United States Senate

                                  Committee on Veteran’s Affairs Field Hearing

                            Improving Access to Quality Healthcare for Rural Veterans

                                                     April 21, 2012

                                                   Billings Montana  

                                                    James F Ahrens                       

Senator Tester and members of the Senate Committee on Veteran’s Affairs, it is my pleasure to present this testimony to you today on behalf of veterans living in rural America. 

I currently serve as Chairman of the Veterans Rural Health Advisory Committee. (VRHAC).  However, the testimony that I am providing today is my own and not the VRHAC’s. It is based upon my lengthy and in depth work with rural health care delivery systems. It also is based upon my involvement with veterans living in rural Montana and rural America.   

Access to VA health care services is a critical and growing issue for rural veterans. There is an increasing need for physical and mental health services to be delivered at local access points for the rural veteran. The VA needs to continue to explore and develop innovative ways to deliver these services.

It is my belief that overall, things are  better now than they were four or five years ago when the Congress really made health care for Rural Veterans a priority issue.  More attention has been given to rural veterans issues, more funding has been provided and new programs have been initiated.

However, we still have a long way to go. Veterans are leaving military service without being enrolled in the VA. DoD and the VA still don’t share information.  Rural Veterans don’t always have access to their medical records.  Rural Veterans are still unable, in far too many situations, to receive medical services close to home or in non-VA facilities. There is a significant gap in collaboration between the private health care sector and the VA.

 I was recently at a meeting in Texas and listened to a veteran who had moved from Sydney Montana to Uvalde Texas. His electronic medical record, which is supposed to be available seamlessly nationwide, was unavailable to whomever needed it in Texas. This veteran had lived in Montana for a quite some time. He had been treated by the VA in Montana, yet there appeared to be no available medical record from his Montana VA provider. At that same meeting I listened to a Texas State Senator, who is a veteran and lawyer, discuss his trial and tribulations with getting the VA to address certain medical issues that his father, also a veteran, had. After months of going back and forth between the client and the VA a formal hearing took place. At this hearing this gentleman represented his father. About a month after the hearing he called the VA to see where things were. He was told that nothing had happened and that the VA had lost the record of the hearing. You be the judge of this. Did the VA lose the record or did they just make this up? The story of lost records is told often.  For other Veterans it is the lack of consistency with contact people that gets them frustrated. They talk to one person one week, a different person the next week and so it goes. Suicides and lack of opportunities for mental health treatments continue to be major issues. 

Nicholas D. Kristoff in the April 15, 2012 edition of the New York Times wrote an article entitled, “A Veterans Death, The Nation’s Shame”. I recommend that you read it. The long and short of the article is that one of two brothers returning from war committed suicice and the other is suffering from severe mental problems. The article exposes an alleged 6 months waiting list for the suicide victim to get into a treatment facility. The VA claims that there was no record for a request for this hospitalization. (Attachment 1)

Montana has its own suicide issues. We have our own mental health issues. The VA builds a facility, which was under construction for many months, but can't open it because qualified staff has not been recruited. We can’t even figure out a way to provide shelter for our homeless veterans at the same VA facility. 

DATA

Rural and highly rural Veterans make up 38 percent of enrolled Veterans across the country. We don’t know specifically how many non enrolled Veterans live in rural and highly rural areas across the country. All we have are estimates.

In Montana we have the following information on Veterans:

The number of enrolled Veterans in Montana                                    46,472

The estimate of the number of Veterans residing in Montana            130,109

The number of enrolled Veterans in Urban Areas (SMA’S)                   11,347

The number of enrolled Veterans in Rural Montana                            35,125

The estimate of the total number of Veterans in Urban Montana         66,423

The estimate of the total number of Veterans in Rural Montana          66,665 

There are three times the number of Veterans living in rural areas of Montana than those living in urban areas of Montana. Because of this, the data indicates a three or four times higher prevalence of morbidity by diagnosis in rural Montana.

For example, this data shows that there were 12,231 diagnoses of Hypertension in all rural areas of Montana and 3,321 diagnoses of hypertension in urban Montana. During 2011 there were 5174 diagnoses of substance abuse in rural Montana and 1720 diagnoses of substance abuse in urban Montana. There were 2827 diagnoses of PTSD in rural Montana and 963 diagnoses of PTSD in urban Montana. 2) 

 The data shows a clear need to make sure that appropriate services are provided at service locations in rural areas. (Attachment 2)

 I have attempted to outline a brief, but not all inclusive, synopsis of the issues that Rural Veterans face. Now I would now like to share with you some personal recommendations for improving VA rural health care. The Committee can assist in bringing about these recommendations by providing the appropriate Congressional oversight. 

1. Those being discharged from military the service should be enrolled in the VA.

2. A system needs to be implemented to ensure a seamless flow of records between DoD and the VA.    

3. There needs to be increased collaboration between all entities in the Federal government who are providing health care to Veterans.

4. The electronic medical record should be available to the Veteran at any point of service.

5.  There should be more health care services provided in places where rural Veterans actually live. 

6. We need to find out where non enrolled veterans reside. If AARP can keep a fairly accurate data base on where everyone over fifty years of age lives in the United States then the VA should be able to develop a system that keeps tracks of all Veterans. 

7. Demographic studies should be utilized in determining where new programs should be started.

8. Existing programs should be refined based upon enrolled patient origin studies and clinical diagnosis information.

9. Veterans, in an emergency situation, should be seen immediately on a 24/7 basis. This will require the utilization of non VA resources in rural and highly rural areas. 

10. The VA medical record should be available immediately to any provider who sees veterans in Emergencies. 

11. The VA needs to offer a secure version of VISTA (The Veterans Health Information Systems and Technology Architecture) medical records package to rural practitioners who see Veterans.

12. Mental health services should be readily available to all veterans especially those living in rural communities. If you build them they will only come if there is someone to see them. 

13. A new and sustained effort is needed to bridge the services of the VA and private rural health care systems. Resources are needed to educate rural health care providers on how to work within each other’s systems and cultures. Rural providers need help in learning how to navigate through the VA system. The VA needs more information on the quality of care delivered by rural providers. The VA should continue to utilize physicians and other providers through contracts and fee for service arrangements; however this arrangement should be expanded to include ancillary services. There is no reason for a Veteran to be seen in a CBOC for routine care and then be required to drive 1 to 2 hours to another VA facility for an MRI when the MRI service is available in a community facility in the same town where the initial services were rendered.

14. There needs to be extensive collaboration between the VA and the private sector in providing health care services. Technical assistance needs to be provided to both entities in order to make this happen. S1613 “A bill to authorize the establishment in the Department of Veterans Affairs a center for technical assistance for non-Department health care providers who furnish care to veterans in rural areas, and for other purposes” needs to be enacted. Established in highly rural state, The Rural Veterans Health Care Technical Assistance Center would provide the necessary technical assistance to make collaboration happen. One of its main purposes would be to act as a consulting center to enhance the collaboration between non Department health care providers and the VA. There are willing partners throughout the country who would like to work together. Often they don’t know how to integrate the separate systems or they do not have the time needed to do it. The center would provide the consulting assistance necessary to bring about this shared community activity.

This entity would be different from the VA’s Resource Centers in that it is a non Department center. It is important to have it established in this fashion in order to bring a new perspective on collaboration. In my opinion there is too much in breeding of the VA infrastructure and the Center would have the advantage of looking beyond that. It would also be less encumbered by the bureaucracy and hopefully be able to move quickly in establishing new collaborative arrangements.

In many ways it will act as an incubator for new service arrangements and programs. These programs will be jointly implemented by the shared service model developed between the private sector and the VA. I urge the committee to pass this legislation and encourage a robust funding source.       

Senator Tester and members of the Committee, I want to thank you for the opportunity to make these points. I hope that we are able to continue providing quality health care services to our Veterans living in rural areas. I would be happy to address any questions that you might have at the appropriate time.