility within Network 23 fulfills important missions for
VA, and there are no plans to reduce or eliminate VA programs or
services in Nebraska or any other state within the network. For the
foreseeable future we plan to maintain a network presence in Lincoln.
Unique programs. such as the partnerships VA created with community
hospitals in Grand Island and Lincoln, Nebraska, to provide acute
inpatient medical care, serve as models for exploring new opportunities
and creating new initiatives.
The new Network will continue to address a number of challenges,
including managing unprecedented growth within appropriated funding;
exercising stewardship of all resources; increasing market share;
continuously improving quality of care and veteran satisfaction; fully
integrating administrative and clinical programs and processes;
investing in capital improvements and information technology; and
effectively communicating with veteran groups. labor partners,
educational affiliates and other stakeholders.
We will monitor the integration process carefully, and I can assure
you that service to Nebraska veterans will be preserved. If resources
permit, we hope to expand services in community-based outpatient
clinics so that we can provide better access for veterans living in
rural Nebraska. We expect this integration to provide us better insight
for providing care to patients in rural communities, and, as a result,
Nebraska veterans will see more accessible and better-coordinated care.
I assure you that VA is committed to redeeming the debt we owe to
Nebraska' veterans and to all of our Nation's veterans.
Mr. Chairman, thank you for this opportunity to testify.
Senator Nelson. Thank you, Mr. Secretary. Would your
preference be to hear the rest of the panel?
Congressman Bereuter. I'm willing to do that. Thank you
very much.
Senator Nelson. Yes. Dr. Petzel.
Dr. Petzel. I would defer to Mr. Hilgert.
Senator Nelson. OK. Director Hilgert.
STATEMENT OF JOHN HILGERT, DIRECTOR OF VETERANS AFFAIRS, STATE
OF NEBRASKA
Mr. Hilgert. Good morning, Senator Nelson, Congressman
Bereuter, Secretary Principi, distinguished guests and fellow
veterans.
Mr. Secretary, welcome back to Nebraska.
I'm John Hilgert, Director of Veterans Affairs for the
State of Nebraska. I am rather new to this position. I became
director in late November of last year. Prior to serving the
State of Nebraska as Director of Veterans Affairs, I served in
the Nebraska Unicameral Legislature as a State senator. Also
prior to taking on this responsibility, I worked for 10 years
at Catholic Charities of the Archdiocese of Omaha. My
background therefore is in government and in private nonprofit
behavioral health field. I am a Gulf War veteran having served
in the 1st Infantry Division in the U.S. Army.
The merger of Veterans Integrated Service Network (VISN) 13
and 14, was announced on January 23, 2002, and as Director I
was made known of many concerns that veterans in Nebraska had
regarding the prospect of the merger. Among the foremost of
concerns was the access of care for our veterans and the
quality of care for our veterans. The prospect of diminished
control over limited funds as well as a more distant and
therefore less accessible leadership of the VISN was also of
great concern.
Since the creation of VISN 23 I must report according to my
perspective that the transition directed by Acting Director Dr.
Robert Petzel has been fairly transparent. Electronic and
written communications regarding the transition have been
numerous. Dr. Petzel has visited Nebraska several times and I
myself have had occasion to speak with Dr. Petzel in person at
least in four instances while he has been in our State. I also
report that Dr. Petzel's traveled across our State even
attending the County Veterans Service Officer School that was
held last week in Scottsbluff. This is very encouraging and
helps diminish somewhat the concerns that I had regarding the
merger. Communication is essential to a smooth transition.
However, I remain concerned about the allocation of
resources that directly impact Nebraska veterans' access to
service as well as the quality of their service. To my
knowledge, both VISN's and former VISN 13 and former VISN 14
have financial deficits. I have also been told that at least
one factor that led to the merger was the prospect of financial
savings. I am not convinced that savings through management
efficiencies can satisfy the combined deficit of VISN 23. There
lies the basis for my concern regarding access of care and
quality of care. Simply put, where will the cuts, if additional
funding is not forthcoming, be made? I do recognize that this
is not singularly relevant only to VISN 23 and there is need
throughout the system. I see the challenges that the employees
of the Veterans Administration are facing. They are challenged
to treat more patients, exceed expectations and at the same
time do this with limited staff and limited resources.
Some particular observations regarding access to service
and quality of care and please infer nothing by the order of
which I make them. A concern or need is the top priority to
every individual that is affected by that need.
It has been related to me that there are documented
deficiencies regarding the surgery and ICU units at the Omaha
VAMC. Additional resources are required to remedy these
deficiencies. I do not have the specifics about these
deficiencies, but I have been told VA staff that they are
indeed documented.
I am concerned about the future of Nebraska's medical
centers and community based outpatient clinics. I was
encouraged last Wednesday in Scottsbluff when Dr. Petzel
observed and volunteered on his own to examine this issue
recognizing the great distances that some Nebraska veterans are
required to travel to access these services. Although I have
been told that there are staffing and budget challenges
throughout the system, the Lincoln VAMC stands out in my mind
as a particular concern. The Lincoln VAMC plays an important
role in service delivery. However, with the loss the VISN
headquarters in Lincoln, one can only project a diminished role
for Lincoln. There is space at the Lincoln VAMC and I would
encourage the administration to use that for a clinical
function, clinical function meaning a clinical use rather than
an administrative use or function. Personally I would like to
see an inpatient dual diagnosis unit established at the Lincoln
VAMC. I believe there's an ever increasing need for such a
facility in Nebraska. Nebraska has one of the lowest
penetrations for PTSD services utilized by our veterans. I
believe this also would be a great asset for Nebraska's State
veterans homes to refer veterans in order to treat and
stabilize those veterans in need of those services before
admission into a home. There's an ever increasing acuity among
the veterans seeking entrance into our State veterans homes.
Obviously I would encourage and support any use of that space
that translates into greater service for Nebraska's veterans.
There is also a need for additional clinical pharmacists in
order to support our physicians. I believe this would result in
time savings for the doctor, freeing her up to maximize time
with the patient directing addressing the whole health needs of
the patient. Quality would be enhanced as well as probable
financial savings. I have been encouraged by reports of
cooperation between the two former VISN's in this area, the
willingness of former VISN 14 to adjust their formula to match
former VISN 13's.
It has been recognized by the VISN 23 leadership that the
greatest challenges that VISN faces is the large geographical
area, the employees and veterans travel distances, the budget
shortfalls, the large number of Priority 7's and the
infrastructure maintenance costs. This recognition is very
encouraging.
These are some of my observations that I have made in my
short tenure as director of Veterans Affairs for our State. I
look forward to continuing the dialog with VISN 23 officials. I
look forward to working with the VA as we address the issues
concerning the Thomas Fitzgerald Veterans Home in Omaha. I look
forward to working with the VA as we continue to work toward
the establishment of State veterans cemeteries in Alliance and
in Grand Island. It is with great pride and confidence that all
Nebraskans can rely on the oversight by Nebraska's
congressional delegation.
There are many concerns that remain among Nebraska veterans
and you will hear from them today. There are many challenges
facing VISN 23 as well as the entire system. Extensive
communication must be maintained. Access should not be
diminished, but rather enhanced and quality must always be top
priority. The system, no matter what the management style,
organization or by what moniker it is called must always,
always be veteran centered.
Thank you for the opportunity to share with you my
observations. Thank you, Mr. Secretary, for coming to our State
and thank you, Senator Nelson, for convening this field hearing
in Nebraska for Nebraska's veterans. Thank you.
Senator Nelson. Thank you, Director Hilgert.
Dr. Petzel.
Dr. Petzel. I have no prepared remarks, but am here and
available to answer questions.
Senator Nelson. That would be fine.
Mr. Nugent.
Mr. Nugent. Mr. Chairman, I have no prepared remarks, but I
would be more than happy to answer any questions.
Senator Nelson. Thank you. I'll defer to my colleague for
the first questions.
Mr. Bereuter. Thank you very much, Senator.
Secretary Principi, I wonder if I have made clear my basic
concern about VERA, that there must be an underlying structure,
a minimum structure at least providing quality care throughout
the whole country even though the veterans are piling up the
sun-belt States with their political clout which keeps us from
changing the formula because of the large population in the
south and California and Texas and Florida today that there
must be a very basic structure of delivered services throughout
the whole country, even though the number of veterans in this
region are proportionally quite small and therefore the funds
coming into this area are therefore very limited.
Mr. Principi. Mr. Bereuter, you have made your point very
clear and I hear what you're saying. I too agree. As I travel
the country, and this is my second trip to Nebraska, Kansas,
and the Heartland, I too am concerned about rural health care
and to ensure that we have adequate resources that are coming
to places like Nebraska to care for veterans who for whatever
reason can't get down to the sun-belt and retire are here
working on the farms or whatever.
I think the VERA model generally speaking is a good model,
it does fund workload. There have been supplementals that have
gone to former--the VISN 13 in the past. We are looking at
refinements of the VERA model to make it more equitable to
address some of the issues that you have mentioned. But
generally speaking, I hear the points you're making. I think
it's a very, very important one and something that needs to be
addressed to ensure veterans in rural America are not suffering
as a result of this model.
Mr. Bereuter. Mr. Secretary, thank you for your recognition
of this problem. If it's impossible for us to change the
allocation system, thus far we have been unable to do that by
legislative requirement because of the limited number of votes
we have in the Northern Great Plains and the Northern Midwest.
Is it possible that we can rely more heavily on outpatient
clinics which I think are moving into the right direction? Can
the funds for the outpatient clinics be considered separately
for sparsely settled parts of the Nation?
Mr. Principi. I think that's what we need to look at. Now,
we have 37 or 35----
Dr. Petzel. Thirty-five.
Mr. Principi [continuing]. Thirty-five outpatient clinics
in the new Network 23. There were nine community-based
outpatient clinics in the old Network 14 and that may be the
answer. Our goal is to have an adequate number of community
based outpatient clinics within 30 miles of a veterans home.
That way veterans can access the VA health care system and they
can use that as the entry point. If they need complex inpatient
care, they can then go to one of the urban hospitals which may
be a little further from their home. But I believe that by
consolidating some of those complex surgical procedures, it has
been proven that the quality is much better as a result.
I think that's been true in both the private sector and in
the VA. When, for example, you have consolidated open heart
surgery and providers do more surgical procedures, the quality
becomes much better. Today we have a moratorium on opening new
clinics, until the budget situation is clarified. But that is
something that I will look very, very seriously at--to see if
there is a need for outpatient clinics in this area and to see
if it is possible for us to either expand existing ones or open
new ones as the 2003 budget becomes more.
Mr. Bereuter. Mr. Secretary, we would very much appreciate
that. I know in the Heartland--in contrast of having a clinic
available within 30 miles of every veteran, we'd feel very good
if there was one within 60 miles of every veteran, in many
cases, of course, the alternatives are much longer as Director
Hilgert pointed out, our problems are the travel time for the
veterans and for their families to visit. The history is, of
course, that we have had two hospitals out of the three close
in this State, the ones in Grand Island and Lincoln, and so it
is the Black Hills, Hot Springs, South Dakota, or Denver or
Omaha that are the alternatives for inpatient care.
There was a very interesting case which I think presents
our concerns about whether or not a consolidated VISN
headquartered in the Twin Cities is really going to understand
and be sympathetic and address the problems that we have. I
will give you this example. It made quite a newspaper story.
A veteran living in west central Nebraska, not in my
district, in Congressman Osborne's district and, of course,
constituencies of our two Senators as well, the poor man was
suffering not only from physical problems that required
pharmaceuticals, but from Alzheimer's as well, and in order to
get his prescriptions renewed on an annual basis to be given
the kind of scrutiny by a physician to see if, in fact, those
prescriptions were still appropriate, the man has to travel to
a veterans hospital or at least perhaps to an outpatient clinic
like the one in Lincoln, but this woman cannot even with help
take her husband to those clinics, she physically--because of
his Alzheimer's problems and the travel difficulties, and so
she's faced with a very high prescription by going to a local
doctor and not being able to get the prescription filled by the
VA. So it occurred to us as we looked at it in the initial
stages, well, you could have your VA people basically doing
circuit riders around the State to handle those kinds of
extraordinary situations which are unfortunately not unique,
not too uncommon where it's a difficulty to come in even
annually for a reexamination to renew the prescription, or
second you could permit local physicians on a contract basis in
that community to do that work for the VA.
This woman has no alternative with her husband in the
current condition for getting his prescription renewed so she
can get VA prescriptions, and that is just something that came
to our attention. We were looking for a legislative solution,
but really an administrative solution just presents itself very
clearly to one when you think about that, permitting a doctor
on a contract basis to do very basic kind of examinations and
prescription renewal in isolated parts of our State. Do you
have any reaction to this problem?
Mr. Principi. Well, certainly. In that specific case, if
the veteran is enrolled in the VA health care system--other
than periodic exams--all of his prescriptions should be mailed
to him there. We have a wonderful consolidated mail-out
pharmacy program, so----
Mr. Bereuter. Secretary, excuse me for interrupting, but it
is the periodic exam that is the problem.
Mr. Principi. The problem.
Mr. Nugent. I'm actually familiar with this case and I
think someone from Congressman Osborne's office contacted us
and when we were aware of it, we tried to get a physician up
there and I believe that we can supply the information for the
record, but we were going to either send one of our staff up or
contract with one of the physicians in the area to go out and
see this particular veteran.
Mr. Bereuter. I wish you would consider one of those two.
This just happens to be a notorious case that made the paper,
but there are others.
Mr. Chairman, Senator Nelson, thank you, and I'll turn to
you for your questions, of course.
Senator Nelson. Thank you, Mr. Bereuter, and again, thank
you, Mr. Secretary.
What the veterans are concerned about is any kind of
reduction in the quality or quantity of services or in their
ability to deal with the administration of those services. So
it's both about clinic and management that we are here today.
Obviously the more distant the administrative headquarters is
the more concern people have about how you deal with that
administration, how you're going to interface with them to make
sure the quality and quantity of services are not reduced. So
I'm encouraged, Dr. Petzel, by Director Hilgert's comments
about your having been in Nebraska a lot and we hope that that
will continue. Obviously we would love to have you be a
Nebraska resident, but we want you to be a near resident and
qualify for our income tax laws.
That's how much we want you to be here because I think
that's the heart of what this is about today in terms of
veterans. I mean, we don't have to go through why veterans are
entitled, maybe not under the law, but morally entitled to
these kinds of services. We don't need to go through that,
everybody in the room understands that and everybody outside
the room understands that. How we deliver it is so critical.
Our concern is that we have reassurance that there won't be any
reduction in the quality or quantity of either management or
clinical care and/or services that they're entitled to.
Is there anything that the Secretary can tell us
specifically that might help us have that kind of reassurance
beyond where you are at the moment? For example, I think that
there was a location issue that's been raised and one of the
recommendations in the business case study was to establish a
satellite VISN 23 office in Nebraska for the transition
process. Has that been accomplished and is there something that
might take us beyond that transition office?
Dr. Petzel. Thank you, thank you. There is a plan to have a
satellite as you put it network office in Lincoln. We will
maintain a presence as a network office for as far into the
future as I can see. We've not done anything definitive, we
won't until there's a permanent network director named and we
begin the actual process of consolidating the network offices,
but it's already been identified that there is a need to
maintain that.
I should also add that my wife thinks I spend more time in
Nebraska now than I do in Minnesota since the 23rd of January.
Mr. Principi. Well, I can certainly commit to you, Mr.
Chairman, Mr. Bereuter, that I will watch the situation very,
very carefully. I intend to hold my people accountable to
ensure that resources are equitably distributed just as I
expect you will hold me accountable in the discharge of my
responsibilities as head of the VA, but I believe this is a
good management step that we have taken. We have two relatively
small networks. We know we have a declining veteran population
across the country as the World War II population passes on. We
are just trying to take good management steps to ensure that we
are stewards of the public trust--of the taxpayers' dollars,
that we are spending those dollars wisely, efficiently and
effectively across the country and, as you have indicated, to
ensure that the veterans across the country have equitable
access to the VA as best we can. Now, you can't do it in every
community in America, and certainly there are stories of
factories closing down and veterans not having health care or
there is no VA facility in an area etc. Those are always very
heart wrenching. But I think to the degree we can, we have
tried to move health care closer to the veteran. Of course, 30
miles in transiting Chicago or one of the larger areas is a
great distance. It probably takes you as long to go 60 miles,
as you have indicated, out west, where you don't have as many
traffic lights or congestion, but we are trying to ensure that
access to health care is equitably distributed.
Mr. Bereuter. One final question, Mr. Chairman. Secretary,
with the shortfall last fiscal year, $92.7 million, is it worth
all of the concerns that we are going to fail to have adequate
administrative contact and concern to save $600,000 or at the
most $6 million, which is the highest estimate I have seen and
isn't this a very minor savings as compared to a huge problem
that this VISN region faces even in a more populated area of
VISN 14, 13 combined? $92.7 million shortfall in 1 year
suggests there's something basically wrong with the allocation
system, I believe.
Mr. Principi. Mr. Bereuter, you are absolutely correct.
This is really a very, very small issue relative to the larger
issues facing the VA health care system. I don't know how else
to say it. I have never seen anything else quite like it. Now,
I have been in and out of this business for 20 years since I
first went to the U.S. Senate, starting with the Armed Services
Committee and then Veterans' Affairs Committee and then with
President Bush One. I get a call every day from a Member of
Congress. I mean, from Florida to Seattle, WA and everyplace in
between. We have more and more veterans coming to us for care
and, you know, the waiting lines are growing longer.
The clinics we opened just a year or 2 ago, and which we
thought would not reach capacity for several more years, are at
capacity. As I indicated, we are treating a million more
veterans today than we were treating just a short time ago. So,
we do have a serious issue here and it's just not in Nebraska,
it is everywhere.
Mr. Bereuter. Is this shortfall of $92.7 million for fiscal
year 2001 the largest shortfall in the region on a per capita
basis in the whole country?
Mr. Principi. No, I don't believe so. We have much larger
shortfalls in other parts of the country.
Mr. Bereuter. On a per capita basis?
Dr. Petzel. Yes.
Senator Nelson. Dr. Petzel, maybe you can----
Dr. Petzel. We do in New York and Boston, both of those
places.
Mr. Bereuter. No wonder they are always helping us when we
try to bring this issue to the floor.
Dr. Petzel. Oh, yes, yes. They have the same serious
problems as we do.
Mr. Principi. Now, the good news is that the Congress--the
House has just marked up a supplemental appropriation for 2002
for the VA. We had requested $142 million in additional funding
for the VA health care system. We now have that figure up to
$417 million for 2002. That, combined with some of the
management steps we have taken, such as procurement reform and
information technology spending, if we get that amount as it
goes through the Senate, we will be fine for 2002. Much of that
shortfall, I don't want to say every penny of that shortfall,
but much of the shortfall in places like VISN 23, will be
offset by that supplemental.
For 2003, it's another set of challenges. We have requested
about a $1.6 billion increase in VA health care alone. I think
Congress is looking to add to that budget. So will it be
enough? Maybe not, but I think we're moving in the right
direction. So I think the shortfall will be offset by the
supplemental.
Senator Nelson. Mr. Secretary, my question is in the form
of cost containment. What can be done to control costs, where
they are controllable, not by taking away services, but by
making sure that utilization severity and the provision of
services is appropriate to the conditions? Ordinarily when you
have a centralization of authority and you pull people away
from an area where they can otherwise watch it more closely,
wouldn't this argue for more decentralization? Somebody closer
to the scene could watch the dollars a little bit more closely
and watch the provisions of services to make sure that they are
appropriate and cost effective?
Mr. Principi. Well, that's a good question and I may--Dr.
Petzel may have a little different take on it because he's in
the field, but I don't pretend or believe that you can
centralize all of management in Washington, DC or corporate
headquarters in the private sector. I think there needs to be a
balance between in our case Washington, DC and the field. You
have to manage health care closest to where the patient is, but
at the same time, I think in some instances we have
decentralized too much and we have 21 separate health care
systems all competing against one another for the dollars and
without recognizing this is a zero-sum gain. At the end of the
day, you give us an appropriation, and we have to allocate that
appropriation across the country. Maybe at one time, we had
medical centers competing against one another, but now we have
networks competing against one another for those dollars, and
we have this imbalance. I like to look at it as kind of a
Federalist approach but you've got to balance it. Washington
has to make the policy, has to oversee the operations to make
sure it is equitable and then allow the people in the field
like Dr. Petzel, who really understand health care and
understand their network in accordance with those guidelines,
to distribute the dollars and manage the workload.
One thing that the president told me that has stuck with
me, he said, ``You know, every dollar we spend is a dollar that
some American has to send to us, take out of his or her pocket
and send to us.'' In my case, I'm the steward of those funds,
and I have the responsibility to ensure that those dollars are
spent wisely and effectively. Compassion is not how much money
we are spending; compassion is measured by the results we get.
That's basically what I am trying to do as Secretary, to ensure
that we are spending the dollars, and those dollars are
reaching veterans. The only reason we exist is to serve
veterans, and I take that responsibility very seriously.
Mr. Nugent. I wonder if I could add just one comment----
Senator Nelson. Sure.
Mr. Nugent [continuing]. From just the operational aspect
of the hospital system. The creation of these small cells
creates problems for us as well. Three or 4 weeks ago, we
attempted to get a patient into another network only to be
informed that they didn't take patients from our network. Now,
we were able to resolve that with some help, but it does create
a level of competition that I think is unhealthy and creates
different levels of care across the country.
Senator Nelson. Thank you very much, and Secretary
Principi, will you please join us here.
Mr. Bereuter. Senator Nelson, I need to go back into my
schedule around Lincoln. Thank you so much for permitting me to
be part of the Senate Veterans' Affairs Committee hearing
today. I am leaving my Veterans' Affairs caseworker, Jeanie
Walker, back here who will give me full reports on what has
been said here and the kinds of things that we might need to do
to help. Thank you for inviting me.
Senator Nelson. Well, thank you very much, Congressman
Bereuter. It's a pleasure to have you here. It certainly makes
this a bipartisan effort. Thank you.
We'll just take a second or two here to invite up the
second panel which I might introduce as the name cards are
being changed. We have Elaine Bernhardt who is the President of
American Federation of Government Employees, Local 2601; Mike
Crawford, the President of American Federation of Government
Employees, Local 2270; Keith Fickenscher, the Executive
Director of Tabitha Health Care Services--the former Director
of the Department of Veterans Administration Affairs in
Lincoln; Jim Cada, the Chairman of the Inquiry and Review Board
of the Nebraska State Veterans Home, and Dr. Jane Potter,
Harris Professor of Geriatric Medicine, the Chief of the
Section of Geriatrics and Gerontology, the Department of
Internal Medicine at the University of Nebraska Medical Center.
Doctor and everyone, we are very delighted to have you join us
here today. We will start first with Ms. Bernhardt. If you
would share with us the concerns you have on behalf of the
employees.
STATEMENT OF ELAINE BERNHARDT, PRESIDENT, AFGE LOCAL 2601,
GRAND ISLAND, NE
Ms. Bernhardt. Thank you, Senator Nelson.
My name is Elaine Bernhardt. I'm the President of Local
2601 AFGE in Grand Island. When I first talked to Eric Pierce
about this hearing today, he asked me to identify some
opportunities that I could associate with integration. That was
2 weeks ago and I haven't been able to do that. I have been
racking my brain and I just can't think of very many
opportunities. But the second thing he told me was that if I
identified some problems, if I could please identify solutions
at the same time. That's been even tougher. I think the budget
crisis--and I understand what the Secretary was saying earlier,
we have an appropriation we have to live with--but I do have to
question the distribution of that budget. I think Nebraska has
suffered tremendously under the old administration of VISN 14.
There was a deficit in VISN 14. Nebraska was to assume $4
million of that deficit as compared to $300,000 that Iowa City
was to assume.
As it is now, under Dr. Petzel's leadership, he did put
$7.7 million into the Nebraska budget that wasn't there before,
but that still leaves us with a deficit of close to $7 million.
It doesn't equate to me, but then I'm not a mathematician
either.
We've take some measures in Nebraska to deal with the
deficits. Some of the things that we have done is curb our
pharmaceutical costs. We have limited travel, particularly
employee travel for education. We've done some other things.
FTEE ceiling, we have limited that and we have cut some of the
control points. Every control point has been cut.
What happens is that the employees recognized that they're
not going to have those positions filled, so that person is
gone who used to work beside them--and there's not enough money
in the control points to even buy arm bands for our VA officers
when a fellow officer was killed on duty in another part of the
United States. Instead what they were told to do is take a
piece of electrical tape and put it on their badges. That's
pretty tacky.
We need to take a look at the budget and the distribution,
and what is that telling the employees. How they feel about
this right now is that yeah, there's a lot of things wrong with
the integration because these things weren't happening before.
There was a hiring freeze, but now their nose is being kept to
the grindstone and they are not able to travel for education.
And that's where the rubber meets the road. Those are the
people that the veteran sees and who they deal with when they
come in for attention. We need someone in Grand Island--every
one of the facilities in Nebraska--in a visible place to answer
some of the questions that the veterans have. Right now if they
have insurance questions or they have billing questions, what
they do is call a number and nine times out of ten they get a
voice mail, they leave their voice mail, the calls are not
returned, their billing questions go unanswered. If they go to
triage, they have to call Des Moines, IA, and that's really a
tough one to answer those health questions or tell those
veterans they can indeed go to a private hospital for their
care if it's an emergency in the case of Grand Island.
Those are the things that need to be looked at very, very
hard and we need some answers. I don't have the answers to the
problems. I mean, it's easy to throw resources at things when
you have the resources, but we don't have them. So what I have
managed do is identify some problems. I don't really have any
solutions other than give us more money. And with that, I will
close.
[The prepared statement of Ms. Bernhardt follows:]
Prepared Statement of Elaine Bernhardt, President, AFGE Local 2601,
Grand Island, NE
opportunities for va nebraska/western iowa health care system with the
integration of visn's 13 and 14
Mental health
Not unlike other health trends, it has been found that most
patients respond in a more positive manner when treated in a non-
institutional setting. The current Mental Health Outreach programs in
Nebraska are successful but are grossly understaffed and under-funded.
Veterans in rural Nebraska would benefit from expansion of this program
and the VISN would realize compliance with DVA performance standards.
Extended care
This field encompasses all aspects of expanded care for the aging
veteran populace. The Nursing Home Care Unit in Grand Island provides
transitional care and terminal care for veterans in the entire state.
The renovation project will satisfy this need for a few but as the
veterans age, the demand will grow. Nebraska communities are unable to
keep up with the present day demand and it is not expected they will
meet future private needs for long-term care yet alone, veterans'
requirements. The vacant building in Lincoln could be utilized for
Geropsychiatric care, and/or an Alzheimers Unit, but the building needs
to be equipped with an adequate sprinkler system. The projected costs
for this project have been largely inflated. All three Nebraska VA
buildings could be utilized for Adult Day care, Hospice, Geriatic
Evaluation Units, Geropsych, Alzheimers. etc. There is adequate space
in the main hospital buildings on all three sites if offices were moved
to vacant outlying buildings.
Community based outpatient clinics
These clinics, have proven to be expensive for the VA to maintain.
It is expected that the expense will increase as medical costs rise.
The most expensive method of providing this benefit is through
contracts with community health providers. This process limits the
number of veterans that can be in the community panel and once
established, is subject to the providers' demands when the contract is
renewed. For example, the Norfolk Community Based Outpatient Clinic is
limited to approximately a 300 veteran panel with limited number of
visits per year and has recently increased the cost of care for this
panel. The North Platte Clinic provides this service to approximately
1500 veterans with unlimited number of visits and at a much smaller
expense. VA staffed CBOCs seem to be the answer.
There is the threat that the Lincoln facility will be downsized to
a minimal service CBOC. This cannot happen if we are to continue to
provide high quality, efficient outpatient medical attention at a
minimal cost.
Transportation
The Nebraska VA Transportation Network benefits veterans in rural
Nebraska by bringing them into the Outpatient Clinics at all four VA-
staffed Outpatient Clinics. The van runs include O'Neill, McCook, North
Platte, as well as Grand Island, Lincoln and Omaha. VA employees and
Veterans Service Organizations staff the transportation system. The
system is in need of constant refining and is in dire need of more
staff. Presently, higher-paid tradesmen are covering for drivers'
absences. This occurs, nearly daily in Grand Island.
Staff issues
Nebraska/Western Iowa HCS has employed various methods to recruit
staff in the field of nursing but the national shortage is felt at all
three campuses. The few retention incentives available are subject to
supervisory initiation/approval and we monetary only. In Grand Island,
there is a movement to provide quality, affordable Day Care in a vacant
building, which will aid greatly in recruitment and retention efforts.
Day Care Centers in Lincoln and Omaha would provide the same incentive.
The staffs in all three facilities have been taxed during the past
several years. The hiring restriction that was imposed last summer
remains as NWI is limited to a cumulative FTEE level of 1302. Ninety
Nebraska positions need to be cut in order to adhere to the FTEE
ceiling. At the same time, ceilings on overtime usage have been imposed
and budgets for each department have been decreased. These constraints
have placed a huge burden on the employees; consequently the initial
impact from the integration has been negative.
Although our FTEE levels are perceived to be high (down 19% in the
past five years) the personnel cost for medical care per patient is
less than the national average. The median salary in VISN 14 was the
lowest in the nation, and the Nebraska side of the VISN average salary
was lower than the Iowa side.
Communication
The communication and referral process between and among the three
NWI campuses is in dire need of improvement. Follow up responsibility
in shifted from campus to campus while the veteran awaits word on the
results of testing or what is to be done next. Procedures for early
detection of any medical condition need to be performed quickly, not
delayed for three months, which is often the case when we limit
ourselves to the Omaha VA.
Customer satisfaction
Veteran satisfaction would increase drastically with implementation
of the following:
A designated Customer Service Representative at each
campus. This person would be placed in a visible area to answer
questions from our veterans. Presently, veterans are required to call a
voice mail number in Omaha for billing and insurance questions and
often their messages are not returned.
Insurance information needs to be obtained at time of
eligibility determination and when VA patients are seen at the contract
facilities. Many months can pass before insurance information is
obtained and in the meanwhile the patient pays full co pay amounts and
interest accrues.
Realistic establishment of panel sizes for providers.
Presently, the panel size is undetermined, as a satisfactory
``formula'' has not been developed.
Presently appointment times for established patients are
20 minutes. For the reason that our clientele in older and sicker than
the private sector, these times need to be increased to 30 minutes with
one hour appointments for more complex now patient exams.
We need a hospitalist at each contract hospital. On an
average, we house 12 patients a day at St. Francis Medical Center. The
Medical Officer of the Day is currently responsible for inpatients at
the contract hospital while still maintaining his/her regularly
scheduled clinic appointments.
Ancillary services personnel need to be increased as the
FTEE in these services have stagnated while the number of providers and
number of uniques has increased drastically.
Opportunity for research
With the integration comes the opportunity for the highly-acclaimed
Minneapolis VA Research Department to expand their subject clientele
and research issues to include the aging veteran population in a rural
setting.
Opportunity for fair and equitable consideration
NWI has endured the short end of a biased VISN administration prior
to the VISN 23 management. With the new management comes an opportunity
to target incentive and recruitment dollars for distribution to the
front line rather then bonuses for VISN Managers that ranged anywhere
from $5000 to $20,000. Presently, travel dollars are restricted and
most bargaining unit employees are not approved for travel associated
with training. No other facility in the new VISN 23 experiences these
restrictions.
Senator Nelson. Thank you.
Mr. Crawford.
STATEMENT OF MIKE CRAWFORD, ENGINEERING EMPLOYEE, NEBRASKA-
WESTERN IOWA HEALTHCARE SYSTEM (NWIHC), OMAHA, NE
Mr. Crawford. Senator Nelson, Secretary Principi.
My name is Mike Crawford and I am an engineering employee
for the Nebraska-Western Iowa Health Care System at the Omaha
facility. I have worked there for over 20 years and have 26
years of government service. I also serve as President of the
American Federation of Government Employees, Local 2270,
representing approximately 600 dedicated and hard-working
employees at the Omaha facility.
I want to thank you for giving me the opportunity to voice
some of our concerns regarding the integration of Networks 13
and 14.
During my over 20 years, we have seen our share of changes.
We have gone through districts, regions, local authorities,
statewide mergers, VISN's, independent CBOC's and now merged
VISN's. Just one more change in a long line of changes.
For years it has been rumored that VISN 14 was going to be
dissolved. There has been talk of sending us to at least three
different VISN's and even talking about splitting Iowa and
Nebraska and sending each State to a different VISN. The reason
has always been the same, VISN 14 has been operating with a
budget deficit. It is common knowledge that in fact there are
15 VISN's that are currently operating with a budget deficit.
Therefore I maintain as I always have, that the VISN concept
has not worked since its inception and however well meaning,
this merger will not work either.
In Nebraska we have seen our wait times for our veterans
increase at a substantial rate, up to 9 months for some of our
specialty clinics and Veteran Satisfaction Surveys have fallen
because of it. A lot of this is due to the continued increase
in our patient workload. When compared to fiscal year 2001
workload, our fiscal year 2002 outpatient visits are expected
to grow by 6 percent and we anticipate seeing 187,000 patients
in our clinics. Once our new outpatient exam rooms are open, we
will be able to see more patients in a timelier fashion. But if
we are not allowed to increase the needed full-time employee
equivalent, FTEE, to care for them, the increased workload will
only prove to compound our problems.
Because of both parochialism and political pressures on
VISN 14, I believe that the Nebraska facilities have suffered
unnecessarily under the policies of VISN 14. I would like to
lay out some specific examples:
As far as staffing is concerned, in comparing the Omaha
facility with the Iowa City facility, excluding CBOC's, we find
that Omaha reported more patient days, discharges, outpatient
visits and encounters than Iowa City, but Omaha was expected to
do this with 65 fewer FTEE's. The impact on Omaha has seen
increased use of overtime, mandatory overtime, increased use of
contract nurses which we all know equates to extremely high
costs, restricted number of ICU beds, employee burnout and low
staff morale.
Mr. Gary Nugent, our current Chief Executive Officer, upon
arriving in Omaha noted the staffing issue and began taking
action to correct the problem. At the insistence of VISN 14,
all facilities in VISN had to do a comparative bottom-up review
with like facilities. This information has not been used but
does indicate the need for additional staffing to meet our
increasing workload. About 6 months ago, VISN 14 placed the
Nebraska-Western Iowa Health Care Divisions on a hiring
restriction. All positions after being reviewed by local
management had to be referred to senior management at VISN
level for recruitment approval. It seems absolutely ridiculous
to me that we would have VISN senior management officials
spending time to determine if we should be filling housekeeping
positions in our facility. Is that not part of the local
facility director's responsibilities to ensure that we have the
proper level of staff. We saw this same form of VISN control
play out at the Kansas City VA and we certainly don't want a
repeat of the embarrassment that occurred there.
In 2002 VISN 14 budget allocation process, the Nebraska-
Western Iowa Health Care System allocation was cut by more than
$4.2 million from its budget request and the Central Iowa
Health Care System was cut 6.1 million, yet the Iowa City
facility was asked to only cut 300,000. Again, we have
comparable size and workloads, but disproportionate budget
allocation. Another interesting fact is that in the Iowa City
budget allocation was an additional 2.5 million to deal with
their backlog in getting patients into clinics. If you would
look at the backlogs in Central Iowa and Nebraska you could
justify the same infusion. When you compare the Iowa City and
the Omaha campuses workloads, you will see that Omaha had the
larger inpatient and outpatient workload, but Iowa City before
the infusion already had 30 more physicians on staff. Why did
they need an infusion? Logically you would think that with 40
more physicians than Omaha there should never have been a
backlog.
In VISN 14 there continues to be staff mix and pay grade
disparity between network facilities. Employees find it
difficult to understand why a position in Omaha is graded lower
than like positions at another VISN 14 facility. My many
requests for physician standardization have fallen upon deaf
ears. This contributes to the low morale, low job satisfaction
rating and mistrust among VISN 14 facilities.
I believe that there will be no significant cost savings
associated with this merger. In fact, I can see increased
costs, for example, travel. Nebraska-Western Iowa is required
to send officials to Minneapolis to discuss the merger. To meet
this financial demand, the employee education money and
employee travel fund will be used. Has this same practice been
instituted throughout both VISN's or will just the Omaha
employees pay the price? Did anyone at the VISN level ask
central office for financial relief for this mandated travel?
This will not only increase the deficit at the Nebraska-Western
Iowa Health Care System, but penalizes the education and travel
fund set aside for employees.
One of the noted goals of this merger was that all VISN
staff would be retained. VISN staff will most likely need to be
absorbed into local facilities. It was also announced there
will need to be some form of VISN staff left in the Lincoln
facility while the major VISN staff will be located in
Minneapolis. Again, logically this does not seem to make much
sense. There will be the cost of maintaining the property,
office administration and obviously duplicated positions.
Currently VISN 14 reports that it has a staffing level of
16 FTEE. This is inaccurate. All facilities in VISN 14 have
staff working full time for the network that are costed to the
local facility and counted against their FTEE. Local management
has no authority to delay or disapprove filling these
positions, but is held accountable when they exceed their
assigned FTEE ceiling.
I believe the million dollars being spent in the operation
of a VISN could be better utilized in providing health care to
our veterans. I would propose that instead of an integrated
merged VISN, we would look at having a regional chief executive
officer, fiscal officer and medical officer. We should allow
our facility directors to utilize their training, experience
and expertise to operate the local facilities in the best
interest of the veterans they serve. These directors should be
held accountable for their actions to the three regional
directors I have previously mentioned.
Finally, I want to assure you that no matter what direction
the VA takes in the proposed merger, our employees will
continue to provide the high quality health care this Nation's
veterans have earned and deserve. We must honor the commitment
this Nation has made to its veterans. Again, thank you for
giving me the opportunity to speak before you.
Senator Nelson. Thank you.
Keith.
STATEMENT OF KEITH FICKENSCHER, IMMEDIATE PAST DIRECTOR,
VETERANS AFFAIRS FOR NEBRASKA
Mr. Fickenscher. Thank you, Senator Nelson, Secretary
Principi. I am pleased to be here. I think I bring kind of a
historical perspective, having been through a lot in this VISN
during my tenure as Director of Veterans Affairs from 1996
until just about 10, 11 months ago.
In July 1996 I was appointed Director of Veterans Affairs
for Nebraska by Governor Ben Nelson. Change was just beginning
to occur in the care model for VA medical centers across the
country. Those Nebraska veterans who were eligible to use the
system, were very proud of our State's three VA medical centers
in Omaha, Lincoln, and Grand Island. Quality of care and
compassionate service were both highly acclaimed. The only
significant dissatisfaction that I recall came from those
Category C, now Priority 7 veterans, who were denied access to
the VA health care system. They felt strongly that their
government had made implied and explicit promises of perpetual
health care for them in exchange for their service to their
country. As a group, they were pretty upset about the way the
VA health care system denied them access.
In my early months as Director, the three VA hospitals in
Nebraska were operated pretty much independently. However,
there was a lot of information coming from the system
indicating the financial picture, especially for Grand Island,
was not good. There were rumors about closing Grand Island,
which was an option vehemently opposed, especially by veterans
west of Kearney. Eventually the solution the VA recommended was
to integrate Grand Island and Lincoln. This was supposed to
solve the financial crunch. At the time, I recall veterans
being very skeptical because there was a belief that Grand
Island was a cost efficient operation operating in the black,
whereas Lincoln was not. A year later, the deficits were still
piling up and there was a push to integrate Lincoln and Grand
Island with Omaha. Veterans were wary because the previous
integration had resulted in the loss of inpatient medicine,
dialysis, ICU and telemetry at Grand Island. Surgery at Grand
Island had been previously discontinued. The argument used by
the VA for integrating Lincoln and Grand Island with Omaha was
that the inpatient and surgical census at Lincoln did not
warrant continuation of those services. Veterans believed the
VA had perpetuated a self-fulfilling prophesy. By excluding
care to large groups of veterans, their inpatient numbers were
dwindling. Nebraska veterans felt they had given up enough with
the loss of services at Grand Island and they did not want to
see the same thing happen at Lincoln, but it did. With the
integration of Lincoln and Grand Island with Omaha, Lincoln
lost acute inpatient medicine, general surgery, urology,
orthopedic, psychiatry, and substance abuse rehabilitation.
Throughout the process of both integrations, Nebraska
veterans were given five consistent messages by the VA: No. 1,
the result would be seamless to the veterans, they would never
know it; 2, savings from integration would be put back into the
system to provide better health care; 3, the VA would have
contracts with the local hospitals, St. Francis in Grand
Island, St. Elizabeth's in Lincoln, to provide care to veterans
when transportation to Lincoln and then later Omaha was not in
the patient's best interests; 4, the VA would operate an
extensive transportation network in the State to transport
veterans to the appropriate VA facility; and 5, veterans were
told that they needed to encourage their comrades to enroll in
the VA health care system to get the numbers up and thereby get
a bigger piece of the VERA revenue pie for Nebraska.
Taking these points in order, the actual affect on veterans
was quite different from what they believed they could expect.
First, the changes that were implemented were not seamless,
they resulted in a concentration of services in Omaha, making
care much more inaccessible to outstate veterans; second, there
never were any savings. Every year veterans were told new
horror stories of the burgeoning budget deficits in Nebraska's
three VAMC's and in VISN 14. If no savings were realized from
the previous two mergers, we wondered why this one would be
different; third, the process to obtain care in a non-VA
facility was never well understood, which resulted in veterans
being stuck with medical bills and ambulance charges they
thought the VA was going to pay; fourth, and to this day, I am
told the VA transportation system is no better than it was in
1997 when Grand Island was integrated with Lincoln. A veteran
in western Nebraska is not likely to believe that an
administrator in Minneapolis is going to fix this problem; and
fifth, Nebraska veterans responded to the invitation to enroll
their comrades.
As I recall in one particular year, Nebraska led the Nation
in enrollment percentage increases. The problem was most of
them were Priority 7's and the VA then began telling us these
Priority 7 veterans were bankrupting the system because VISN 14
did not receive any reimbursement for providing them care.
Furthermore, we were told the additional enrollment of Priority
7 veterans was creating a huge burden in the cost of supplying
them their prescription medications. So in effect, by doing
exactly what they were asked to do, Nebraska veterans helped
increase the deficits and put more pressure on cutting costs in
VISN 14.
I recall a discussion I had with a county service officer
who told me he wasn't going to enroll any more Priority 7's
because every time he did, he was contributing to the demise of
the VA health care system. In a tragic and sad way, he may have
been right. This VISN even canceled scheduled health screening
clinics because they produced too many new enrollments.
Given this historical overview, which admittedly has
omitted many veterans' frustrations involving emergency care
situations, transportation, lodging, billing errors and
extraordinarily long waits for appointments, I believe it
should be apparent why Nebraska veterans might mistrust yet
another integration. Hopefully, there are no plans this time to
strip any more services or product lines out of Nebraska.
So where do the efficiencies arise? We could conceivably
eliminate the VISN director for Nebraska and Iowa and the VISN
office in Lincoln. That wouldn't be enough.
As this integration goes forward, Nebraskans deserve to be
told the truth, Mr. Secretary, up front about what will happen
to their facilities and services. They deserve a commitment to
a plan that will resolve the transportation problems. They
deserve to have clear, consistent rules about when and how they
can access care outside the VA system and still expect the VA
to pay for it. They deserve to have Medicare cover the cost of
their care. They deserve to have an associate director at their
facilities in Omaha, Grand Island and in Lincoln. And finally,
I don't know if they deserve this or not, but it would be
awfully nice if whenever they called their VA medical center
regardless of the time of day, a live, helpful and
knowledgeable person would answer the phone. I think it is
disrespectful to those who have served this country to expect
them to deal with an answering machine when they have health-
related concerns.
Senator Nelson and Secretary Principi, thank you for this
opportunity to present my views to you. And in ending now, I
would just add that I do say that you have a great group of
people in Nebraska. It was a great honor for me to work with
people like Gary Nugent, Ken Huibregtse, Cindy Sestak, Dr.
Graham and I always admired Dr. Petzel from afar, as a great
leader. You have the right people here, but they just simply
don't have the resources to do the job that they want to do.
Senator Nelson. Thank you.
Jim.
STATEMENT OF JIM CADA, STATE COMMANDER, MILITARY ORDER OF THE
PURPLE HEART, NEBRASKA DEPARTMENT, LINCOLN, NE
Mr. Cada. Thank you, Senator Nelson, Secretary Principi.
In January I presented a letter to Secretary Principi and
to the Nebraska congressional district and other members of the
Senate Committee on Veterans' Affairs, a copy of the letter has
been provided and the information in that letter continues to
be correct and the questions asked therein are still
unanswered.
As the State Commander of the Military Order of the Purple
Heart, I am here today as a veteran that is deeply concerned
for the care of all veterans. In the late 1990's as Senator
Nelson discussed, we had some studies and those studies showed
that the merger would not bring any benefit, either for the
patient or for the financial situation. So the big question is
why was there another VA VISN study accomplished in secret and
what was the Veterans Administration hiding by not providing
that to us until they decided to merge in January? The VISN
case study was to clearly identify advantages, disadvantages
and opportunities and potential efficiencies. It's just
impossible in any way to say that this merger is going to save
us money.
A sound business decision based on adding two very large
financially deficient entities and concluding that the bottom
line results in financial stability is certainly next to
impossible to understand. If my law office was millions of
dollars in debt, I wouldn't be creating a merger with another
law office that was worse off than mine, let alone being
located several hundred miles away from each other and
expecting to receive economies of scale, and satisfied
customers by sending them to Minnesota.
So what is really being accomplished? It appears that the
VA is trying to drive veterans away so they will seek other
health care providers and use their Medicare benefits instead.
Is that why our veteran patients are being told if they want VA
to pay for their cardiac care, then it will be accomplished at
the VA in Minneapolis not Bryan LGH in Lincoln? They are told
if you want to go to Bryan, you will need to use your Medicare
benefits. I have sort of a conflict of interest in that we
represent Bryan Hospital in Lincoln and Bryan does provide
inpatient care for some of our veterans. But we have stories
about the VA coming into their rooms, closing the door and
saying, ``If you want care, you're going to have to go to
Omaha. We are going to stop paying for your care at the
hospital--at Bryan Hospital,'' and there are many of those
stories.
It appears that the VA is trying to close down veterans'
care in Nebraska because the VA has not given this VISN a
director with the vision and power and the resources to improve
care for all Nebraska veterans.
It appears that the VA is trying to close the Lincoln
facility by downsizing, by sending veterans away, by requiring
travel and delays in care, and making care for veterans
unpleasant or discouraging them with the transfer of the
administrative power to Minneapolis.
The VA has reduced care for Nebraska veterans by
eliminating certain types of care in Lincoln and Grand Island.
It appears that the VA has reduced care for Nebraska
veterans due to reduction of staff, which is going on in
Lincoln at the present time, and the loss of doctors and staff
because of the underlying fear that they have of closure of the
medical facilities. It appears further that the Nebraska
veterans health care continues to be the target for new ideas
that increases the deficit rather than decreases the deficit.
VA administration approved the contracting out of all inpatient
care in Lincoln and Grand Island. VA studies show that it is
cost prohibitive to do that. But now the VA administration has
made a decision to merge without evidence that favorably
supports that decision. The first initiative has been extremely
costly to Nebraska veterans. The second initiative is resulting
in rationed health care.
So in summary, before my yellow light even goes on, the
veterans of Nebraska have the right to receive the same health
care benefits that are provided to veterans that live in other
parts of the country, and that's not so, at the present time at
least. Veterans should not have to worry if the VA can afford
to treat them. The men and women who were wounded and served
our country in the armed forces have earned and paid in full
for the medical care that should be made available. I want to
thank you very much for allowing me to speak. I appreciate the
opportunity and I am finished.
[The prepared statement of Mr. Cada follows:]
Prepared Statement of Jim Cada, State Commander, Military Order of the
Purple Heart, Nebraska Department, Lincoln, NE
In January I presented a letter to Secretary Principi, the
Nebraska congressional delegation and other members of the
Senate Committee on Veterans' Affairs, a copy of that letter
has been provided. The information in that letter continues to
be correct, and the questions asked therein are still
unanswered.
As the State Commander of the Military Order of the Purple
Heart, I am here today as a Veteran that is deeply concerned
for the care of all veterans. The battle might appear to have
been won, but the war will not be over until such time that the
smoke screens or ``Veterans'' are gone.
During the late nineties questions were raised by both the
congressional delegation and service organizations as to why
VISN 14 was being considered for a merger. The answer given and
received was that ``VISN 14 is to small to support its self''.
A substantial amount of money was spent on various outside
consultants that were tasked to study, analyze and provide a
written report on the feasibility of merging V14 with another
VISN. Feedback on all accounts was that there was ``NO
Benefit'' to both the patient and the financial situation.
The big question is why was there another review ``VHA
Business Study'', accomplished in secret? What was the Veterans
Administration trying to hide? By the time the veteran and
their constituents caught wind of the internal review and tried
to make their voices heard, the ink was already dry on the
merger papers.
Lets get down to some hard facts. The smoke has cleared the
screen, the merger has happened but the veterans want some
answers. I won't bore you with the details of the fifty four-
page Business Study. The Business Case Study was to clearly
identify advantages, disadvantages, and estimated cost savings,
clinical opportunities and potential efficiencies. It is
ridiculous for anyone to say that this merger is going to save
us money? The only tangible dollar savings even mentioned
within the document is or was the ``possible savings associated
with joining the two Network Offices''. A million dollars is
nothing when you are facing a $140 million shortfall tins year
alone.
Besides you couldn't even count the VISN 14 Network
Director's salary since that position was temporary and had
been vacant for 19 months. That savings had already been
realized in VISN 14.
Why didn't we just do away with facility Directors and save
twice the money? If VISN 14 was so small why not treat it like
one facility and reduce the number of top management officials,
i.e. facility directors, facility chief operation officers,
facility associate directors, etc.
A sound business decision based on adding two very large
financially deficient entities and concluding that the bottom
line results in financial stability is certainly next to
impossible to understand. Give me a break! If my Law office was
millions of dollars in debt I sure wouldn't be creating a
merger with several other law offices that were worse off than
mine, let alone being located several hundred of miles away
from each other and expecting to receive economies of scale,
and satisfied customer by sending them to Minnesota.
What is VA really doing?
(1) It appears that the VA is trying to drive Veterans away
so they will seek other health care providers, and use their
Medicare benefits instead. Is that why our Veteran Patients are
being told if they want VA to pay for their cardiac care than
it will be accomplished at VA Mpls not Bryan LOH? They are told
that if you want to go to Bryan you will need to use your
Medicare Benefits.
(2) It appears that the VA is trying to close down
veteran's care in Nebraska, because the VA has not given this
VISN a director with the vision and power to improve care for
all Nebraska veterans.
(3) It appears that the VA is trying to close the Lincoln
facility, by downsizing, by sending veteran's away, requiring
travel and delays in care, making care for veterans unpleasant
or discouraging them with the transfer of the administrative
power to Minneapolis.
(4) The VA has reduced care for Nebraska's veterans by
eliminating certain types of care in Lincoln and Grand Island.
(5) It appears that the VA has reduced cue for Nebraska's
veterans due to reduction of staff, and the lose of doctors and
staff because of the underlying fear of closure of the medical
facilities.
(6) It appears that Nebraska veterans healthcare continues
to be the target for new ideas that increases the deficit
rather than decreases the deficit. VA administration approved
contracting out of all inpatient care both in Lincoln and Grand
Island. VA studies show that it is cost prohibitive to do that.
Now VA administration has made a decision to merge without
evidence that favorably supports such a decision. The first
initiative has been extremely costly to Nebraska VA Healthcare
Resources. The second initiative (merger) is resulting in
rationed healthcare.
In Summary, the veterans of Nebraska have the right to
receive the same health care benefits that are provided to
veterans that live in other parts of the country. Veterans
should not have to worry if the VA can afford to treat them.
The men and women who were wounded or that served out of the
country in the Armed Forces have earned and paid in full for
medical care that should be made easily available.
Senator Nelson. Thank you.
Dr. Potter.
STATEMENT OF JANE F. POTTER, M.D., HARRIS PROFESSOR OF
GERIATRIC MEDICINE, CHIEF, SECTION OF GERIATRICS AND
GERONTOLOGY, DEPARTMENT OF INTERNAL MEDICINE, UNIVERSITY OF
NEBRASKA MEDICAL CENTER, OMAHA, NE
Dr. Potter. Yes. I would like to thank Secretary Principi
for his visit and also thank Senator Nelson for the opportunity
to speak. I need to say that missing from my credentials is 20
years of very proud service as a member of the medical staff at
the Omaha Veterans Administration Hospital where I also led the
section of geriatrics within medical service for 6 years.
In 1982 I came to Nebraska as the first geriatrition in
Nebraska. And Senator Nelson, I think it's very important that
we all appreciate how important the Veterans Health
Administration has been in leading efforts nationally to
improve the care for our aging population.
The VA's focus on aging veterans, on increasing knowledge
of aging, on transmitting that knowledge to health care
providers and ultimately improving the quality of care for the
aged has been unparalleled nationally.
VA set up as a cornerstone for their programs in aging back
in the 1970's, programs known as geriatric research education
and clinical centers. Public Law 99-166 expressed Congress
intent that there would be a geographic dispersion of the GRECC
programs across the United States. There would be 25 of these
geographically dispersed. Every network was to have a GRECC,
and prior to the merger of VISN 13 and 14, Nebraska/Iowa was
one of three such VISN's nationally without a GRECC. This
Congress also had recommended appropriations for an additional
two of these geriatric research education clinical centers in
the current congressional budget. We have been aware of this
program over many years and have planned and built out programs
and services specifically waiting the opportunity to apply.
I am here representing the researchers, the clinicians and
educators in our network. Our specific request is that the
Secretary allow this region to compete for a GRECC as would
have occurred prior to the merger.
Every GRECC not only serves its region, but it also serves
VA nationally. The VA region in Nebraska I would say in
particular is well equipped to address two important VA needs.
That includes, not surprisingly given the conversations this
morning, the needs of rural veterans.
Currently there is no geriatric research and education
clinical centers in the country specifically addressing the
needs of rural veterans. And second, the Omaha VA Medical
Center and the national VA appreciates the importance of aging
and alcohol and substance abuse problems. The Omaha VA Medical
Center has 1 of 2 VA funded alcohol research centers which
would nicely combine with a GRECC in research education and
clinical programs to address the problem of aging and alcohol
use within VA.
And then in closing, it is my request that our network, the
Nebraska-Iowa region, be allowed to compete for a geriatric
research education clinical center so that the veterans in the
Nebraska-Iowa region don't become the only geographic region in
the country without one of these very important valuable and
laudable VA resources. And I thank you for the opportunity to
be heard.
[The prepared statement of Dr. Potter follows:]
Prepared Statement of Jane F. Potter, M.D., Harris Professor of
Geriatric Medicine, Chief, Section of Geriatrics and Gerontology,
Department of Internal Medicine, University of Nebraska Medical Center,
Omaha, NE
geriatric research education and clinical center (grecc)
Summary
During the next 30 years, growth in the older population will
transform our society. Caring for a large and growing older population
is a national challenge that is more complex when the target population
resides in rural setting. The country's largest health care delivery
system, the Veterans Health Administration (VRA) has long led efforts
to meet these challenges.
The University of Nebraska Medical Center (UNMC) requests funding
for a VRA Geriatric Research Education and Clinical Center (GRECC) at
the Omaha Veterans Affairs (VA) Medical Center. A GRECC program would
provide support for 12 full-time employee equivalents at roughly $1
million annually. This core support would be used to:
(1) develop unique research programs on rural aging veterans
and on alcohol use disorders in aging veterans
(2) educate health providers in practice and those still in
training on care of the aged
(3) provide innovative clinical care and services to benefit
both rural and urban aging veterans.
Need
Between the year 2010 when the first baby boomers turn 65 years of
age and 2030, the population over the age of 65 years will more than
double. The greatest growth will be among persons aged 85 and older.
Nebraska and Iowa already lead the nation in the proportion of the
population over 85 years. This mid-western region is additionally
challenged to serve an aging population that is dispersed in rural and
thinly populated frontier areas. As is true elsewhere, there are far
fewer health professionals trained than are needed to serve the
burgeoning older population.
The Veterans Health Administration in 1970 initiated a strategy to
focus attention on the aging veteran, increase basic knowledge of
aging, transmit that knowledge to health care providers and improve the
quality of care to the aged. The Geriatric Research Education and
Clinical Center (GRECC) program is the cornerstone of this strategy.
Public Law 99-166 expanded this program with the intent of establishing
25 of these centers geographically dispersed across the US. Every
network was to have a GRECC program. Prior to the merger of the
Nebraska/Iowa Veterans Service Network with the Minnesota/North and
South Dakota Network in January 2002, Nebraska/Iowa was one of 3
Veterans Networks nationally without a GRECC program. Congressional
approval of 2 more GRECCs in the 2002 budget should have allowed UNMC
and the Omaha VA to compete for this program with the two other
unfunded networks. With the merger, our ability to compete for this
program will be lost unless the criteria are changed to allow us to
file an application. Moreover, the merger of two rural networks has not
reduced the important regional need for a GRECC program to serve our
aging rural veteran population or the intent of Congress to place these
programs in geographically dispersed regions.
Requested action
Response to the GRECC application submitted an behalf of UNMC/OVAMC
to serve the veterans of Nebraska and Iowa region by the provision of:
12 full time employee equivalents, approximately $1 million
annually.
Designation as a GRECC also allows: competitive application for
ongoing research awards in aging and geriatrics; request for training
stipends in medicine, nursing, pharmacy and allied health; and
application for continuing education funds.
Institutional uniqueness
The Omaha Veterans Affairs Medical Center is a leader in the
conduct of research, education, and tertiary care for veterans in this
region. Roughly 630 medical trainees study at the Omaha VA each year
for nearly 27,000 hours annually. Since 1991, the Omaha VA and its
affiliated program in geriatric medicine from UNMC have laid the ground
work for a GRECC through health professional education, outpatient and
inpatient services, quality improvement projects and through education,
research and training at the affiliated state veterans' home.
Throughout these activities service to rural veterans has been
emphasized.
UNMC has a federally funded Rural Research Center that has
a major interest in service delivery to older people. No VA GRECC has a
program addressing rural veterans.
The Omaha VA has one of three Alcohol Research Center's in
the VA system. Alcohol related disorders are an important problem in
older veterans and one that has not been addressed at any VA GRECC
program.
The Omaha VA is in a unique position to address alcohol
use problems and rural veterans under a GRECC.
The UNMC Section of Geriatrics has been a regional leader in
education and training for the last 20 years.
Gerontology and geriatric medicine has been taught as part
of the curriculum for medical students at UNMC since 1981. Training in
geriatrics has been mandatory for Internal Medicine residents and
Family Practice residents since 1985 and 1987, respectively.
Since 1993, the Omaha VA has served as the primary
geriatric-training site for residents of Internal Medicine from
Creighton University.
In 1986 UNMC initiated the first (and still the state's
only) advanced training program in geriatric medicine for physicians, a
program which also employs the Omaha VA as a training site.
In 2000 the UNMC College of Medicine was one of 20 U.S.
medical schools to receive support from the American Association of
Medical Colleges to develop model programs for geriatrics education in
medical schools.
In April 2001, the College received a $2 million grant
from the Reynold's Foundation to increase enthusiasm among medical
students for care of the aged and to provide training within each year
of primary care residency training in programs across the state and
within the surgical specialties.
In 2002, the UNMC will complete plans for a geriatric
center located between UNMC and the VA. This facility will house the
UNMC education, research and clinical, and community outreach program
in close proximity to the proposed GRECC.
A GRECC program at the Omaha VA would focus on two unique research
areas. health services research for rural veterans and on research on
aging and alcohol use disorders. The Omaha VA has a strong geriatrics
program and is affiliated with a nationally recognized program in
geriatrics at UNMC, making our application for a GRECC unique in the
region.
Conclusion
The Omaha VA serves an essential role in health professions
education for this region and in the health care of its aging
population. Under a GRECC program, the Omaha VA Medical Center in
partnership with UNMC is uniquely qualified and prepared to raise the
standard of care for both rural and urban veterans, conduct unique
research an two important problems of aging, and serve as a regional
resource in geriatric education. Resources under a GRECC program would
provide annual support of one million dollars to meet the challenge of
caring for our aging veteran population.
Senator Nelson. Thank you very much, Dr. Potter.
Mr. Secretary, do you have any questions you would like to
ask of any of the panelists?
Secretary Principi. No, not at this time, Mr. Chairman.
Senator Nelson. Thank you very much for your presentations.
I appreciate your being here. Thank you.
As the next panel is arriving, I would like to introduce
them. First of all, we have Greg Kulm, Chapter 260 Officer,
Military Order of the Purple Heart, Nebraska Chapter; Jerry
Bove, the Nebraska Department Commander, The American Legion;
Alfonso G. Martinez, Jr., Nebraska State Council President, the
Membership Chair of the Vietnam Veterans of America; Howard
Braman, the Commander of the Nebraska Disabled American
Veterans; and Craig Enenbach, Treasurer and Member, Board of
Directors, Great Plains Chapter of the Paralyzed Veterans of
America.
Howard, you drew the long straw.
STATEMENT OF HOWARD BRAMAN, COMMANDER, DISABLED AMERICAN
VETERANS
Mr. Braman. Yes, sir, it sure looks that way, sir.
Mr. Nelson and Mr. Principi. My name is Howard Braman. I'm
the Commander of the Disabled American Veterans Department in
Nebraska. I'm a retired 26-year-plus military man, 70 percent
disabled. I am here because I'm kind of upset the way VISN 13
and 14 was combined. I would like to know why the veterans were
not notified in the two districts. I would like to know why the
people had to travel so far from one element to another element
to another element. I would also like to know why the moneys
are lost between the two elements, VISN 13 and 14, and why we
cannot have more CBOC's.
We had two elements out west, one is in North Platte across
a CBOC. It's a regional hospital, bigger than any hospital here
in Omaha. We have another one in Scottsbluff, the same way, and
yet again, we send people from Scottsbluff all the way up to
Hot Springs and Cheyenne.
Why can't we send them across the street in Scottsbluff and
North Platte? And why do we have to send people from North
Platte to Omaha when we have three--as you said, two hospitals
between here and there and they're not being used, and yet,
again, they want to take and combine 13 and 14 into one
humongous VISN. I don't understand that, and I want you to
explain to me why this was done so that I will be able to
understand it and let the Disabled American Veterans,
Department of Nebraska, know why you did this. So please
explain to me why.
Senator Nelson. If we could go forward then, we will take
notice of that.
Mr. Braman. I'm done.
Senator Nelson. Thank you, now Al.
STATEMENT OF AL MARTINEZ, STATE PRESIDENT, VIETNAM VETERANS OF
AMERICA AND LEGISLATIVE COORDINATOR
Mr. Martinez. Yes. My name is Al Martinez. I'm State
President of Vietnam Veterans of America and Legislative
Coordinator for the State as well.
Honorable dignitaries and distinguished fellow colleagues,
comrades, ladies and gentlemen. Our concern that the 200,000
veterans in our VISN that use the VAMC is--even through at
great lengths of cutting budgets, employee reduction,
readjusting staff and increasing the number of veterans that
use the VA health care system, we were merged with a larger
VISN that is also failing according to the VA data and reports.
How can two wrongs make a right? Because they are larger, we
are not merged, we are absorbed. This is bad enough that we
will be competing for moneys funding on a lager scale and that
Nebraska and Western Iowa on the lower scale half would make
things and matters worse.
We will now compete among the VAMC's in our area for
survival. It has been proved more than once time and time again
that the problem was not with the employees, staff or veteran
patients, but rather the upper administrative task force
employed by the VA and health care system. Do not chastise our
VAMC employees and patients for the lack of competence in the
upper administrative and operating system that have caused the
VA to lose money in care of funding by the Federal Government.
Not long ago our VISN Director Vincent Ing was transferred
to us in Nebraska to help us and it turned out that he brought
problems from previous VISN's and when it was all said and
done, we lost Vincent because of the inadequacies and problems
that came with him. Now you bring us a new VISN person, Mr.
Petzel, and we don't know him as well, but our concern is that
this is not a failing VISN coming to help another failing VISN
and that the veterans will not be taken in at the expense of
inadequacy of administration and policy of administration in
care of the infrastructure.
We now have a better understanding of the 44
classifications of veteran patients. I believe they might have
even added a few more. But they are only three forms of amounts
of VERA reimbursement, approximately $105, $2,800, and $3,200
per patient. Over the previous past years our VISN lost moneys
in over 50,000 patients to a negative because of the lack of
oversight administratively. Since then, over 20-plus employees
were resigned, terminated, or transferred. This is only one
level and everything goes wrong at the highest management
level. Staff and employees take the pressure, but higher level
positions are transferred and become someone else's problem.
This needs to be addressed.
Already the Omaha VAMC is overwhelmed with parking space
from priority veterans. A smaller staff and employees are
serving a greater number of increase in veteran patients. Even
though a greater number of veterans are using the VA health
care, VAMC's are competing in our area to stay open. Once
again, this kind of stress on employees and staff at the
expense of saving a dollar and jeopardizing health care for the
veteran is not acceptable. Furthermore, transferring and
rearranging upper level management to cover mistakes at the
expense of the VA is not helping our cause.
Just recently President Bush approved $107 million and
added $400 million to our emergency funding for the VA health
care system. This should not be about asking for a loan or a
handout. This should be about capitalizing on the hard work and
effort that VISN 14 originally made and continues to make for a
better present, future of our VAMC's. Therefore, if our VISN 14
was merged by VISN 13, absorbed to make 23, make sure we are
not dissolved in the process and when moneys funding is
allocated on a priority basis, we in Nebraska and Western Iowa
find ourself at the bottom of this number scale.
My time is out and I have a few more things to read, but
the only thing I will ask you is this: With the merger of 13
and 14, what are the benefits the VA and veterans of both
VISN's who are in will lose or win? With the shortfalls of VERA
funding, what efforts will this have on the merger of 13 and
14? Where do we stand on an opening at--admitting centers of
excellence for Hepatitis C and where will the closest one be to
us? How do you account for the VISN directors and the hospital
directors who fall with a golden parachute and can't be
touched? Should they be held more accountable? What are the
long-term plans to improve the VA system and to back up the
shortfall of moneys that we have lost in the past?
Thank you.
[The prepared statement of Mr. Martinez follows:]
Prepared Statement of Al Martinez, State President, Vietnam Veterans of
America and Legislative Coordinator
Our concern, the 200,000 Veterans of our VISN 14 that use the VAMC
system, is that even though VISN 14 went through great lengths of
cutting budgets, employees, readjusting staff and increasing the number
of Veterans that use the VAMC Healthcare; we were merged with a larger
VISN 13 that is also failing according to V.A. data and reports. How
can two wrongs make a right? Because they are larger, we were not
merged--we were absorbed. It is bad enough that we will be competing
for monies funding on a larger scale with Nebraska and Western Iowa on
the lower half, but, to make things/matters worse, we will now compete
among the VAMC's in our area for survival. It has been proven more than
once, time and time again, that the problem was not with the employees,
staff or Veteran patient, but rather the upper administrative task
force employed by the V.A. Healthcare System. Do not chastise our VAMC
employees and patients for lack of competence in upper administrative
operations that have caused the V.A. to loose money c/o funding by
federal government. Not too long ago our VISN Director Vincent Ing was
transfered to us in Nebraska to help us and it turned out he brought
his problems with him from his previous VISN. Now you bring us Mr.
Robert A. Petzel from another failing VISN to help us again? Not all
Veterans are highly educated especially in the areas of the V.A., but
they see what is happening to their healthcare system.
Examples:
1. We now have a better understanding of the 44 classifications of
Veteran Patients, I believe they might have even added a few more. But
there are only 3 forms (amounts) of VERA Reimbursement--approximately
$105.00/patient, $2,800.00/patient, or $3,200.00/patient. Over the
previous/past years our V.A. system lost monies on over 50,000 patients
to the negative because of this lack of oversight administratively.
Since then over 20+ employees were resigned, terminated or transferred.
This is only on one level. Everytime something goes wrong on a higher
management level, staff and employees take the pressure. But higher
level positions are transferred and become someone else's problem. This
needs to be addressed.
2. Already the Omaha VAMC is being overwhelmed with parking space
for priority Veterans. A smaller staff and employees are serving a
greater number/increase in Veteran patients. Even though a greater
number of Veterans are using the V.A. Healthcare. VAMC's are competing
in our area to stay open. Once again, this kind of stress on employees
and staff at the expense of saving a dollar and jeopardizing healthcare
for the Veteran is not acceptable. Further more, transferring and
rearranging upper level management to cover mistakes at the expense of
the V.A. is not helping our cause to stay open and functional. As for
priority 7 affecting the budget at this time 1-3 become service
connected changing their state.
3. Just recently the President of the U.S. Honorable Bush approved
$107 million with and added $400 million c/o our Emergency Funding for
the V.A. Healthcare System. This should not be about asking for a loan
or a handout. This should be about capitalizing on the hard work and
effort that VISN 14 originally made and continues to make for a better
present and future of our VAMC's. Therefore, if our VISN 14 was merged
by VISN 13 / absorbed to make VISN 23. Make sure we are not dissolved
in the process when monies/funding are allocated on a priority basis
and we in Nebraska and Western Iowa find ourselves at the bottom of the
numbers scale.
4. Satellite clinics were established in Norfolk, Nebraska and
other areas to save on transportation and facilitate service to
Veterans in rural areas. This is great up to the point when funding
allows for 200+ and the needs are 300+ as an example. Enrollment and
the bulk of services and special clinics remain at the Omaha VAMC which
is fine as long as the increase of services and patients is equal by
funding, staff and employees to provide these services. Quality of
LPN's, RN's, PA's, and specialized staff/personnel should also be
maintained and monitored based on their qualifications and not on the
work-overload.
5. Recently areas of special need were addressed. Example:
Pharmacy--The question extra personnel needed to evaluate the issue of
overmedications was brought up and keeping up with waiting time for
medications. This is fine as long as time and money is not shifted and
over concentrated/spent on higher paid (evaluations) employees/staff to
supervise and less effort on actual pharmacy service and time element/
waiting for medications to be dispensed to Veterans.
6. When Veterans are transported from one end of the state to
another, without informing them of doctor cancellations, this is burned
to the Veteran especially if Veteran is told he will be seen later that
day and later told to come back the next day and no provisions are made
to cover the cost of overnight lodging for that Veteran.
7. Numbers of Veterans using the V.A. will continue to grow/
increase based on older Veterans, Millennium Bill and approved service
connected disabilities long over due c/o radiation; Agent Orange;
P.T.S.D.; diabetes; heart, lung and cancer medical problems; Persian
Gulf Syndrome and more. But they (V.A.) will not meet the needs of
these Veterans if the VAMC's are not allowed to maintain the needed
funding budget to continue services so that Veterans can continue to
come back and want to come back. Keep in mind that our V.A. Healthcare
System has not only improved nation wide in comparison, quote, to the
private sector. But is actually a very important factor in the future
of this country/nation regarding Biological/Chemical Hazards c/o
treatment, P.T.S.D. c/o terrorism of victims, the Security of the Land
Plan should include the knowledge and experience the V.A. has not the
private sector in dealing with combat and biochemical hazards of war.
If anything, the more you invest in our V.A. Healthcare System now the
better you secure and insure the needs of our future Veterans and
Citizens of this country/nation.
8. Regarding questions and answers about the VISN merger, I have
attached the VISN's response and will write my response.
Question A. Why the study was done?
VISN Answer. There in fact is an increase in Veterans using the
V.A. not because of the declining Veteran population but rather more
Veterans using the V.A. due to age, loss of civilian healthcare due to
income, increased eligibility of benefits c/o service connection and
the Millennium Bill.
My Answer. VA is constantly looking for ways to improve services
for veterans and to expand programs to more veterans. Moreover, VISNs
13 and 14 have small, declining veteran populations as well as
overlapping populations in several areas. By merging the management
teams at the VISN levels, VA can continue to serve veterans with
quality medical care while reducing overhead cost, and combining their
strengths to form what we expect wilt be an exceptional network.
Essentially, the consolidation at the management level should be
transparent to the veteran.
Question B. How much money will be saved?
VISN Answer. Prior to the merger, money was saved due to a
reduction in V.A. spending and employees being reduced to a smaller
staff. A better understanding of the VERA Program c/o Veteran
classification as patient vs. reimbursement. Unfortunately, our farmers
were penalized in eligibility of benefits.
My Answer. The goal of the merger is not to save money, but to
redirect resources toward patient care. How much will be redirected to
more patient care is unknown.
Question C. Why aren't other VISN's merging?
VISN Answer. We are not unique, unless it is because we are the
smallest, or the easiest one to work with and use for an example to the
rest.
My Answer. The VISN 13-14 merger is unique due to the
characteristics and geographic proximity of the two networks. No other
mergers are under consideration at this time.
Question D. How many employees will be affected by this?
VISN Answer. That is not the question. The question is how many
more now and how many more in the future.
My Answer. Only a small number of employees at the VISN level will
be immediately affected at the time of the merger. The exact number of
employees is yet to be determined. We will make every effort to find
continued employment for affected employees within VA.
Question E. How will the merger be managed?
VISN Answer. The Integration Advisory Committee Team is composed of
10 to 15 people who have survived being transformed, resigned and
retired. They will now be led by a new VISN Director who comes from a
failed VISN. What is wrong with this picture?
My Answer. A joint, VISN 13-14 Integration Advisory Committee will
be formed to develop the plan. This will be a team of 10 to 15 people.
Question F. Will services at some locations be closed or
consolidated at other locations?
VISN Answer. This question should not be a question. Especially
since steps are already being taken to do the above and since employees
already feel the need to compete or risk being closed.
My Answer. No facilities are scheduled to be closed under this
merger.
Question G. What will the new network be called?
VISN Answer. VISN 23 c/o 22 VISN'S.
My Answer. VISN 23.
Question H. Office to be located and consolidated?
VISN Answer. Originally in Lincoln, that has now changed.
My Answer. That will be decided by the Joint advisory committee.
I am only one (1) of 200,000 Veterans that will be affected.
Hopefully this will give you some ideas of my/our concerns. I have
more documentation and data I will have at the hearing.
Senator Nelson. Thank you, Al.
Jerry.
STATEMENT OF JERRY P. BOVE, STATE COMMANDER, THE AMERICAN
LEGION, DEPARTMENT OF NEBRASKA
Mr. Bove. Secretary, Mr. Congressman.
My name is Jerry Bove. I'm a State Commander for the
Department of Nebraska, American Legion. I've got about 55,000
people that call me occasionally. I'm here today representing
not only to bring forth some of their concerns, but my own
experiences as the veterans across the State do call. First of
all, I will discuss my personal experiences.
I must say at this time that prior to the merger of VISN 13
and 14, I was well satisfied with the service and treatment
that I received from the VA medical facilities. Since 1986 I
have had 10 surgeries in Minneapolis, Lincoln, and Sioux Falls.
I'm a 100-percent disabled veteran that was taken care of. I
have had various procedures including physical therapy at non-
VA facilities and payment to these facilities was no problem
until now.
I'm receiving a bill from a non-VA facility for services in
September 2001. I contacted Des Moines and their comment was,
well, it wasn't preapproved, we are going to deny it. When the
letter gets there, appeal it. We will have the board look at it
and probably approve it since you are service-connected. The
problem is that it is already too old and interest is
multiplying. One problem seems to be that county veterans
service officers don't call in in a timely manner and they say
it's not preapproved. I think this is part of the county
veterans service officers' job, but when I asked Des Moines
about it, they said, well, they don't work for us and it's your
responsibility. If I'm in an ambulance going to a hospital, am
I supposed to say wait a minute, am I supposed to call Des
Moines and get this thing approved before you can drop me off?
Appointments are being canceled and rescheduled regularly.
According to the VA medical center, this is due to a personnel
problem. I call the hospital about rescheduling an appointment
with my primary care doctor and was told October would be the
earliest that I could get in. Six months seems to be a bit too
much here.
I spent some time years ago working on combining
appointments as I live 250 miles from a hospital. It was
working until the changes. They want me to drive over 500 miles
for a 10-minute chat for the doctor. I get paid mileage, I
spend over 8 hours driving. It doesn't make a lot of sense to
me.
It seems as though the doctors are on kind of a part-time
schedule, although clinics are scheduled every day. It's a
different one every day, so you can't combine your appointments
to 1 day. They want you there all week.
Now, it might be my imagination, but things seem to have
gone awry after the integration. Do we blame the problem on the
merger or do we blame the hospital administration? Some of
these problems are not hospital related.
The current administration budget calls for the Category 7
veterans already in the system to pay the first part--to pay
part of the first $1,500 of their annual health care. Now, as I
understand, this has been dropped now. They want to drop the
Category 7 veterans. Well, that got shot down. They did raise
the co-payment on their drugs $2 to $7 per prescription. Now, I
understand if they drop Category 7 this year, do you look at 6
the next year as a cost-seeking matter? It doesn't really make
sense to me, but----
Many veterans are receiving inaccurate insurance and co-
payment bills from the VA. Now, this is an administrative
problem. The VA is not making timely payments, nor are they
submitting insurance claim forms in a timely manner.
As Commander of the American Legion, I have received
letters from veterans about their problems. I received a letter
from a lady veteran who was treated, but the bill took so long
to get to her, her insurance refused to pay it because it was
not submitted in a timely manner. In other words, it didn't
make the 6-month cutoff. One of the first questions asked of
you when you check in at the VA is do you have insurance. They
then forget to send the bill to the insurance company. Nine, 12
months is not unusual now. And when the insurance company
refuses to pay, who gets stuck? The veteran.
Another veteran was in an ambulance. He was taken to a non-
VA facility. He needed immediate help. And he's a 40-percent
service-connected veteran, but he was told that treatment was
not preapproved, the bill was his responsibility and he cannot
afford it.
Now, I understand there are rules and regulations and
hospital administrators have their problems. VISN 23 has its
problems, but who loses through all of it? It's the veteran.
Now, I understand there are veterans in Florida who wait up to
3 years to see a doctor, so maybe we are the lucky ones.
Thank you for the opportunity to speak. I appreciate it.
Thank you.
Senator Nelson. Thank you, Jerry.
Greg.
STATEMENT OF GREG KULM, ON BEHALF OF THE MILITARY ORDER OF THE
PURPLE HEART
Mr. Kulm. OK. Senator Nelson, Secretary Principi. My name
is Greg Kulm and I'm here representing the Military Order of
the Purple Heart. I would like to thank you for allowing me the
opportunity to voice my concerns and personal opinions
regarding the veterans of this region as well as the rest of
the country. While serving with the U.S. Marine Corps at the
age of 18 in Vietnam as a rifleman, I was severely near fatally
wounded while patrolling in an area that was filled with land
mines. I lost both my legs and suffered multiple complications
while being cared for immediately after my injury occurred. I
have been coming to the same VA medical facility since 1970,
over 32 years, for all the medical complications I have
incurred because of my injuries in Vietnam.
Regarding the merger of VISN's 13 and 14 to one VISN, my
first concern is how does it affect the veterans seeking
medical care. This is a management change. You are taking two
regions--correction--VISN's that are currently underfunded and
combining them into one larger VISN that will nearly be under--
that will be underfunded. The veterans seeking care at the
medical facility will not see any difference in the daily
operation and care with this merger. Will there be an increase
in budget in combining these VISN's? There's only two ways to
solve the problem, increase the funding for the hospitals, cut
back on the patient load by turning certain veterans away.
In the last few years I have personally seen and have been
affected myself by the deteriorating care for the veterans at
the Omaha VA Medical Center. It's not the VA employees, it's
the overbooked schedules and the lack of staff that provides
the care in a proper and timely manner. I know the solution and
I think that Washington knows the solution. It's money. And
it's my opinion that the current politicians don't want to
appropriate funding for adequate medical care that the veterans
so deserve, why give funding to people who will not be around
in 5 to 10 years to vote for them.
Is it who you know in Washington because it just took 1
year to get $17 million for Nebraska to build a foot bridge
over the Missouri River? Just how many people are going to walk
over the river from Omaha to Council Bluffs? Think of how much
medical care that amount of money would have provided to the
veterans of the VA medical center.
I ask you, have the politicians lost sight of where their
priorities should be? Holding hearings, setting up committees
and changing management is a waste of time. All of these things
do nothing to assist the veterans with their medical care. It
just delays it until the problem disappears.
Thank you.
Senator Nelson. Thank you.
Craig.
STATEMENT OF CRAIG F. ENENBACH, NATIONAL DIRECTOR, GREAT PLAINS
PARALYZED VETERANS OF AMERICA
Mr. Enenbach. Senator Nelson, Secretary Principi and staff
and others responsible for conducting this hearing, I want to
thank you on behalf of the members of the Great Plains
Paralyzed Veterans of America. The merger of VISN's 13 and 14
into a new VISN 23 represents a major reorganization of the
Department of Veterans Affairs Health Care Delivery System for
the upper midwest and the Great Plains of Iowa and Nebraska.
The merger also affords the VA with opportunities for
efficiencies and improved services to veterans. However, for
veterans with spinal cord injuries, several issues must be
addressed.
PVA members and all veterans with SCI rely upon the VA for
a lifetime of health care ranging from acute care, immediate
postinjury care, through rehabilitation, sustaining care and
finally, Various options for long-term care. VA and Congress
have over the years clearly recognized the need for this full
continuum of care and have created the VA's unique spinal cord
injury system. This system is a nationwide system with
centralized guidance and not constrained by VISN alignments.
This is clearly evidenced by the fact that neither VISN 13 nor
VISN 14 has a spinal cord injury center and veterans with
spinal cord injury residing here must travel significant
distances for their care.
Many of the members of Great Plains PVA travel to
Milwaukee, St. Louis, and even Seattle for their care at a VA
spinal cord injury center. In fact, as we speak, one of our
members is recovering from surgery in Milwaukee. This care has
been augmented by the creation of a hub-and-spoke feeder system
that relies upon specialty teams of clinicians who serve as
primary care providers directing veterans with spinal cord
injury to VA spinal cord centers when medically appropriate and
necessary. This system must be maintained with the merger and
the overall provision of care for veterans with SCI must be
assessed in an effort to more clearly facilitate access and
decrease travel times.
The Minneapolis VAMC has evolved into an exceptional source
of care for many veterans with SCI and its elevation to a fully
recognized VA spinal cord center is strongly supported by PVA.
A center in Minneapolis will greatly enhance the availability
of SCI care in the new VISN 23 by significantly reducing travel
distances. PVA has analyzed current patient demographics and
SCI center utilization and has determined that the creation of
a center in Minneapolis can be achieved without the patient
base of other centers being eroded. This center must, however,
be established and operated consistent with VA policy and
guidance currently established in VA Handbook 1176.
Finally, Senator Nelson, I would be remiss if I did not
point out that regardless of efficiencies and opportunities
created by the merger of 13 and 14, this area and all of the VA
needs more money if it is going to continue to meet the needs
of enrolled veterans in a timely and appropriate manner. PVA is
a coauthor of the Independent Budget with AMVETS, Disabled
American Veterans, and the Veterans of Foreign Wars, and this
year we are calling upon the administration and Congress to
adequately fund VA. A supplemental appropriation is currently
being considered by Congress for this current year, fiscal year
2002, and it is our firm belief that VA needs at least $400
million to meet its present obligations. We also believe that
an increase of $3.1 billion over next year's level is necessary
to fund VA health care for fiscal year 2003.
Thank you for this opportunity to present the views of
Great Plains PVA and I will try to answer any questions you may
have.
Senator Nelson. Thank you very much.
First of all, Mr. Secretary, any questions or comments you
would like to make in connection with this panel?
Secretary Principi. Well, Mr. Chairman, I too appreciate
the testimony of the men sitting before me today, and I
appreciate their insights and their concerns.
Maybe a general observation. And I don't want to sound
defensive--I want to sound positive. There is no nation on
Earth, no nation, and I have looked because I was chairman of
the Congressional Commission on Service Members and Veterans
Transition Assistance a few years ago, known as the Transition
Commission, and I was chairman of that Commission, and our
congressional commission summoned representatives from all of
our allied countries around the globe to Washington to receive
testimony from them as to what their countries do for their
Nation's veterans, and it was extraordinary how little they do
and how much we do. Now, that's not to say that we can ever
repay the debt that we owe to any man or woman who serves in
uniform or combat, especially someone like Mr. Kulm who lost
half of his anatomy in Vietnam. You just cannot repay that
debt. There is simply no way to do that. But our Nation is a
generous nation. Our President, our Members of Congress are
very, very generous to VA.
I happen to lead the second largest department in all of
Government, and with this year we'll probably be close to $60
billion in appropriations. Again, is it enough? No. 220,000
employees. No department has that many people other than
Defense, and they have a lot more. They're in a class all by
themselves. But I just believe, and I don't want to say I
disagree, but I just believe that our Nation cares very, very
deeply about men and women in uniform. I mean, the fact that
more and more veterans are coming to us for care is not an
indication the care is lousy, it's an indication that the care
is darn good. It is so good, as a matter of fact, that they
want to come. Their benefit package is so attractive and, as
you know, many Americans have to spend $300, $400 a month, who
are not veterans, to get their prescriptions filled. My mother
is one of them. I sent her a check every month for $400 so she
could buy her medication. Any veteran in this Nation, whether
they are someone like Mr. Kulm who is 100 percent service-
connected and paid almost the ultimate price, or someone who is
making $50 million a year and never saw combat, doesn't have
any disabilities, no military service disabilities are treated
equally under the law. No one has a priority for care, and they
can get the nonservice-connected wealthy veteran who can come
to VA and get his or her drugs for $7 and can be in front of
the line. But that's the way the system has evolved, and as a
result of it, we have so many more veterans coming to us in
places like the Sun Belt and Florida, and we try to do the best
we can with the resources we are given. And I'm not going to
sit here and say to you that we have all the dollars we need.
We don't. I have been very, very honest about it, and I said
hard choices have to be made. One is Medicare subvention. If we
don't get Medicare subvention, then copayments for those who
are nonservice-connected high-rank help to share in the cost of
their care. Another is to suspend enrollments for Priority 7
veterans. I came very close to doing that last year because I
felt that the quality of health care in VA was being impacted,
and veterans are not well served when they have to wait 6
months or a year to get into an outpatient clinic for care. We
are not meeting their expectations, and that's not the way we
should be conducting ourselves. So I said rather than disenroll
anybody, I should suspend enrolling new Priority 7's so those
who are enrolled can at least get into the clinic on a timely
basis. But fortunately the President and Members of Congress
came to my aid, and we have a supplemental pending before
Congress, and hopefully that will be approved soon, and we'll
be able to continue to keep the doors open to everyone. But
those are just some of the dynamics of the challenges we face
in providing health care. There are no easy answers. If there
were easy answers, they would have been done a long time ago.
The easy answer for me is to do nothing, argue for more money
and not make the tough decisions that have to be made, but I
felt that suspending enrollment was the right decision. Tough
politically to do, but I think the right decision.
Consolidating the two networks is an issue. Now, network
people are very important people. They're wonderfully dedicated
people. They're support people, and you need support people.
Just like in the military, we needed support people. You know,
you have the folks in the trenches, and you had the folks in
the rear echelon providing support. But I want to make sure
that our truth-to-detail ratio is balanced as well. That's when
I saw we had two networks that were really quite small relative
to the others and with veterans, of course, declining not only
in Nebraska and Iowa, but everywhere else as well. I felt it
made sense to be more efficient, to be more effective, that we
can consolidate those support functions into one network rather
than hiring a new network director at a relatively high level.
But I insist, I insist that the veterans of this area of
Nebraska be treated fairly and equitably, and if they're not,
then I will take steps to ensure that happens. But I have every
reason to believe that under Dr. Petzel's leadership, that will
be the case. The fact that he has been here so many times is
ample evidence to me that he cares deeply about the veterans of
this area, and he's not going to shortchange them to send the
money to Minneapolis. Minneapolis is an important medical
center. And if I need open heart surgery, I may want to get on
a plane to go to a place like Minneapolis where I know that
you've got some superb surgeons there, not that you don't have
them in Omaha or other parts of this wonderful State, you do.
Obviously I just saw the magnificent hospital down the road, I
believe the University of Nebraska. So we do have that here.
But the fact is that we've got to make some tough choices
gentlemen, and I'm not going to shy away from making them. I
mean--I only have one concern at heart and that is veterans.
I've got two sons on active duty in the Air Force, one in
Southwest Asia, I've got a son who's joining the Marines. I
care deeply, very deeply about men and women in uniform who are
our Nation's veterans, and I would do nothing at all ever to
compromise that concern, and I believe that the people who work
for me feel the same way. It's not to say it's easy, but I feel
that we're going in the right direction and I feel with support
from people like Senator Nelson and the members of this
delegation, Chuck Hagel, another great Vietnam veteran, and Mr.
Bereuter and Osborne and the rest of this delegation, that
you're in good hands. Thank you.
Senator Nelson. Thank you very much, Mr. Secretary. And as
we draw to a conclusion, there are a couple of observations I
would like to make. First of all, I think that the concern here
is that there's a question of whether it's a merger or
absorption--to merge or to absorb. Based on what you're telling
us and what Dr. Petzel is telling us, is that we're not going
to be absorbed in Nebraska and be a subset of Minneapolis
administration and management. You'll continue to provide the
kinds of services as close to home for our veterans as is
entirely possible, recognizing that there are some challenges
in a State like Nebraska. We are geographically challenged; a
large area and a smaller population. We're not alone in that
regard, but we are affected that way.
Also, there is a concern about funding. There's no question
that what we must fund these programs in the most appropriate
and generous way possible. While recognizing all the needs we
have as an American government, challenges with war, but also
challenges with needs here at home. You have my full commitment
to work with you as a member of the Veterans' Affairs Committee
to make sure that we work in every way possible to get adequate
funding for our veterans, and particularly as it relates to
this area.
I often hear how bad things are, as we all do, because
there are challenges here and challenges there. I know we must
identify and deal with those challenges as quickly and as
appropriately as possible.
I know you have been on Capitol Hill talking to us about
the challenges that you have. You're hearing from people right
here on the ground, the folks who receive the benefits, about
their challenges. I hope we can always continue to work
together, as we have, to try to deal with each of the
particular situations we find, but to also try to improve
overall. We can reduce the number of challenges that we have by
better management, but also by the delivery in the quality and
quantity of care.
I think today's hearing has been productive. I certainly
have learned more. It's important to hear specifics. In
Washington, all too often we deal with generalities, but I
think it's good for us to be here. We are talking to people who
have the availability of those services, who have used them,
and who hear from their peers about what their experiences are,
otherwise, we're looking at numbers and I'm one who likes to
put faces together with numbers every time that I possibly can.
I want to thank you very much for being here with us today
for your testimony and also for staying with us to hear panels
II and III.
I would also like to thank my staff, particularly Eric
Pierce, my staff in DC and the staff here in the Nebraska
offices for your help in putting this together, and, of course,
the staff from the Veterans' Affairs Committee who are here
today making sure that this is, in fact, an appropriate hearing
conducted under the auspices of the Senate Veterans' Affairs
Committee.
With that, I get to do this again now, [raps gavel] with
that, I call the hearing concluded.
[Whereupon, at 12:11 p.m., the committee was adjourned.]
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