Wednesday, June 16, 2010







"Today we will discuss VA health care in rural areas," declared Senator Daniel Akaka this morning calling the Senate Committee on Veterans Affairs to order. "Rural settings are some of the most difficult for VA and other government agencies to deliver care. I beieve, and I know many of my colleagues on this Committee share the view, that we must utilize all the tools at our disposal in order to provice access to care and services for veterans in rural and remote locations."

Before the testimony could start, Chair Akaka explained that the VA had not submitted their prepared statements in time and the VA's Robert Jesse to convey that message.that "the Department's testimony was submitted over 29 hours late." May 19th, OMB also struggled to meet a known deadline when appearing before the Committee. Jesse was on the first panel along with Disabled American Veterans' Adrian Atizado, Veterans Rural Health Advisory Committee's James F. Ahrens and Haywood County Veteran Service Officer Ronald Putnam. The second panel was composed of Yukon's-Kuskokwim Health Corporation and Brig Gen Deborah McManus.

Adrian Atizado noted that 1/4 of the US population lives in rural areas and over 44% of the military recruits serving today are from rural areas; however, only 10% of physicans are practicing in rural areas. This limits their access to health care. This leads to "disparities and differences in health status between rural and urban veterans." Atizado advocated for the expansion of tele-health capabilities. Ronald Putnam stated, "The rural areas of our country have become a sanctuary for many veterans who suffer from Post Traumatic Stress Disorder and other service connected disabilities which adversely affect the veterans." He further noted, "Although a lot of the VA's current efforts to communicate more closely with veterans by utilizing modern media and technology, I want to remind both this Committee and the Veterans Administration that there are still a number of WWII, Korea and Vietnam veterans that have unique education deficiencies and social disconnects that make it extremely hard to receive the information that is being presented on these twenty-first century medians. I will remind this Commitee, the Veterans Administration and all my colleagues that the best communication with these veterans is face-to-face interaction with someone who is knowledgeable, well trained and willing to assist these men and women that we owe such indebtedness to."

On the issue of getting providers to rural areas, raised by Senator Jon Tester, it was pointed out by Ahrens that most of the training centers for veterans providers are in urban areas and that getting the residents into rural areas would likely help that. Tester asked about home dialysis and Dr. Jesse responded that approximately 7% of veterans (apparently of veterans receiving dialysis) get home dialysis. "It's doable," he explained. "It doesn't require sending someone into the home. Even patients and their families can do it." Asked if it is cost-effective, Dr. Jesse replied, "We think it's at least cost-neutral."

What is tele-health? Tele-health -- more commonly spelled "telehealth" -- is diagnosing over the phone, it also includes video-conferencing, counseling, allowing x-rays and other screenings to be interpreted outside the rural area and discussed via a phone conference or 'visit.' Dr. Jesse stated that tele-health programs are currently in 140 of the VA's medical centers and allow "41,000 veteran patients to remain living independently in their own homes."

Senator Mark Begich represents a state which is largely rural: Alaska. We'll note his exchange with the first panel.

Senator Mark Begich: You had made the comment, you're trying to expand these contracts and you used Anchorage as an example and you're working through it. Can you elaborate a little more, what does that mean? And why I say this is because, to be very frank with you, I've heard that on a regular basis. There's one thing that we have is a huge opportunity of medical facilities and then health care services is a great example because the way we manage them up there but also huge facilities both in Fairfield and in Anchorage that I think are under-utilized. But help me understand when you say you're working out a process or you're working through contracts, tell me what that means and what kind of a timetable?

Dr Robert Jesse: I-I-I-I think Mr. Schonhard could speak to that better since he's the one involved in that.

Senator Mark Begich: He's behind you and smiling. So that's --

Dr Robert Jesse: It's Providence --

Senator Mark Begich: If you want to reserve some of your answer, you can.

Dr Robert Jesse: Since you've asked, it's - it's the Providence Health System in Anchorage that they're in the process of developing or negotiating to cover at least the cancer care.

Senator Mark Begich: Let me ask you if I can -- and I'll hold more detail for the next panel -- but let me ask you can you or do you keep data on -- in any state -- how utilization of non-VA facility by VA receipiants -- In other words, do you have data points so if I said to you, "What's the percentage in Montana or Nebrask or in Alaska that take advantage based on proximity and other things?" Do you have such a -- And what kind of services do they receive?

Dr Robert Jesse: Well this is complex because, uhm, there's-there's a couple of terminologies that we need to be clear about. One is what's called "fee care." Fee care by the strict definition means we don't provide the service and we authorize the veteran to go and get it and we pay that bill.That's a small component of what's in broad-encompassing non-VA care which would include both fee care but also uhm, uhm, care that is through contract, through community providers, care that's delivered through contract or other agreements if you will through our academic affiliates.

Senator Mark Begich: Yes.

Dr Robert Jesse: And, uhm, the other is that we don't have a handle on it because we don't really pay for it is care that the veteran themselves choose to get on the outside because many of them do have secondary insurance and/or in addition to Medicare. And we have uh-uh that dual care is a particular challenge to us -- not from the financial side, but from the managing care side. So we have uhm, uhm, the ability to track fee care obviously. We a lot of the contract care -- the ability to roll it up is less robust because some of it is -- it rolls in rather than a flat rate that we're paying on an annual basis. But we can -- we can tell you what that is with at least some level of precision I'm sure.

Senator Mark Begich: Is that something that you can provide to us?

Dr Robert Jesse: I believe so and, without making a promise, I will go back and tell you what granular area we can apply that in.

Senator Mark Begich: Excellent. And as you said, there's fee and then there's contract and --

Dr Robert Jesse: Right. There's a host of vehicles by which we-we --

Senator Mark Begich: The more defined you can do that, the better off.

Dr Robert Jesse: Sure.

Senator Mark Begich: I'd be very interested in that. Let me, if I can, there's been some good testimony on tele-health and in Alaska we use it a great deal not only from a VA perspective but our Travel Consortium which is our Indian Services is a huge piece of the puzzle of how we move through delivering health care in areas where one -- Even a van -- I know, Mr. Ahrens, I know you talk about increasing the vans, but we can't even get a van there. Let alone a plane depending upon weather. Is there, both of you, uhm, clearly have stated, that where rural health centers are located, that where the Office of Rural Health is located, do you think elevating that to a higher level will get some more recognition of the data that needs to be done, the need to understand it better and deliver it better or is the location -- You [Dr. Jesse] were concerned about where it was located in the kind of system where the office is but Mr. Ahrens, I didn't hear you make a comment on that. Do you have any comment in regards to that?

James F. Ahrens: The Office of Rural Health

Senator Mark Begich: Yes.

James F. Ahrens: I think the higher elevation you can give it, the better off we are. And we're slowly getting it staffed -- been a lot of staff changes -- and I think it's got the attention of the Secretary [of the VA] and we ought to keep it right at the highest level we can. It's very important.

Senator Mark Begich: Do you think that where that it's located now -- You know the tele-health issues? I agree with you, if you don't have the data, it's irrelevant. You can spend a lot of time talking about how important it is. We see it in real life in Alaska. But do you think that has anything to do with the level of data necessary? Or is it just two separate issues that need to be addressed? In other words, data collection has its own and then moving this office up higher?

James F. Ahrens: Well -- I think -- Again, keep the office as high as you can. Data collection is very important. We don't even know where veterans are. And we need to know the utilization of their services -- if that's what you're asking me. And we have to have certain data in order to proceed -- If you're running a business how you going to proceed with that if you don't know where your customers are? And so we have to continue to get that. We can't even make some decisions with our committee because we don't know where they are, what disease entity they might have and what services should be placed in those areas. If we knew a little more about that, we'd be better off. So the Office of Rural Health ought to get on that and get it done.

Senator Mark Begich: Let me -- and my time has expired -- the report that you sent up to the Secretary, do you anticipate that to be public or available to us -- at what point, do you think?

James F. Ahrens: As I said, it's under the Secretary's scrutiny. I'd love you -- If I could release it to you today, I would but I can't. It's a public document, it should be available to you.

A thirty minute recess followed due to voting and other issues. When the Committee returned Senator Begich was presiding and informed the second panel that they would each have five minutes for their opening statements and the clocks would indicate when there time was up. He added some levity to the proceedings by following that with, "If you violate that, the floor will release below you." After opening statements, the remaineder of the second panel was approximately twenty-two seconds. We'll grab that tomorrow or Friday to cover one other domestic topic and one topic (lengthy passage from this morning) that British community members asked be included in today's snapshot.

For the month of April, the US Army announced yesterday, they can confirm 4 suicides among active-duty service memberrs with six still being investigated and there are nine ongoing investigations into May deaths. For the reserves, the US Army said there 7 suicides in April and 2 in May with ten more still being investigated. From the press release:

The Army has identified additional crisis intervention resources available to the Army community. Soldiers and families in need of crisis assistance are strongly encouraged to contact Military OneSource or the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury Outreach Center (DCoE). Trained consultants are available from both organizations 24 hours a day, 7 days a week, 365 days a year.
The Military OneSource toll-free number for those residing in the continental United States is 1-800-342-9647, the Military One Source Web site can be found at . Overseas personnel should refer to the Military OneSource Web site for dialing instructions for their specific location
The Defense Center for Excellence for Psychological Health and Traumatic Brain Injury (DCoE) Outreach Center can be contacted at 1-866-966-1020, and at http://
The National Suicide Prevention Lifeline is available 24 hours a day, 7 days a week at 1-800-273-TALK (8255). For more information see: .
The American Foundation for Suicide Prevention site is, and the Suicide Prevention Resource Council site is .
Information about the Army's Comprehensive Soldier Fitness Program is located at .
The Army's most current suicide prevention information is located at .
The Army's comprehensive list of Suicide Prevention Program information is located at .
Suicide prevention training resources for Army families can be accessed at (requires Army Knowledge Online access to download materials) .

RECOMMENDED: "Iraq snapshot"
"Female Genital Mutilation continues in Kurdistan"
"US Army confirms 11 suicides"
"Brilliant post"
"One more time with Jackie"
"Nonstop Cant"
"could you hear walter cronkite saying that?"
"Barack Obama's Stepford Wives"
"Bob Etheridge belongs behind bars"
"Cheryl Johnson, why didn't we listen to you?"
"The good and the bad"
"New figures, real, honest, for real, truly"
"Grab bag"
"Sneak thief in the White House"