Friday, April 30, 2010

But he breaks just like a little girl





Following a brief mark up meeting, Chair Michael Michaud called to order the Health Subcommittee (of the House Veterans Affaris Committee) to order. The Subcommmittee was receiving an update on a pilot program. Michaud noted, "I recognize and appreciate the VA's efforts in addressing the health care needs of our rural veterans who are more likely to be in poorer health than their urban counterparts. However, more work remains in this area as our rural veterans face unique challenges that are both extensive and complex. The enhanced contract care pilot program is a potential tool for expanding access to health care for our rural veterans in areas where the VA is unable to provide care." VA's Patricia Vandenberg appeared before the Subcommittee accompanied by Gita Uppal. VA is, of course, Veterans Administration. "VISN" is Veterans Integrated Service Network.
A problem that arises repeatedly is that Congress writes a bill, passes it, it's signed into law and then it's not followed. Sometimes there's accidental confusion, sometimes there's intenational confusion. Many times the confusion is not even noticed until well after the project is underway. Today the Subcommitee heard about the status on a pilot program that they passed the legislation for and that is in the process of being implemented. Because the Subcommittee members paid attention and asked important questions, a problem dealing with confusion on the part of the VA quickly became evident.
US House Rep Jerry Moran: You're testimony raises a significant concern for me, however. This started out as legislation that would effect the entire country and, if you lived a certain number of miles from a provider, you would then be eligible for VA care provided with a local provider. It was narrowed to be a certain number of VISNs as a pilot or demonstartion project but your testimony suggests to me that you're now narrowing it even further and that you're going to do a particular community within that vison and that's troublesome for me because we've gone from a broad scope taking care of a large number of veterans to -- I was convinced that we should see how this works. But the CBO score, as we talk about its costs, to me, it was never suggested that we were not going to provide the same opportunity for community based service for every veteran that lived that number of miles -- now that number of minutes from a provider, from a VA provider. Is --Am I understanding the testimony correctly that now we're just going to select certain communities within the VISN? And make that the pilot program?
Patricia Vandenberg: We have asked the visons to identify multiple sites as focal points within their vison for potentially standing up this pilot project. At this point and time that is the direction that we're moving in. We understood the wording in the law when it said the Secretary will select areas, sites -- that that was permissable, that that was feasible in the pilot structure. So we are here obviously today to gain further insight from the committee as to your expectations.
US House Rep Jerry Moran: Well that certainly would be different than my expectations then Mr. Michaud and others may have an opinion but I would -- I'd be very critical of the concept that we're going to narrow the opportunities for veterans even further so if you're a veteran that lives a number of minutes from the provider you may or may not qualify depending upon whether the VISN director decided that your community is one that now qualifies. What I envision and what I hope that the VA would pursue is that if you meet the definition of highly rural and you're in that pilot demonstration VISN, you qualify. In fact, the VA has the obligation for providing a provider, finding a provider for you to meet your health care needs. So I welcome additional dialogue. Maybe other Committee members have an opinion regarding the intention but as I recall the CBO budget information did not narrow it one more step as it suggests that you suggest may occur. So my red flag is up.
Patricia Vandenberg: Thank you for the clarification, sir.
US House Rep Jerry Moran: You're very welcome. The legislation that the president's now expected to sign, do you have a sense, which defines miles to minutes, and the definition of . . . Help me?
Patricia Vandenberg: Hardship.
US House Rep Jerry Moran: Thank you! Hardship. Will it speed up the implementation date? Do you have a sense that now we're moving ahead six months more quickly?
Patricia Vandenberg: It certainly will facilitate us not being impeded by the regulatory process and so we believe that we are on a, uh, path at this point having issued the guidance to the field and asking them to identify sites. We may have to amend that per the conversation we are having. But we don't see any firm impediment except for the fact that I referenced earlier, we have no way of knowing when this goes out to the provider community what the level of receptivity would be. So I would say that the rate of progress going forward will be a function of the contracting mechanism and the receptivity in the provider community to work with us.
US House Rep Jerry Moran: I think that receptivity will in part depend upon the reimbursement rate that you conclude is appropriate and my understanding is that the VA's current fee base is fee base and you cover the entire cost of care. You provide health care for veterans with local providers today.
Patricia Vandenberg: Yes, sir.
US House Rep Jerry Moran: And I think you cover the entire cost of doing so. That I assume would be the most desirable model for the veteran and for the health care provider in getting this implemented and wide spread use. So I'm hoping that you follow the same practices that you've been following in the past of how you reimburse hometown providers today. Mr. Chairman, my time is expired, but I would welcome your input or the staff input on this issue of a pilot within a pilot. I'm fearful that we're narrowing the scope and the number of veterans that we wanted to take care of across the country was already narrowed to a certain number of veterans -- to a certain number of VISNs. And we need to make sure, in my opinion, that it's not narrowed further, that you have to live in a particular area within that community to access this health care. I thank the Chairman.
Subcommittee Chair Michael Michaud: Thank you very much, Mr. Moran. You're absolutely correct, the whole intent was to have the VISN -- the whole VISN. Not a pilot within that VISN. And I believe we actually got a CBO score predicated on the full VISN, not on pilots within that VISN. And you're 100% correct, the intent of the legislation was for the full VISN. And that is a concern. This is not the first time we've seen this thing. We actually saw it back in legislation that was passed in 2006 relating to state veterans' nursing homes which required the VA to provide full cost of veterans and, through the rule making process, the VA narrowed that down to what full cost meant for the VA and we're trying to correct that issue currently. So but you're 100% correct, Mr. Moran, it was for the full VISN.
US House Rep Jerry Moran: Mr. Chairman, excuse me, and I would point that to my knowledge this is -- at least this is the first time I've heard as we've had briefings from the VA on this topic, this is the first time I've seen the narrowing of the narrowing. And so -- I appreiciate the Chairman's comments.
Patricia Vandenberg: Mr. Chairman, may I make a further comment?
Subcommittee Chair Michael Michaud: Yes.
Patricia Vandenberg: We obviously will respond to the feedback that we're receiving today but just to go back to the question of what further challenge or impediment might we experience I would just like to observe that when attempting to put a provider in place for highly rural veterans who will, no doubt, be dispersed in a VISN, we will likely experience a situation of multiple contracting relationships so that could potentially extend the timely implementation for coverage in an entire VISN. So I'm-I'm just wanting to acknowledge that I hear you, I-I further appreciate the intent and, just practically speaking, obviously going to honor the intent and just realize that we may be dealing -- In a number of instances, it would be ideal if there were a provider network established that had outlets if you will in those multiple venues. Having had some experience in my prior life in Idaho where the organization I was associated with attempted to set up those multiple venues in rural communities, it made it very easy if someone wanted to serve those communities, they just came to my organization and we helped them get that done. In our experience thus far in rural contracting, that hasn't always been the case. So I hear what the Committee is telling us today. We will proceed to respond to this and just work with due diligence to work through the contracting as timely as possible.
Jerry Moran: Mr. Chairman, I think what Ms. Vandenberg is telling me is my two desires of having broad scope and quick implementation may be mutually exclusive. And putting the reminder back to us that this may slow the process down if they've got to contract in a multiple number of ways. But, at least from my perspective, I would put the priority on doing it right, which is to take care of every veteran regardless of where they live, not within a particular communisty as compared to the speed of its accomplishment. We want both but, again, I think we'd make a terrible mistake if we go through this pilot program and we only, in a sense, take the easy areas within a rural VISN in which it's easier to find a provider or there's a multiple number of providers or there's a larger number of veterans. We're still isolating that veteran who lives a long distance from a VA hospital. And so my priority would be back to being sure that we implement this in a way that we can demonstrate that it can be done VISN wide. Thank you.
Subcommittee Chair Michael Michaud: Thank you. Ms. Halvorson?
US House Rep Debbie Halvorson: Thank you, Mr. Chairman. And while we've been discussing all this, there's probably many veterans who haven't been able to find a way to get taken care of. So while we're trying to figure out how to do this, our veterans still need help. So instead of reinventing the wheel or trying to figure out what's "rural," what's "hardship," why aren't we just taking care of our veterans and letting them go where ever it is that they need to be taken care of? Now I may be naive and I am new, this is my first term, but while we're trying to figure out the intent of a law or how to do it the right way, no matter if it takes long, what are we doing right now for our rural veterans? Where are they going and how are they getting taken care of?
Patricia Vandenberg: Thank you for the question. I'm glad you asked it because I can speak very directly to it. We are already providing a significant amount of fee care to rural and highly rural veterans. And under the aegis of the Office of Rural Health in Fiscal Year '10, we have just put out $200 million to the VISNs to afford them the extra resources to provide fee care to rural and highly rural veterans. So I think it's important to note that is a mechanism that is already in place and what I understood the intent of this law to do was to give VA additional incentive and capacity to further contract out care to extend that access even more. But, to answer your question, we are already meeting the needs of rural and highly rural veterans through the fee care mechanism
US House Rep Debbie Halvorson: So then and not to interrupt but so then what's the estimate of how many extra veterans are we gong to take care of and the cost? So we're already spending money, we're already taking care of people, so this program -- what are we assessing the pilot program's cost, the quality and how many veterans are going to be eligible for the pilot program?
Patricia Vandenberg: Let me take the assessment of costs. First, in our initial analysis of the implementation of the pilot as we previously understood it, we estimated up to $100 million. However, we knew that that was putting significant empahsis on primary care service delivery. And as you add in the multi-speciality dimensions of a patient's care, that that cost could rise. So our current working assumption is that the pilot project as we previously conceived it would cost at least $100 million. Now you're second question about quality? That's part of the analysis and the process of contracting and we're using all of the resources of VHA that we currently employ in the contract process. Pulling those in to look at the specifics of assessing the quality of the care and the patient's satisfaction with the care.
US House Rep Deborah Halvorson: So for a hundred million dollars, w'ere going to help more people?
Patricia Vandenberg: Yes, ma'am.
US House Rep Debbie Halvorson: And better?
Patricia Vandenberg: I-I think, uhm, I would just observe that we believe that the standard of care, the quality of care, that is evident in our current fee relationships is of a high quality nature so when we say beter, that could connote that there is something lacking in our current approach. . .
US House Rep Debbie Halvorson: Right and it's not a good word. "Better" is not a good word.
Patricia Vandenberg: I just want to be precise. We definiately are trying to enhance access. And by spreading the network of contract relationships further into highly rural communities and attempting to structure those relationships -- in some instances, they don't exist today -- that will definitely enahnce the quality of veterans care because of the --
US House Rep Debbie Halvorson: Okay, I just hope that we're not reinventing the wheel. It looks like you've taken all this time to discuss "hardship" and "rural" when we should be taking this time to help our veterans with their health care. And now, with 1963 I believe, we take hardship out altogether. We should have no problem now implementing this bill. So I know my time is about up, but I'm concerned about the care of my veterans. Not debating whether they're rural or if they have a hardship. We are talking about people that we just want to take care of. Thank you.
I included Halvorson because I think she did a good job and I think a lot of people are getting very tired and very annoyed by the constant need to refer to study. When you're given a directive, the study process should not be a hold up. Now we saw the government just waste money on a PSTD 'study' which issued their report a few weeks ago and the 'answer' was 'more research and study required.' Nothing to do with really helping those who deal with PTSD. And there is a growing frustration on the part of veterans. Halvorson has worked very hard to be very connected to the veterans in her district and her comments represent what she and other House Reps in contact with veterans are hearing.
And the confusion as to what VA was supposed to be implementing? Chair Michael Michaud noted "this legislation passed in October of 2008. We did not hear back from the VA until March of 2009 of why they can't implement it. And the concern being that when we went through the hearing process, the mark up process, that was the time the VA should have been before us saying, 'Well we need these changes'." Maybe there'd be less confusion, if they'd been present for those hearings. Not just to speak, but to listen.
In other news, US Rep Henry Brown is a Republican who serves on the Subcommittee (in fact, he's the Subcomittee's Ranking Member). His online office, his Congressional website, just won an award from the Congressional Management Foundation "for having one of the best Web sites in Congress." You can click here to visit and evaluate for yourselves. And here's the press release noting the award. His was one of offices receiving an award. The top honor, Platinum Mouse Award went to the online offices of US House Rep Steve Israel (Democrat), US House Republican Conference, Mike Pence (Republican) is the Chair, the House Committee on Science and Techonology which Bart Gordon (Democrat) chairs and the online office of US Senator Lisa Murkowski (Republican). CMF notes:
"These four stood out from the rest and serve as examples for others to follow. Overall, we found the good sites are getting better and the bad are getting worse," said Beverly Bell, executive director of CMF, a nonpartisan nonprofit founded 33 years ago to promote a more effective Congress. "It looks like half of the Congress is racing to the top while the other half race to the bottom. The outstanding sites follow best practices, leverage the power of social media, and serve their constituents well. Those offices falling behind are losing a great opportunity to interact with their constituents in ways the public has grown to expect."
And on the topic of online Congressional offices, we'll close with Michael Applegate's "Stop Outsourcing Security Act HR 4650" (Iraq Veterans Against the War):

Rep Jan Schakowsky and 24 cosponsors are introducing a bill to phase out private military contractors.
A similar bill is being introduced to the Senate by Sen Bernie Sanders I(VT) S 3023
Contact your reps to urge them to support this bill.
Latest Major Action: 2/23/2010 Referred to House committee. Status: Referred to the Committee on Foreign Affairs, and in addition to the Committees on Armed Services, and Intelligence (Permanent Select),
Currently there are 24 cosponsors:
Rep Baldwin, Tammy [WI-2] - 2/23/2010
Rep Conyers, John, Jr. [MI-14] - 2/25/2010
Rep DeFazio, Peter A. [OR-4] - 3/10/2010
Rep Doggett, Lloyd [TX-25] - 4/21/2010
Rep Ellison, Keith [MN-5] - 2/23/2010
Rep Filner, Bob [CA-51] - 2/23/2010
Rep Frank, Barney [MA-4] - 4/21/2010
Rep Gonzalez, Charles A. [TX-20] - 2/23/2010
Rep Grayson, Alan [FL-8] - 3/10/2010
Rep Grijalva, Raul M. [AZ-7] - 2/23/2010
Rep Gutierrez, Luis V. [IL-4] - 2/23/2010
Rep Hall, John J. [NY-19] - 2/23/2010
Rep Hinchey, Maurice D. [NY-22] - 2/23/2010
Rep Holt, Rush D. [NJ-12] - 2/23/2010
Rep Kaptur, Marcy [OH-9] - 4/21/2010
Rep Lee, Barbara [CA-9] - 2/23/2010
Rep Maloney, Carolyn B. [NY-14] - 2/23/2010
Rep McGovern, James P. [MA-3] - 2/23/2010
Rep Moore, Gwen [WI-4] - 2/23/2010
Rep Polis, Jared [CO-2] - 2/23/2010
Rep Shea-Porter, Carol [NH-1] - 2/23/2010
Rep Stark, Fortney Pete [CA-13] - 2/23/2010
Rep Woolsey, Lynn C. [CA-6] - 2/23/2010
Rep Wu, David [OR-1] - 4/21/2010
Please become a citizen cosponsor by going to:

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