[House Hearing, 107 Congress]
[From the U.S. Government Printing Office]




             VA HEALTH CARE: ACCESS DELAYED, ACCESS DENIED

=======================================================================

                                HEARING

                               before the

                   SUBCOMMITTEE ON NATIONAL SECURITY,
                   VETERANS AFFAIRS AND INTERNATIONAL
                               RELATIONS

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

                            OCTOBER 15, 2002

                               __________

                           Serial No. 107-238

                               __________

       Printed for the use of the Committee on Government Reform


  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform


                                 ______

89-163              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2003
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                     COMMITTEE ON GOVERNMENT REFORM

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida         EDOLPHUS TOWNS, New York
JOHN M. McHUGH, New York             PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California             CAROLYN B. MALONEY, New York
JOHN L. MICA, Florida                ELEANOR HOLMES NORTON, Washington, 
THOMAS M. DAVIS, Virginia                DC
MARK E. SOUDER, Indiana              ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio           DENNIS J. KUCINICH, Ohio
BOB BARR, Georgia                    ROD R. BLAGOJEVICH, Illinois
DAN MILLER, Florida                  DANNY K. DAVIS, Illinois
DOUG OSE, California                 JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky                  JIM TURNER, Texas
JO ANN DAVIS, Virginia               THOMAS H. ALLEN, Maine
TODD RUSSELL PLATTS, Pennsylvania    JANICE D. SCHAKOWSKY, Illinois
DAVE WELDON, Florida                 WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
C.L. ``BUTCH'' OTTER, Idaho          ------ ------
EDWARD L. SCHROCK, Virginia                      ------
JOHN J. DUNCAN, Jr., Tennessee       BERNARD SANDERS, Vermont 
JOHN SULLIVAN, Oklahoma                  (Independent)


                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                     James C. Wilson, Chief Counsel
                     Robert A. Briggs, Chief Clerk
                 Phil Schiliro, Minority Staff Director

 Subcommittee on National Security, Veterans Affairs and International 
                               Relations

                CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida              DENNIS J. KUCINICH, Ohio
BENJAMIN A. GILMAN, New York         BERNARD SANDERS, Vermont
ILEANA ROS-LEHTINEN, Florida         THOMAS H. ALLEN, Maine
JOHN M. McHUGH, New York             TOM LANTOS, California
STEVEN C. LaTOURETTE, Ohio           JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky                  JANICE D. SCHAKOWSKY, Illinois
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
DAVE WELDON, Florida                 DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho          STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
              Kristine McElroy, Professional Staff Member
                           Jason Chung, Clerk


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on October 15, 2002.................................     1
Statement of:
    Burger, Leslie, Network Director, Veterans' Integrated 
      Service Network, Department of Veterans' Affairs; Wayne 
      Tippets, Director, Boise Veterans' Administration Medical 
      Center, Department of Veterans' Affairs; and David K. Lee, 
      Chief of Staff, Boise Veterans' Administration Medical 
      Center, Department of Veterans' Affairs....................    38
    Jaurena, Mitchell A., USMC retired, veteran; E. Lee Bean, 
      veteran; William T. Smith, veteran; and Richard W. Jones, 
      Administrator, Idaho Division of Veterans' Services........    13
Letters, statements, etc., submitted for the record by:
    Bean, E. Lee, veteran, prepared statement of.................    18
    Burger, Leslie, Network Director, Veterans' Integrated 
      Service Network, Department of Veterans' Affairs, prepared 
      statement of...............................................    43
    Jaurena, Mitchell A., USMC retired, veteran, prepared 
      statement of...............................................    15
    Jones, Richard W., Administrator, Idaho Division of Veterans' 
      Services, prepared statement of Mr. Teague.................    25
    Otter, Hon. C.L. ``Butch'', a Representative in Congress from 
      the State of Idaho, prepared statement of..................     7
    Shays, Hon. Christopher, a Representative in Congress from 
      the State of Connecticut:
        Prepared statement of....................................     3
        Prepared statement of Rex T. Young, Meridian, ID.........    36
    Smith, William T., veteran, prepared statement of............    21

 
             VA HEALTH CARE: ACCESS DELAYED, ACCESS DENIED

                              ----------                              


                       TUESDAY, OCTOBER 15, 2002

                  House of Representatives,
Subcommittee on National Security, Veterans Affairs 
                       and International Relations,
                            Committee on Government Reform,
                                                         Boise, ID.
    The subcommittee met, pursuant to notice, at 10 a.m., at 
VFW Post 63 Hall, 3008 Chinden Blvd, Boise, ID, Hon. 
Christopher Shays (chairman of the subcommittee) presiding.
    Members present: Representatives Shays and Otter.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Kristine McElroy, professional staff member; and Jason 
M. Chung, clerk.
    Mr. Shays. A quorum being present, the Subcommittee on 
National Security, Veterans' Affairs and International 
Relations' hearing entitled, VA Health Care: Access Delayed, 
Access Denied, is called to order.
    The subcommittee convenes this hearing to continue our 
oversight of the Department of Veterans' Affairs, VA, health 
care system. We meet this morning in Boise, ID because 
Congressman Butch Otter asked us to focus on the unique 
challenges facing veterans and the VA in the Northwest service 
network. Congressman Otter is an active, extraordinarily active 
and very articulate participant in our efforts to make Federal 
programs more effective and efficient. It is a privilege and a 
pleasure to be here with him today. And I will say he didn't 
tell me I could wear jeans.
    Regionalization of VA health care held the promise of 
delivery modes more directly tailored to local needs and 
funding levels more sensitive to area demographics. But rigid 
one-size-fits-all rules continue to produce systemic problems 
with access and waiting times in many regions. These chronic 
shortfalls are addressed only with an episodic infusion of 
supplementary resources. A more permanent approach is needed to 
match veterans' growing needs with VA health care capacity.
    For a variety of reasons, including an attractive 
pharmaceutical benefit, many more veterans are seeking access 
to VA care. Medical centers and community-based outpatient 
clinics are hard-pressed to keep pace with demand relying on 
productivity increases alone. At some point, the quality of 
care will be affected if we continue to ask smaller medical 
staffs to serve more and more patients.
    In this region, waiting lists have reduced slightly and 
patient satisfaction with the quality of care remains high, but 
as we will hear in testimony, access to care for service-
connected veterans can still be long delayed, in effect denied, 
amid the crush of enrollment applications by those in lower 
eligibility categories. So we ask our witnesses to describe how 
the VA health care system can be improved to become the agile, 
sophisticated, patient-centered provider envisioned by 
Congress. We welcome them, and we look forward to their 
testimony.
    And I would just like to say I have been in Boise before, I 
love being here. It is a great community, a wonderful State, 
and I was happy that Butch asked more than once that we come 
and to say that this subcommittee is delighted to be here. We 
look forward to the testimony from our witnesses, and we will 
invite any--at the end, we will invite of those who are in 
attendance today to address the committee. We won't swear you 
in like we will our panel one and two, but we will invite you 
to make testimony to this committee if you would like to.
    At this time, the Chair would like to recognize Mr. Otter.
    [The prepared statement of Hon. Christopher Shays follows:]

    [GRAPHIC] [TIFF OMITTED] T9163.001
    
    [GRAPHIC] [TIFF OMITTED] T9163.002
    
    Mr. Otter. Well, thank you, Chairman Shays, and I 
appreciate you accommodating us and holding this meeting in 
Boise. I also appreciate all of your efforts and your 
accommodation on all our logistical changes, because I think as 
the entire audience knows, we had to constantly change time and 
place as a result of most of our activities, or in some cases 
inactivity, in Washington, DC. And so I also want to say that I 
appreciate all the witnesses and them making the accommodations 
that they had to make in order to be here today.
    Ensuring veterans have adequate access to care at the 
Veterans' Administration is an important issue. In the last 7 
years, the number of veterans using the VA health system has 
doubled. The VA anticipates an increase of another 600,000 next 
year. Changes to the VA eligibility standards, the high quality 
of care delivered by the VA and the existence of the VA drug 
benefit have all added to the increased demand of the VA 
services.
    Given this increase in enrollment it is easy to see why 
veterans in Idaho sometimes wait about a year, in some cases 
longer, just to get into see a VA doctor. In fact, there are 
approximately 3,000 veterans today waiting in Idaho, and about 
two-thirds of those veterans are priority 7 veterans. However, 
once in the system Idaho veterans seem to be very pleased with 
the delivery of the care service that they receive.
    Some have predicted that the creation of a Medicare 
prescription drug benefit would help to relieve some of the 
backing of the VA, one which both you and I voted for. 
Unfortunately, the Senate has not followed likewise. Although 
the House passed the legislation in creating a Medicare drug 
benefit in June, the Senate, as I said earlier, did not follow 
suit. That left the Veterans' Administration again to deal with 
the high number of veterans waiting to receive care.
    In May, this subcommittee held a hearing examining the 
structured problems that are causing the backlog of VA 
hospitals all over the country. During that hearing, I 
expressed my deep concern that a system of prioritizing 
veterans on the waiting list was not in place. I am pleased to 
report that on September 26 of this year the Veterans' Health 
Administration issued a directive entitled, ``Priority of 
Outpatient Medical Services and In-Patient Hospital Care.'' 
Under this directive, the Veterans' Administration will now 
give preference to priority 1 veterans who have a service-
connected disability and a rating of 50 percent or higher and 
will make every effort to see that those veterans within the 
next 30-day period receive such admission.
    I believe this directive is a step in the right direction 
in providing veterans with more timely access to the care that 
they need. However, the Veterans' Administration estimates that 
there are over 280,000 veterans nationwide who will wait 6 
months or longer for an appointment with a Veterans' 
Administration doctor. This directive will certainly help 
reduce that number, but the logistical and financial burdens of 
complying with this directive will be a challenging one for the 
Veterans' Administration.
    I look forward to hearing from those representing the VA on 
how they are proceeding in that process. So as we explore ways 
to improve the Veterans' Administration's ability to address 
the health care needs of veterans, I think that it is important 
to factor into the equation a way to provide the VA with the 
necessary resources, regulatory or financial, to address those 
increasing administrative workloads.
    These hearings are an important chance for us and for your 
representatives in Congress to listen, to find out your 
thoughts on how we can best change the structure of the VA 
medical system to better accommodate the needs of Idaho's 
veterans. Mr. Chairman, I appreciate your leadership and your 
interest. I appreciate all of the hearings that you have had on 
this and the deep and sensitive concern that you have shown to 
every panel member that has come before us, not only today but 
also in Washington, DC. Thank you very much.
    [The prepared statement of Hon. C.L. ``Butch'' Otter 
follows:]

[GRAPHIC] [TIFF OMITTED] T9163.005

[GRAPHIC] [TIFF OMITTED] T9163.006

[GRAPHIC] [TIFF OMITTED] T9163.007

[GRAPHIC] [TIFF OMITTED] T9163.008

[GRAPHIC] [TIFF OMITTED] T9163.009

    Mr. Shays. Thank you. I thank the gentleman. First, before 
calling our--recognizing our panel and swearing them in, I 
would like to get some housekeeping out of the way and ask 
unanimous consent that all members of the subcommittee be 
permitted to place an opening statement in the record and the 
record remain open for 3 days for that purpose. Without 
objection, so ordered. I ask further unanimous consent that all 
witnesses be permitted to include their written statement in 
the record. Without objection, so ordered.
    I would also like to note the presence of Major Ed Freeman, 
a Congressional Medal of Honor recipient. This committee is 
honored that he would be here. Thank you so much for being 
here.
    And to say that he earned this recognition in his service 
in 1965 and 1966 and recently received this long overdue 
recognition, and to say that it takes my breath away to think 
of the number of flights that he made, I think nearly 30, into 
an area that was totally and completely surrounded by the enemy 
and over 300 men were saved, in large measure, because of what 
he did. I would also point out that many of the enemy--we lost 
over 300 men that day or during that battle, and I think that 
the North Vietnamese lost nearly 2,000. So it is an honor to 
have you here.
    But it is also an honor to have everyone who has served our 
country. This committee is profoundly grateful, and I can tell 
you without hesitation when a Congressman looks at our flag we 
try to see this flag through your eyes and recognize that when 
you look at this flag you think of the men who never came home, 
and you think of the conversations you had with family members 
about their lost loved one.
    I would also like to recognize any family members who are 
here and just say thank you for supporting your family member 
in their service to our country. I think sometimes it takes 
more out of the family member than it does out of the soldiers 
who are actually serving in the battle.
    At this time, the committee will recognize our first panel. 
Colonel Mitchell Jaurena is a veteran--did I say your name 
correctly?
    Mr. Jaurena. Close enough.
    Mr. Shays. I want it accurate.
    Mr. Jaurena. Jaurena.
    Mr. Shays. Jaurena. Thank you. That is the way it was----
    Mr. Otter. Is that Irish?
    Mr. Jaurena. Basque Irish. [Laughter.]
    Mr. Shays. Colonel, great to have you here.
    Mr. Jaurena. Thank you.
    Mr. Shays. We have as well--so the Colonel is a veteran. We 
have Mr. Lee Bean, a veteran; Mr. William T. Smith, a veteran; 
Mr. Richard W. Jones, administrator, the Idaho Division of 
Veterans' Services, which is the State provision for veterans. 
At this time, as you may know, we swear in all our witnesses. I 
have been chairing the committee now for 8 years, and I will 
tell you the only witness I have not sworn in was Senator Byrd, 
I chickened out and regret it to this day. [Laughter.]
    Would you please stand.
    [Witnesses sworn.]
    Mr. Shays. We will note for the record all our witnesses 
have responded in the affirmative, and Colonel Jaurena, we will 
invite you to address us first. And we have a 5-minute rule, 
but what we do is we allow you to go into the next 5 minutes 
and ask that you stop before 10.
    Mr. Jaurena. Yes, sir.
    Mr. Shays. But as close to 5 as you can be is appreciated.

 STATEMENTS OF MITCHELL A. JAURENA, USMC RETIRED, VETERAN; E. 
 LEE BEAN, VETERAN; WILLIAM T. SMITH, VETERAN; AND RICHARD W. 
   JONES, ADMINISTRATOR, IDAHO DIVISION OF VETERANS' SERVICES

    Mr. Jaurena. Good morning, Mr. Chairman and Representative 
Otter. I am Lieutenant Colonel Mitchell Jaurena, U.S. Marine 
Corps, retired. I was transferred to the Permanent Disability 
Retirement List on July 1, 2001 after 21 years of honorable 
service because of the degenerative nature of injuries I 
received during Operation Desert Storm while in the Persian 
Gulf. Upon my retirement, I moved back to Idaho and settled in 
Nampa. At that time, I attempted to enroll in TriCare Prime, 
the military system of health care, but was unable to find a 
local provider, as no physician or medical provider in the 
Treasure Valley region was accepting, or is accepting, TriCare 
Prime patients. Subsequently, however, on November 6, 2001, the 
Department of Veterans' Affairs rated me as a 50 percent 
service-connected disabled veteran. Now, as a priority 1 
category disable veteran, I was automatically enrolled in the 
Veterans Health Care system and during December 2001, the Boise 
VA hospital issued me my veterans universal access 
identification card and assigned me to a health care team in 
Boise, ID.
    Unfortunately, I was also told at that time that I would be 
unable to utilize the Boise VA hospital for any care other than 
emergency care, as there was a 2 to 2\1/2\ year-long waiting 
list at the hospital for assignment to a doctor. I was also 
told that I would be unable to utilize the pharmacy, even if I 
had a script provided by a non-VA doctor, as the pharmacy was 
only available to those with assigned VA doctor at the Boise 
hospital. I was also told that there was a 2 to 3-year wait to 
receive optical care but hat I would be able to obtain those 
glasses if I could provide them with the prescription from an 
outside pharmacist.
    Mr. Chairman, I find it absurd that a combat-related 50 
percent disabled veteran with service connection should be 
required to wait for medical care at a VA hospital while those 
without service connection are receiving care. I find it even 
more patently absurd that a priority 1 service-connect disable 
veteran should have to wait up to 2\1/2\ years for the 
assignment of a VA doctor just to be able to fill a 
prescription at the VA hospital while they are under the care 
of a private physician.
    But I do need to point out, as Representative Otter did, 
that the landscape has recently changed. The Secretary Principi 
has directed that these 50 percent disabled veterans, priority 
1 veterans, receive care. And as of this time, I have an 
appointment on October 24, so I will have waited 11 months to 
receive care at this hospital.
    Now, it is really hard to overcome 21 years of training 
provided by the Marine Corps. No Marine complains without 
providing an alternative solution, but I do realize that 
Federal funding is not a bottomless well, and there simply 
isn't enough money to go around. I also realize that some 
veterans will eventually go without. There have been various 
plans proposed also by various service organizations, some of 
them to include a financial means test for veterans seeking 
care, in essence, turning the VA health care system into a 
welfare health care system. I am against any financial means 
test as an eligibility requirement for health care. The only 
eligibility requirement for health care I would support is 
already in place and that is honorable service in the armed 
forces of the United States of America in service of our 
country.
    I do believe that those with the highest need based upon 
service connection disability ratings should be seen first. The 
VA already has a priority health care system for enrollment in 
place. This prioritization starts with priority 1 for 50 
percent or greater service-connected disability to priority 7 
for non-service connected and non-compensable disabled 
veterans. I believe that this already-established system should 
also be used for providing health care and scheduling 
appointments so that those who have honorably served and have 
suffered the most will receive the first use of the limited 
assets available.
    Now, if we use the health care system, will veterans fall 
out if we use that prioritization? Absolutely. Will they be 
deserving of care? Certainly. However, this method of 
prioritization will allow for the most disabled to receive care 
and give Congress and the VA a clear picture of those veterans 
left without VA-provided health care. It would allow Congress 
to decide on the level of funding that it is willing to 
allocate based upon veterans' needs. It would also be up to our 
elected officials to reflect the will of the American people to 
fund or not fund for the care of its veterans. Thank you for 
the opportunity to testify.
    [The prepared statement Mr. Jaurena follows:]

    [GRAPHIC] [TIFF OMITTED] T9163.003
    
    [GRAPHIC] [TIFF OMITTED] T9163.004
    
    Mr. Shays. Thank you very much, Colonel. Would you move 
that pitcher so that you could see the light too?
    Mr. Jaurena. Yes. I beat it by 12 seconds, Congressman.
    Mr. Shays. Thank you. It was an excellent statement. 
Excellent statement.
    Mr. Bean. OK. Are you ready for me?
    Mr. Shays. We are, Mr. Bean. Thank you so much.
    Mr. Bean. OK. I am not disabled or anything, I am in pretty 
darn good shape, except what I have to say here. I served in 
the Navy during World War II aboard ship, and after hearing 
that several veterans my age, World War II, getting more income 
than I do are receiving prescriptions drugs from the VA----
    Mr. Shays. I am going to ask a question. Can people in the 
back hear what is being said right now? Let me just say I 
apologize for not being able to pick you up. I am going to ask 
you--and I am sorry about that, but I am going to ask you to 
hold it up, because I think it is important that everybody hear 
your statement.
    Mr. Bean. My voice is not that good either.
    Mr. Shays. Yes. Colonel, I apologize for that.
    Mr. Bean. OK. I can certainly start over then.
    Mr. Shays. I apologize, yes.
    Mr. Bean. U.S. Navy during World War II, and I heard of 
veterans receiving prescription drugs from the VA that are in a 
similar conditions I am, with more income than me, actually, a 
lot of them, and so I decided on December 21, 2000 I went to 
the VA Center and enrolled for benefits, gave them my financial 
so on and so on. Then in May 2001, after coming home, I found 
out that friends of mine had been receiving prescription drugs 
without even filling out a financial statement in other VA 
hospitals. So then I went to the--called the VA Center and the 
nurse told me to come down in an emergency condition. So I went 
down and was right in and saw a PA, a nurse's physician's 
assistant, and she examined me, questioned me and using my 
doctor's prescription enrolled me to start receiving drugs, 
which I did for about 1 year. In February 2000, I updated my 
income status. In March of this year, I was informed by the VA 
that I would no longer receive drugs because I had not been 
able to see a doctor. I then contacted Mr. Otter and other 
Congressmen, representatives about this.
    It is my belief that if prescription drugs are going to be 
available for some veterans, they should be available to all 
veterans, especially after age 65 whenever you have now become 
on Social Security and limited income, also a lot of us being 
in those notch years where we don't receive as much Social 
Security as other people. I think that the VA should be able to 
use my doctor. I belong to an HMO, I have a doctor who writes 
my prescriptions. Why can't I take them to the VA? Why can't 
they trust my doctor? They're both being paid by government 
funds. That's all I am asking.
    Now, if it is not available for me, let us not make 
available for other people in my situation. I don't have a 
Purple Heart, I have a lot of close calls in Australia while I 
was in the Navy, I know that. But I know my wife is 73, I am 
77, and we both work part-time to supplement our income. So I 
am not afraid of that, I am able to do it. That is about all I 
have to say. Thank you.
    [The prepared statement of Mr. Bean follows:]

    [GRAPHIC] [TIFF OMITTED] T9163.010
    
    Mr. Shays. Thank you very much, Mr. Bean. That is very 
helpful testimony as well. Mr. Smith. Evidently, these are mics 
you have to have pretty close up to you.
    Mr. Smith. Can you hear me?
    Mr. Shays. We hear you great.
    Mr. Smith. Honorable Congressmen, ladies and gentlemen, my 
name is William T., Tom, Smith, and I am here to speak--my 
reasons for speaking are the very deplorable treatment to 
myself and other veterans who are being subject to what I feel 
is a completely overloaded and broken down VA system. They are 
trying to do their best, but they can only do so much. They are 
drastically understaffed and underfunded.
    First, they have no cardiac care unit at Boise VA. For 
heart treatment, they send you to Seattle VA. When I had my 
heart attack in 1996, I spent 5 days at the Boise VA waiting 
for space to be transferred to Seattle VA. It took more than 5 
days to be evaluated by a cardiac specialist after a heart 
attack. This is very hard on patient and family after going to 
Seattle twice for heart treatment in a very crowded system, the 
stress of traveling and being separated from family at such 
critical times. The next time I had a heart problem I requested 
to be transferred to St. Luke's for quicker evaluation, and it 
was a good thing I did. I was near another heart attack, and I 
had immediate bypass surgery, it was a six-way bypass. The VA 
denied co-payment on this surgery, and I was left with all the 
bills my private insurance did not cover.
    Mr. Shays. Mr. Smith, could you just turn the mic the other 
way a little bit? Yes.
    Mr. Smith. I am rated 100 percent service connected. My 
first trip to Seattle they did an angiogram, the second they 
did an angioplasty scan implant. The VA always bills my private 
insurance for all the treatments and surgery and prescriptions. 
The real funny thing about all of this is it would be cheaper 
for the VA to pay the co-payment than fly me to Seattle, and 
yet they denied the co-payment. It does not make sense. I go to 
a cardiologist in private practice because there is not a 
cardiologist on staff at the Boise VA. They have one who comes 
in once a month for clinic, and you must meet certain criteria 
to be seen by him. This is almost a joke if it was not so 
serious.
    Another problem is my hands. I had surgery on two fingers 
on my right hand for trigger finger. I have developed trigger 
fingers in my hand, two of them, and I have bone spurs on the 
right thumb. And this time it has taken me over a year to get 
an appointment for an evaluation. Surgery will be scheduled for 
a later date. In the meantime, my fingers are getting worse, 
and I can no longer open it fully. Gripping anything with my 
right hand is very difficult, and these conditions get worse 
daily and less correctable. When I asked my regular physician 
about a colonoscopy, I was discouraged about having one. It has 
taken over a year to get scheduled for a colonoscopy with the 
medical profession recommending you should have one after age 
50. This just doesn't seem right.
    The problems I have stated above plus some old back 
injuries have been shuffled off to a physician's assistant. I 
have not seen my regular physician for the last two scheduled 
appointments. In addition to the other problems, I have upper 
spinal injury which causes tremors and excruciating pain in the 
arms and the shoulders. Plus I have had back surgery on the 
lower back and two hernia surgeries.
    Parking is always horrendous at the VA. If you can find a 
place to park, it is generally three to four blocks away from 
the entrance, and some days it seems like you can't find any 
place to park there. They really need to do something about the 
parking there. The lab is another bottleneck when you go in and 
if you are going to have any blood work done or anything. It is 
not anything to see an hour's wait to have the lab work done. 
If you see your doctor and go to the lab and get a prescription 
filled, you can spend a day at the VA.
    My suggestions would be to have the representative talk to 
the people at the VA, get their statements. If you catch them 
coming out of there real fresh, you can get some good input. I 
am sure they would tell you that they feel like cattle being 
herded through or just a number.
    And the doctors are very reluctant about letting you see 
another doctor about your problem. One of the doctors at the 
specialty clinic will ask you how you are today. If you tell 
him you have some problems, he will tell you, ``We are all 
getting older and expect the aches and pains to be worse.'' And 
then he will tell you to come back and see him in 3 months.
    It is very reassuring to me to have you Congressmen 
investigating trying to assist us veterans with our health care 
problems. I truly hope my statements here will help others and 
assist you in your fact finding. With my sincerest thank you 
for working to make things better for the veterans. Please keep 
up the good work.
    [The prepared statement of Mr. Smith follows:]

    [GRAPHIC] [TIFF OMITTED] T9163.011
    
    [GRAPHIC] [TIFF OMITTED] T9163.012
    
    Mr. Shays. Thank you, Mr. Smith, for your helpful 
statement. Mr. Jones. I am going to ask if anyone is in the 
back and can't hear, you just raise your hand and we will just 
make sure that I direct the witnesses to speak more into the 
mic.
    Mr. Jones. Good morning, sir.
    Mr. Shays. Good morning.
    Mr. Jones. It is my pleasure to be here this morning and 
present the testimony on behalf of Patrick Teague who was not 
able to be here and was scheduled to actually provide testimony 
before you. I do have his written testimony before me. Patrick 
is our program supervisor of the Office of Veterans' Advocacy 
for the State of Idaho, so reading his testimony.
    Committee members, veterans and guests, I wish to express 
my appreciation for being invited to speak on behalf of Idaho's 
veterans today. It is indeed an honor and a privilege to appear 
before you.
    I would like to begin by saying the care at our VA medical 
centers serving Idaho's veterans is outstanding. Sure, you have 
the occasional horror story of a veteran who has been 
mistreated or neglected but these instances are few and even 
fewer once investigated. In my job as a veteran service 
officer, I speak to veterans and their dependents throughout 
the State, and almost to a person they all tell me that once 
they get through the door into the VA medical center, they 
receive excellent care. Which brings us to the reason we are 
here today: Access to our VA medical centers.
    If you are a veteran who has been assigned a team, has a 
doctor or a physician's assistant, then you are indeed 
fortunate. If you are a veteran moving one State to another, 
you are facing a wait of up to a year or longer just to gain 
access to our VA medical centers. The exceptions to this are 50 
percent service-connected veterans or those requiring emergency 
care. By far and away, however, the majority of new accounts 
are being told to get into an ever-increasing line and don't 
call us, we will you.
    This is simply unacceptable and must be corrected. The real 
tragedy here is that as service officers we are told for years 
to go out and find those veterans who have never been enrolled 
in our VA medical centers and get them enrolled. When queried 
by the service officers if the medical center would be 
available to provide care for those veterans, the answer was a 
resounding yes, so we did. We went out and found those veterans 
who had never been in the system and had them submit their 10-
10EZ forms. Some of those veterans are still waiting to be 
assigned a team. In the meantime, for every new account, or 
``uniques,'' as the VA calls them, the VA medical center gets 
approximately $1,5000 placed in their account. I have no 
problem with that, but I do not understand why the veteran is 
denied access if the VA medical center has received $1,500 for 
enrolling that veteran.
    Another problem we have that I do not understand is when 
the Boise VA Medical Center cannot provide specialty care at 
the Boise VA Medical Center, they then schedule the veteran for 
care in Palo Alto or Seattle. If the veteran is sent to 
Seattle, the Boise VA Medical Center gives him $40 for a bus 
ticket to Seattle. The veteran then finds transportation from 
the bus depot to the Seattle VA Medical Center. When the 
veteran is finished with is stay in Seattle, he must get the 
Seattle VA Medical Center to give him $40 for his trip back to 
Boise. Once again, it is up to him to get from the VA Medical 
Center to the bus depot. Then he has the long bus ride back to 
Boise. In many cases, these veterans are convalescing and the 
bus ride takes its toll on them. Wouldn't it be better for the 
veteran and their families if the Boise VA Medical Center would 
refer them for specialty care at St. Luke's or St. Alphonsus? 
The Millennium Health Care Act states that if care in a VA 
medical center is not available, then the veteran should be 
referred to the community. They do not normally do it as it 
impacts the Boise budget more than they can afford. Clearly, 
something must be done for these veterans who fall through the 
cracks and are sent to other VA medical centers for their care.
    We must also address the problem of proper funding for 
those who travel for a VA medical center appointment, as Idaho 
is one of the most rural States in the Union. Some of our 
veterans must travel over 500 miles roundtrip for a medical 
appointment. An example of this would be Salmon, ID in Lemhi 
County. Those veterans travel 252 miles one way to receive 
treatment at the Boise VA Medical Center. Veterans traveling to 
those appointments receive 11 cents per mile for that 
appointment, and some of them have $6 deducted from that travel 
allowance. Any appointment that is not for a compensation and 
pension examination will have the $6 deducted from the 
veteran's reimbursement, not to exceed $18 in 1 month. This is 
simply ludicrous because the VA medical centers are only 
reimbursing 11 cents per mile as it is. A raise is certainly in 
order to help alleviate the cost of traveling to and from an 
appointment.
    In summation, I would like to reiterate that once in the 
door of the Boise VA Medical Center, the care is excellent. It 
is getting through that door that is the problem. We must 
secure more funding for our VA medical centers if we are to 
make a difference in the current situation. Our Nation's 
veterans deserve no less. Thank you for your attention.
    [The prepared statement of Mr. Teague follows:]

    [GRAPHIC] [TIFF OMITTED] T9163.013
    
    [GRAPHIC] [TIFF OMITTED] T9163.014
    
    Mr. Shays. Thank you very much, Mr. Jones; appreciate it. 
We are going to start off with Mr. Otter asking some questions, 
and I will have some questions as well. And if we ask one of 
you but another of you wants to answer the question as well, 
just jump in after that person is finished speaking.
    Mr. Otter. Well, thank you, Mr. Chairman, and I would 
direct this question to all of the panelists. During our 
hearings, several hearings, that we had earlier this year and 
one late last year, there were--obviously, we heard about an 
awful lot of horror stories, and I think that is what 
precipitated the priority 1 change that came about September 
26. I can remember in the committee room me offering an example 
that I am prior service but I have no service disability, no 
service-connected disability. And yet if I showed up at the VA 
hospital with a rodeo accident, I would certainly be put ahead 
of, depending upon if I showed up on that priority list, I 
would be put ahead of anybody who may have gotten some 
disability as a result of any military action or any other 
military service. We thought that was patently unfair.
    My question actually as a result of listening to several 
folks that testified and trying to come up with some sort of a 
recipe, if you will, that said that the level of service-
connected disability coupled with age should bring us some sort 
of a ratio of setting priorities. Would you agree or disagree, 
and I am not prepared to say you have got to be a certain age 
with a certain disability, but would you agree or disagree with 
setting a priority, No. 1, based upon the disability and the 
level of disability and, No. 2, the age of that veteran that is 
disabled?
    Mr. Jaurena. I will kick it off here, Representative Otter. 
I agree with you on the first part. Service connection and the 
type of disability, I would absolutely agree with that. 
However, it makes no difference whether you are 46 like I am or 
76 is if you have a degenerative disease caused by a service 
injury that you are required to take medication for. As it 
stands now, I cannot get in to get my medication at the VA 
hospital simply because I have been bumped by priority 7 
people. So I do not believe an age requirement is justifiable. 
You have a system already established within the health care. 
It is priority 1 through priority 7. Priority 1 group is 50 
percent or greater, priority 2 is 30 or 40, priority 3 is 
former POWs, 10 or 20's or Purple Hearts. Those folks have a 
service connection. We have already established a system to 
determine whether they are eligible or not and set a priority 
group. I believe we should stick to it and not deal with the 
age issue.
    Mr. Otter. Great. Thanks, Mitch. Lee.
    Mr. Bean. I think age partly should be involved because of 
your ability to go out and make a living. If I have a good 
income to where I could go out to dinner once in a while and 
things like that, I wouldn't even be here. I wouldn't be asking 
for prescription drugs, and that is all I am asking for. And 
one of the reasons I am asking for that is I have a lot of 
friends who are getting these prescription drugs from other VA 
hospitals by walking in and getting them.
    Mr. Otter. My apologies for stopping you right there.
    Mr. Bean. OK.
    Mr. Otter. That is another question I am going to ask, and 
since you brought it up I want to ask you that now. If we had 
seen a successful conclusion of the house-passed Medicare drug 
benefit bill, which was $350 billion over 10-years, would you 
then seek access to your drugs through the Medicare program 
rather than through the VA program?
    Mr. Bean. I probably would, yes, because I am paying for 
health insurance right now, and the high cost of drugs is what 
is killing some of us; $55 a month for health care--
supplemental health care in an HMO is not a big deal, but when 
you start paying a couple hundred dollars a month for two 
pills, it gets a little ridiculous.
    Mr. Otter. Thanks, Lee. Tom.
    Mr. Smith. I don't think that age should really play a 
factor in it. I think that any disability, any disabled vet 
should be--the care should be accessible for him. I agree with 
Mr. Bean that there is a lot of people out there that are 
getting medication that--I know some that are getting 
medication and Mr. Bean would be just as entitled to it as they 
are. I don't have anything further, I don't think.
    Mr. Jones. I agree with the comments by the other 
panelists. I am concerned that it should be based upon their 
disability. My concern is that you have individuals who had 
degenerative conditions and other conditions that with such an 
undo waiting list, undo waiting time, their condition would 
deteriorate so significantly from the time that they attempted 
to enroll to the time that they would actually be seen by a 
physician and receiving care. I don't believe that this is 
correct.
    Mr. Otter. All right. Let me start with the entire panel 
again, and I will start with you first, Mr. Jones, because you 
brought it up in your testimony that you represented in Mr. 
Teague's place, you mentioned out-contracting or community 
contracting. Do you know that is now the practice in any other 
place in the United States where they actually have out-
contracting within a Veterans' Administration region?
    Mr. Jones. I am not aware, but I can find out and let you 
know very quickly.
    Mr. Otter. I think we will probably get some testimony from 
Mr. Tippets or Dr. Lee a little later on on that. How about 
you, Tom?
    Mr. Smith. Really, I don't know of any other place where 
they are contracting out. However, I do know that the VA here 
does contract some out to St. Luke's. I think I would like to 
see the heart care increase a little beyond that, because after 
a heart attack or anything it is important to get the treatment 
and know where you are at immediately.
    Mr. Otter. Tom, relative to your experience between Boise 
and Seattle and traveling back and forth from the operation, 
the six-way bypass that you had in Seattle, do you think you 
are----
    Mr. Smith. No, I had the six-way bypass here at St. Luke's.
    Mr. Otter. Oh, excuse me. I misunderstood. Was your--so you 
rehabilitation was actually right here in Boise in your home--
--
    Mr. Smith. Oh, yes.
    Mr. Otter [continuing]. Around your family.
    Mr. Smith. That is right.
    Mr. Otter. OK. Well, let me ask you the question anyway in 
a hypothetical sense. Do you believe that your healing process, 
that your rehab process was much faster as a result of being 
home within your own community and around your own surroundings 
than it would have been had you had to have that in Seattle?
    Mr. Smith. OK. Now, I can relate on that a little bit 
further here. After my heart attack I went to Seattle. I waited 
5 days here for a bed in Seattle in the Cardiac Care Unit. I 
went to Seattle, and I came back--when I came back I was 
probably more distressed than I was before I left. The second 
time I went to Seattle and they did a skin implant and I came 
back, I was feeling better because the stint was pretty 
successful, and it is not a real invasive procedure. And I was 
feeling better and so recovery was probably good. But when I 
had the six-way bypass, if I would have had to travel from 
Seattle back to here after a six-way bypass, I don't know how I 
would have done it. It is just unbelievable to me that people 
do that. I don't know.
    Mr. Otter. OK. Lee.
    Mr. Bean. No. I have nothing to say about that. The only 
thing I was talking about age is that I think all service-
connected veterans should all be first, No. 1. All I am talking 
about are medications. That is all I am talking about when it 
comes to age.
    Mr. Otter. OK. Thanks, Lee.
    Mr. Jaurena. I know of no outsourcing. I haven't had any 
medical care here yet, so I can't talk intelligently about it.
    Mr. Otter. But in your testimony didn't you offer to us 
that your prescription that you got from your own doctor was 
initially filled through the VA facility?
    Mr. Jaurena. No, it was not.
    Mr. Otter. Oh, I am sorry.
    Mr. Jaurena. It was not. They will not fill the script here 
from a private physician. You must have a physician in the VA 
hospitals before they will fill the script here in the 
hospital. That is one of the things I find absurd.
    Mr. Otter. I see. I am sorry, Lee. I guess it was you, just 
one more question. Lee, I think it was you that said that your 
prescription which you received from your own doctor was 
eventually filled.
    Mr. Bean. Yes. I saw a physician's assistant, a nurse, and 
she looked me over. I didn't see a doctor, no, but I got my 
prescription for 1 year cutoff because I didn't see a doctor.
    Mr. Otter. Thank you, Mr. Chair.
    Mr. Shays. Thank the gentleman. I am delighted that this 
committee is here, and I was thinking before we started that we 
talked about how the first hearings of the Supreme Court were 
wherever they could have a hearing, sometimes in taverns, and I 
just will note that while we are at a tavern of sorts, the bar 
is not open. [Laughter.]
    And also to say that our perspectives are so different. I 
am a Yankee, grew up in New England area, and my constituents 
have some real complaints but they are a little different. I 
will just say as a side when I was in Whitefish, Montana with a 
close friend there were three cars coming in on a main street 
that we were trying to get on and my friend was driving, and I 
wanted to see how she had to react because she had to wait as 
one car went by, then another car went by and then another car 
went by and then we got on the main thoroughfare, and she 
turned to me as she was driving and she said, ``I hate 
traffic,'' and I was thinking, boy, you would have to wait for 
30 cars before you could get on a main street where I live. And 
then I was thinking of distances and I was thinking, though, 
that my veterans, if they have to go 60 miles, consider that an 
outrage. And you all have to go the equivalent in my area where 
I live near New York of having to go up to Boston or to 
Columbus, Ohio, in one or two instances, to get the kind of 
service you need. So it is important that Members of Congress 
get exposed to these different perspectives, because ultimately 
we are looking for ways to write legislation that is going to 
meet the needs of the veterans but is flexible to the different 
groups.
    My first question then relates to this. I will start with 
you. Are there any community-based health care clinics? For 
instance, in Connecticut, as small a State as we are, we are 
like a county here, we have one main facility in Westhaven 
which is kind of centrally located, at least between the north 
and the east and west, right on Long Island Sound, but we have 
about four community-based health clinics that our veterans can 
go to to get the kind of prescription services that you need, 
not to have a bypass but to go there. So are there any 
community-based health care clinics that you get to utilize?
    Mr. Jaurena. There is, Mr. Congressman, there are several 
out here, but I have not used them so I can't speak 
intelligently about them. I don't even know where they are at 
yet, because I haven't had any appointment.
    Mr. Shays. We will be able to ask the second panel about 
this.
    Mr. Jaurena. I think Mr. Jones and down the line will know 
about them also.
    Mr. Shays. But I would be anxious just to know if any of 
you--Mr. Smith, did it ever serve your need, or Mr. Bean, to go 
to a community-based health care clinic? Are they a big deal in 
this area or not that important?
    Mr. Smith. Not me.
    Mr. Shays. OK.
    Mr. Smith. The only thing I have done was St. Luke's with 
the heart bypass.
    Mr. Shays. Mr. Bean, did you have occasion to use a 
community-based health clinic as opposed to coming to the main 
facility?
    Mr. Bean. St. Luke's or St. Jones.
    Mr. Shays. Yes, Mr. Jones; yes, sir.
    Mr. Jones. Congressman Shays, there are three community-
based outpatient clinics in Idaho: One in Pocatelo, which is I 
believe under the Salt Lake VAMC; one in Twin Falls, which is 
under the Boise VAMC; and one in Lewiston. The one in Lewiston 
is a part-time--part-time it opens. In all three, it is my 
understanding is that you still run into the same situation 
that there is a waiting list, and you would still need to go 
through the VA enrollment process to receive those services. It 
is unfortunate that recently, and I would have to look up the 
name, of the individual that had given a directive that we were 
to stop advertising the community-based outpatient clinics, and 
that has resulted in a lot of flack that she has received for 
that. But those are in existence and working in discussions 
with the CARES Group there are discussions of additional 
community-based outreach clinics opening up, and I think it is 
a very appropriate outlet to reduce the pressure on the VAMCs.
    Mr. Shays. The VA does a lot of things quite well, and one 
of the things, though, there had been this debate and I would--
this may seem a little off the subject, but it would be helpful 
to know. I want to take advantage of knowing how you all would 
feel in this part of the country. There are some that argue, 
and I frankly took this argument but have backed off a little 
bit because of the response from the veterans, and that was 
that there are some who say why not give a veteran a card that 
notes that they are a veteran and let them go to any hospital 
in the country and get service? I am not going to tell you what 
the answers were of my veterans, I want to know what your 
answers are, and then I am going to respond to that. Colonel, 
we will again start with you. In other words, if you could get 
a card that said you are a veteran, you can go to any facility 
and you wouldn't have to just go to a veterans' facility, would 
you like to see that kind of system?
    Mr. Jaurena. I run parallel. I have a card from DOD, it is 
called TriCare Prime. I can't get a doctor to take it because 
the Federal Government doesn't pay enough to those doctors and 
pays in such a poor manner and so late that they refuse to take 
it. I believe the same thing would roll with the VA system. I 
am in a system already that does that, and I wouldn't adhere to 
any other system that does the same thing. It doesn't get me 
care, so we need----
    Mr. Shays. You would rather be treated in a VA facility.
    Mr. Jaurena. I would rather be treated in a VA facility 
because our payments, I believe, will never keep up with what 
the civilian community is going to require, and they will not 
take us. I would even take it if we did and had a reasonable 
copayment, sure, but I don't believe we can keep up with it. 
The DOD can't keep up with it, I see no reason the VA can keep 
up with it.
    Mr. Shays. Mr. Bean? You know what I think I am going to 
do, I am going to rotate so that way you can switch the 
microphone. We will go to you Mr. Smith, and then I will go to 
Mr. Bean. So the question is would you prefer to be treated in 
a veterans' facility or if you could have a card and go to the 
hospital in the Nation and prefer that?
    Mr. Smith. Well, right now I would say that the treatment 
at the VA center is excellent for what you get, and then I 
would like to stay with the VA system. However, it is terribly 
underfunded here and understaffed, and with the understaffing 
and underfunding, I am seeing a cardiologist right now on the 
outside because we don't have one on staff full-time here at 
Boise VA.
    Mr. Shays. Well, you trigger a second question, and that is 
would you want to see a hybrid? In other words, if, for 
instance, at Boise they couldn't provide the cardiac type of 
health care that you needed, would you like to be able to go to 
a non-VA hospital and get that kind of care so you wouldn't 
have to go to Seattle to get the care that you needed?
    Mr. Smith. Yes.
    Mr. Shays. OK. Mr. Bean.
    Mr. Bean. I don't think I really qualify because I am not 
disabled, I am not in full claims.
    Mr. Shays. No, you qualify because you are a veteran and I 
want to know what you think as a veteran.
    Mr. Bean. I would just as soon use my Medicare and if the 
government can help with a supplemental insurance type thing go 
to the regular hospital because there are more available.
    Mr. Shays. OK. Mr. Jones.
    Mr. Jones. I would prefer to go to the VA medical center, 
but if services at that center were not available, I would 
prefer outsourcing within the community so that I wouldn't have 
to leave the community for service.
    Mr. Shays. And let me just say that is kind of the way I 
should have said it. In other words, we outsourced it in the 
community.
    Mr. Jaurena. Mr. Shays.
    Mr. Shays. Yes.
    Mr. Jaurena. Again, I would like to jump back in. Now that 
you have thrown a second one into the pile, absolutely, I would 
like to go to the VA and then if they could not provide those 
services, outsource it out for specialty care.
    Mr. Shays. So you could be local.
    Mr. Jaurena. I believe that system would work wonderfully.
    Mr. Shays. I can't think of it being more difficult, Mr. 
Smith, than to go to--to have a major operation, I mean one 
that is one safe but a major operation and not be relative near 
your home, near your family, near your friends. So I have that 
sense.
    Mr. Smith. I just can't agree any more than what you said 
there. If you are not near your family, you are worrying about 
them, they are worrying about you, the whole situation is not 
good.
    Mr. Shays. Now, let me just say to any veteran or anyone 
else who wants to testify, after we finish one or two, that 
question would be something I would be interested for you to 
address. The response from my veterans is they are afraid that 
if we get rid of the VA system, that ultimately the card will 
become meaningless, and they at least like to know they have 
got this pole in the ground that basically says this is a VA 
facility. Also, they feel that the VA facilities have a little 
more sensitivity to the illnesses of veterans but also to 
understanding their perspective. So the outsourcing, I think, 
probably would be more--my own constituents would be more 
inclined as long as they didn't see it replacing the VA 
facility.
    Let me just--I have some questions that staff believes I 
need to put on the record, so let me just run through this as 
well, and we will start with you, Mr. Bean, since you have 
the--have you felt that a communication with the VA facility 
has been done in a professional way, and do you feel that you 
have always been kept informed by the VA when you have had 
requests out there?
    Mr. Bean. I don't feel like I have been kept informed, but 
any time I have called to talk to them they have been very 
nice, no problem there at all, but I have not been informed.
    Mr. Shays. Mr. Smith.
    Mr. Smith. Yes. They have been very professional.
    Mr. Shays. And they stay and keep you informed.
    Mr. Smith. And they keep me informed.
    Mr. Shays. OK.
    Mr. Smith. The appointments are noted and mailed, and 
everything is--if I call with a question, it is answered. There 
is not any real problem there.
    Mr. Shays. Colonel.
    Mr. Jaurena. They have been very professional and very 
informative. Not only do they send an initial appointment 
letter, they send a reminder letter. So they have been very 
good. The level of care I can't talk about.
    Mr. Shays. Let me just ask another question. When you go 
into the facility you have to wait to get there, but once you 
are there do you have long waits?
    Mr. Jaurena. I can't talk to that. I walked in and 
registered and got my card, and they said, ``Don't call us, we 
will call you.''
    Mr. Shays. Right. OK. So you are a work in process right 
now. Mr. Smith.
    Mr. Smith. There can be some long waits. As I noted, the 
lab is small for that size hospital. I feel there are not 
enough people in there. They can't get people through that need 
to be done. The pharmacy is a little bit of a bottleneck. It is 
better than it used to be, they are trying to improve things. 
It is the funding and the staffing.
    Mr. Shays. I would just ask you to answer that question, 
Mr. Bean, and then, Mr. Jones, I will finish up with you.
    Mr. Bean. I was only there two times and each time I had to 
wait, oh, maybe half an hour, something like that, which was 
reasonable as far as I was concerned.
    Mr. Shays. In my part of the country, veterans will 
sometimes literally wait half a day before they get--they come, 
they are told to get there, and they are queued up in big lines 
and so on. Source of tremendous disappointment. You know, they 
wait a long time to get there, and once they are there they 
wait.
    One of the things I want to put on the record is that the 
VA has one of the best drug programs in the Nation, if not the 
best, because we buy in bulk and we pass on the savings, and 
the savings are considerable. And we are using the VA model as 
a way to look at Medicare, because Medicare purchases by the 
government are basically paid for individually at individual 
prices, not at bulk prices. Totally understandable why anyone 
who is needing drug assistance would go to the VA facility, 
because you pay a fraction of what your neighbor may pay if you 
are fortunate enough to get in that system. And I understand 
why, Mr. Bean, you would be working overtime to have that 
happen.
    Mr. Jones, just in a--we need to get to the next panel so 
we need to move along, but let me just ask you this: Describe 
to me how the State VA facility interfaces with the Federal 
system as briefly as you can do that.
    Mr. Smith. Certainly. Let me just start off by saying they 
have been extremely professional. The Division of Veterans' 
Services in Idaho operates three State veterans' homes located 
around the State. Each of these veterans' homes is being 
serviced by a different VAMC, so I am able to relate and 
respond not only to the Boise VA but to the one in Spokane and 
the one in Salt Lake as well. In each case, they have been 
highly professional. The veterans' homes received a much 
greater level of service from the VAMCs prior to the State-
directed certification by Medicaid. Once they were certified by 
Medicaid, there were a number of services that had been 
previously available and provided by the VAMCs that were no 
longer available to the veterans who were residents within the 
veterans' homes. The VAMCs also operate long-term skilled 
facilities themselves, and that is certainly an issue that is 
being addressed by the Mill bill and some things like this. But 
a long story short, they have been very professional.
    Mr. Shays. I would just note for the record that when we 
had a hearing in New York State about 2 hours north of the 
city, the room was packed. It was about a little smaller than 
this, it probably had about 300 people in it. And at one point, 
I was defending the VA, which was not the mood of the group, 
and a police officer came up to me and whispered in my ear, he 
said, ``In case you have to leave early, there is a door in the 
back.'' And I just want to thank you for the fact I can go out 
the front door in this hearing. [Laughter.]
    If there are no more--do you have any other questions?
    Mr. Otter. No, I have none.
    Mr. Shays. Let me say that you all--your statements were 
really pertinent and ripe to the topics of the questions, so we 
had a number of questions to ask, but you answered them in the 
questions. So I just thank you for your participation, you have 
been wonderful witnesses, very helpful to the committee and we 
will go on to the next panel, unless there is just--I usually 
do this, I forgot to do this. Is there any closing comment that 
anyone on this panel would like to make? Yes, Mr. Smith.
    Mr. Smith. I would like to make one. There is just one 
statement I would like to make and that is the things that I 
have had here and everything are true, but the main thing that 
I would like to see is on heart care. I just hate to think 
about somebody laying up there for 5 days like I did the first 
time when I had the heart attack and then transferring to 
Seattle. Five days waiting to find out how much heart damage 
you have got is just unreasonable.
    Mr. Shays. It is.
    Mr. Smith. And I would like to see something like that 
changed.
    Mr. Shays. And I think both Mr. Otter and I would totally 
and completely agree with you. Probably some people in the VA 
would as well. So we are going to try to find a way to solve 
that problem.
    Mr. Smith. Thank you.
    Mr. Shays. Any other comments? At this time, then, let me 
call Dr. Leslie Burger, Network Director, Veterans' Integrated 
Service Network, Department of Veterans' Affairs; accompanied 
by Mr. Wayne Tippets, Director of Boise Veterans' 
Administration Medical Center, Department of Veterans' Affairs; 
accompanied by Dr. David K. Lee, Chief of Staff, Boise 
Veterans' Administration Medical Center, Department of 
Veterans' Affairs.
    Before I swear in the first panel, I do want to put in the 
record another witness who was going to be here, Rex T. Young, 
from Meridian, ID. Meridian, I am sorry, Meridian. And the part 
of the statement he said, ``With all the emphasis on early 
detection and early treatment, it is not very comforting to be 
told by a doctor after an examination that I need to see a 
urologist and also need a colonoscopy and be told the 
urologists are making appointments 9 months out and having a 
colonoscopy appointment made 9 months out.'' He basically said 
the delay on seeing the urologist and obtaining a colonoscopy 
through the VA system could have life-threatening. He was in 
fact told to have one because there was a concern about his 
life. That is I think consistent with what we have heard in 
other places around the country and consistent with the panel. 
We will put this, without objection, his entire statement on 
the record.
    [The prepared statement of Mr. Young follows:]

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    Mr. Shays. He would have liked to have been here. I don't 
know if it is the hunting season and he is out hunting. Is that 
a possibility? I understand. OK.
    If you would, please, rise before you. Raise your right 
hand. Thank you.
    [Witnesses sworn.]
    Mr. Shays. Note for the record our witnesses have responded 
in the affirmative, and we have one testimony. Our testimony is 
from you, Dr. Burger, but all three will respond to questions, 
if necessary.
    Mr. Burger. And we will all give some testimony too if you 
would permit.
    Mr. Shays. Right. Oh, you all three want to give some? That 
is fine. Yes, that is fine. Let me ask you, though, I am going 
to ask you to hold that mic up but close enough so we can hear 
you.
    Mr. Burger. Usually I am pretty loud.
    Mr. Shays. OK. Well, Dr. Burger, delighted that you are 
here. Thank you, and be happy to take your testimony.

   STATEMENTS OF LESLIE BURGER, NETWORK DIRECTOR, VETERANS' 
 INTEGRATED SERVICE NETWORK, DEPARTMENT OF VETERANS' AFFAIRS; 
WAYNE TIPPETS, DIRECTOR, BOISE VETERANS' ADMINISTRATION MEDICAL 
  CENTER, DEPARTMENT OF VETERANS' AFFAIRS; AND DAVID K. LEE, 
CHIEF OF STAFF, BOISE VETERANS' ADMINISTRATION MEDICAL CENTER, 
                DEPARTMENT OF VETERANS' AFFAIRS

    Mr. Burger. Thank you, sir. Mr. Chairman, members of the 
committee, on behalf of more than the 7,600 dedicated----
    Mr. Shays. I am going to ask you to put the mic closer.
    Mr. Burger [continuing]. Employees at the eight facilities 
and 17 community-based outpatient clinics of VISN 20, the 
Northwest Network----
    Mr. Shays. Tell me, the Northwest Network includes how many 
States?
    Mr. Burger. Four, Mr. Chairman: Alaska, Washington, Oregon 
and much of Idaho.
    Mr. Shays. OK.
    Mr. Burger. We claim to be the--we encompass 23 percent of 
the geography of our great country, actually, and that does 
present, as you alluded to, one of the major issues that we 
have. Our facilities are several hundred miles apart, getting 
patients seen up in Anchorage, Alaska and so on and. The idea 
is our CBOCs, even though we have 17 CBOCs, they are still a 
considerable distance among all our facilities. It has been a 
major challenge for us.
    Mr. Shays. Let me just parenthetically ask you, I know a 
lot of service men and women who have had the opportunity to 
serve in Alaska and then decided to retire there, so are you 
getting a fairly large population of veterans going to Alaska?
    Mr. Burger. Yes, sir. We serve between 10 and 15,000 
veterans in Alaska and have opened a couple of CBOCs there and 
again have really challenges of getting people from Nome and 
Barrow and the Keeneye Peninsula and so on.
    Mr. Shays. How many veterans total in the VISN 20?
    Mr. Burger. How many are living there?
    Mr. Shays. You know what? Get on with your statement. I 
shouldn't get this--get right to your statement, please.
    Mr. Burger. We served 11,000 veterans this past year in 
Alaska.
    Mr. Shays. OK.
    Mr. Burger. If I might, before I make the statement, to 
respond to a couple of the questions that were raised from 
panel one, just some data for you. We indeed do use contract 
care considerably in the network, and fee schedule, fee basis 
care. I have some data for that. Non-VA care amounted to over 
$76 million last year across our network. And I did comment to 
you about the CBOCs that now number 17. About half of those 
opened in the last few years.
    My statement, since the inception of the Veterans 
Integrated Service Network some 7 years ago, our network has 
been a recognized leader in the quality of care it provides to 
veterans in the Northwest. Winner of several quality awards, we 
really are proud of the fact, as we heard from the first panel, 
that those veterans who use our services consistently rate us 
among the best in VHA in the patient satisfaction surveys that 
we do. And something that we are equally proud of is that our 
employees rate us very highly in employee satisfaction surveys. 
I have provided for you a copy of the Malcolm Baldrige National 
Quality Award application. We have been applying--have applied 
for the Malcolm Baldrige Award. A health care organization, 
private or public, has never won this award, and we are really 
pleased in how we are progressing in doing that. That really 
does speak to the quality of our organization.
    Mr. Shays. Good luck.
    Mr. Burger. And as you have heard here from the first 
panel, with the passage of eligibility reform and the opening 
of several CBOCs across our network, our veteran users have 
grown some 32 percent, from 125,000 in 1997 to approximately 
165,000 this past year. This represents an overall market share 
of about 17 percent of the more than 1 million veterans that 
live in our network catchment area.
    We have consistently served the highest percentage of 
priority 1 through 6 veterans in VHA, and that accounts for 
about 82 percent of our workload. We are No. 1 in VHA in 
serving priority 1 through 6 veterans. Our market share of 
service-connected and low-income veterans in our area is 33 
percent. I would point out to you, Mr. Chairman, that with 
approximately 30 percent of our patients being age 65 or older, 
we are one of the youngest networks, demographically speaking, 
and we will face many of the issues that you face back east in 
the next decade or so as our veterans age.
    Mr. Shays. I am going to ask you to put the mic a little 
closer. See, we hear you all right, but I just want to make 
sure.
    Mr. Burger. OK. Maintaining high quality and increasing 
productivity has been achieved in no small measure by dramatic 
shifts from in-patient care to ambulatory care and from acute 
episodic care to a patient-focused primary care and disease 
prevention strategy. There have been many innovative practices 
that have allowed us to drive down or otherwise control 
increased costs in laboratory and pharmacy and radiology. We 
have adopted changes in care delivery to include such things as 
group visits, the use of more structured telephone followup 
care, by establishing a 24 by 7 telephone care system for our, 
by improving patient flow in clinical areas and advanced 
telemedicine to deliver patient care and other staff activities 
and advanced clinic access for appointing. These are some of 
the many practices that have really changed the health care 
delivery landscape for us and helped us to provide more and 
more care more efficiently for our veterans. Each of these 
innovations is really patient-focused, designed to empower our 
veterans as well as to improve our efficiency.
    Speaking to budget for a moment, approximately 96 percent 
of our network's budget is allocated through the Veterans 
Equity Resource Allocation model, the VERA model. This 
distribution formula takes into account workload, patient 
complexity and other local factors. Without sizable increase in 
workload over the past several years, our network has fared 
fairly well in this distribution process, receiving more funds 
percentage-wise than the national average in all but one of the 
last 6 years.
    I have provided an attachment in the testimony that really 
speaks to the marked increase in the numbers of patients that 
we have taken care of, while at the same time we have been able 
to hold down the costs for veterans served, which is really a 
tribute to the staff and being able to accomplish that.
    Until recently, we have been able to keep pace with these 
demands for services, but as you know with the economic 
downturn here in the Northwest, unemployment is one of the 
highest in the country. As of a couple of weeks ago by looking 
at the Bureau of Labor and Statistics Web site, Alaska was 51st 
in unemployment, highest unemployment in the country, 
Washington State was 50th, Oregon was 49th, Idaho was 30th. So 
unemployment is a major issue for us here in the Northwest. The 
States of Washington and Oregon have been heavily penetrated by 
health maintenance organizations, and over the last couple of 
years some of these health maintenance organizations have 
dropped coverage on thousands and thousands of beneficiaries, 
many of whom are veterans.
    I would also point out that health care inflation is at 
least twice the overall inflation rate, and the growing cost of 
medication, which is up some 15 to 19 percent these past couple 
of years, and a shortage of health care workers all together 
have made it such that the demand for health care services have 
now exceeded our ability to provide those services.
    The backlog, as you have heard from the first panel, 
patients waiting for their first appointment and those waiting 
for more than 30 days for appointments has dramatically 
increased. I would point out that this is a very dynamic 
waiting list. Every month, hundreds and hundreds of people are 
taken off the waiting list and there are hundreds and hundreds 
more people that are placed on the waiting list.
    Mr. Shays. Yes. The tragedy, though, is in order to get 
service, sometimes you are waiting for someone to die.
    Mr. Burger. I would comment to that, sir, and that is that 
as our veterans enroll we are now using a questionnaire, so our 
veterans are asked about their health status and what it is 
they are actually seeking from us. We are trying to find those 
veterans who have a medical acute need, and we are placing 
those folks, trying to give them appointments right away.
    Mr. Shays. No, but I am not trying to incite here, I am 
just trying to suggest not that we are denying someone services 
who is about to die, but in order for a veteran to get service 
he has to sometimes wait, or she, but has to sometimes to wait 
for people to literally pass away so that they are then on that 
list, and that is a challenge for us.
    Mr. Burger. OK. Another comment to that, it turns out that 
about 25 or 30 percent of our veterans turn over every year. 
Many of those----
    Mr. Shays. I want the definition of turnover.
    Mr. Burger. Many veterans come to us for a single purpose--
single visit for a single purpose. They don't come back by 
their choice. Other veterans indeed to pass on, and another 
group of veterans actually are transient, they are no longer 
living here. And that really accounts for most of that 25 
percent turnover. I point this out to mean that of the 165,000 
veterans that we have served this year, that means that 40,000 
of those we did not serve last year and we have taken on, in 
addition to that, another 9,000. We have increased about 5 
percent over last year. So of that 165,000 veterans, about 
49,000 of them did not come to us for care last year. So it is 
a very dynamic process. But even so we are not keeping up. 
There are more people coming on that list than we are capable 
of taking off that list.
    We have taken many measures to cope with this increased 
demand. I mentioned that we are querying people at the 
enrollment process so if there is medical circumstances that 
require it, we give people appointments quickly. We have 
expanded clinic hours, we have increased our patient panel size 
to 1,000 to 1,200 patients for each of our primary care 
providers, we have applied supplemental funding that the 
Congress has given us, we have begun the process of expanding 
our ability to provide primary and specialty care with that 
money. In the past 2 months, our waiting list for primary and 
specialty care across our network has decreased more than 20 
percent. It was as high as 30,000. It is currently well under 
23,000. And Mr. Tippets and Dr. Lee will address Boise 
specifically about that. On October 1, we did institute a plan 
to give priority for appointments to veterans with 50 percent 
or greater service-connected disability. We have begun to 
contact those veterans by phone and by mail.
    We have taken a balanced approach now with the additional 
resources that have been provided in order to meet the full 
spectrum of the needs of our veterans. That includes primary 
care, specialty care, long-term care and to meet the dramatic 
increased demand for compensation and p pension examinations. 
We can't do one without the other. These are all connected, and 
we are trying to do this in a balanced way. We have tried to 
craft a plan that will be sustainable by bringing on some new 
staff, by calling on our affiliated universities to assist, by 
contracting for some services and using fee schedule for 
others.
    I would emphasize to the committee, as you pointed out, 
that the application of supplemental funding is a temporary 
solution for us. With this year's budget, we will not be able 
to sustain a large number of--the increase that we have taken 
on and sustain these services next year. For this reason, there 
is a hesitancy for us to hire employees as the sole means of 
dealing with this increased demand.
    Mr. Shays. Let me just ask a question. Your compatriots are 
also going to testify. It is 10 minutes now, I did interrupt 
you a few times here. How much longer do you think you need?
    Mr. Burger. I have just a closing comment.
    Mr. Shays. OK.
    Mr. Burger. I just wanted to summarize by saying we have 
been a consistent leader in VHA and the quality of care that we 
are providing, and in spite of the many efforts we are putting 
forth to provide care efficiently and effectively, including 
the increase in resources we have been given, we really have 
come to a point where the demand has far exceeded our ability 
to do that. We are assuring that patients with acute medical 
needs are having those needs met. We are getting priority to 
veterans with 50 percent or greater service connection, and we 
do anticipate in the very near future giving priority for 
others for their service-connected conditions. Thank you very 
much.
    [The prepared statement of Mr. Burger follows:]

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    Mr. Shays. Dr. Burger, you would have easily finished 
within the 10 minutes had I not interrupted you. And also I 
think both Butch and I--Congressman Otter and I would want you 
to know is that we do know demand exceeds supply, so we are not 
coming here asking why you are not able to do all the things we 
want you to do. We have to provide you the resources to do it. 
Also, just say for the record, we have 600--we are increasing 
the number of veterans who are served nationwide about 600,000 
a year. So we are trying to get more, but there is more than 
600,000 that need help, particularly because of our drug 
benefit. We have got a lot of new customers.
    Mr. Otter. Mr. Chairman, if I may note for the record----
    Mr. Shays. Sure.
    Mr. Otter [continuing]. Dr. Burger, your entire statement 
in its entirety, and having read that it is very informative, 
will be submitted for the permanent record.
    Mr. Shays. Absolutely.
    Mr. Burger. Thank you.
    Mr. Shays. And also to say that I don't know which of you 
gentlemen, Mr. Lee or Mr. Tippets, should go next.
    Mr. Tippets. I will go.
    Mr. Shays. Yes. Thank you, Mr. Tippets.
    Mr. Tippets. Chairman Shays, Congressman Otter----
    Mr. Shays. Is that mic on? Yes.
    Mr. Tippets. Chairman Shays, Congressman Otter, it is my 
privilege to make a few remarks regarding the patient care at 
the Boise VA Medical Center. Just briefly, I will discuss 
workload, access to care, the current waiting list and the use 
of supplemental funds to decrease the waiting list. If I could 
refer you to page 9 of the written testimony, attachment A. In 
fiscal year 1997, we treated 10,654 patients; in fiscal year 
2002, which just ended, that has increased to 15,329 patients. 
That is an increase of 44 percent. In fiscal year 1997, we had 
99,000 outpatient visits; in fiscal year 2002, that has 
increased to 155,000 outpatient visits. That is an increase of 
57 percent. During this same time period, funding per patient 
has fallen from $4,895 per patient to $4,489 per patient. That 
is a decrease of 8 percent in funding over that time period in 
spite of the workload going up.
    Mr. Shays. Give me the time period again.
    Mr. Tippets. 1997 to 2002, for 5 years.
    Mr. Shays. So you have less per patient today than you had 
5 years ago.
    Mr. Tippets. Yes, sir.
    Mr. Otter. By 400 bucks.
    Mr. Tippets. Yes. About 8 percent less.
    Mr. Shays. And if you then equate to increased costs, then 
the number would be even----
    Mr. Tippets. If you--yes. We did not do this on this 
attachment, but if you actually put in the medical inflation, 
that figure goes down to $3,500 or $3,600 per patient, yes.
    Access. During that time period, we have opened a CBOC in 
Twin Falls, which is approximately 120 miles east of here. We 
staff that CBOC with two physician's assistants, two nurses, 
three clerks and a mental health provider. Each one of the 
physician's assistants treat about 800 patients. We currently 
have a waiting list of about 800 patients at that CBOC. We are 
actively recruiting a physician and during the last couple of 
months have been interviewing. We think we might have a 
physician to go to Twin Falls. If we do, that should eliminate 
that waiting list at Twin Falls CBOC. At least right now it 
would eliminate it, but the waiting list will grow again.
    At the Boise Hospital, we currently have a waiting list of 
about 3,600 veterans that are waiting for primary care 
appointments, and that is broken out approximately into 50 
percent category 1 through 6 and 50 percent category 7s. And 
like I said, the Twin Falls CBOC has approximately 800 patients 
on their waiting list. With the new directive, if a priority 1 
service-connected veteran walks in the hospital, that 
individual gets an appointment within 30 days. We have 
approximately 200 service-connected veterans, 50 percent and 
over, that are on our waiting list. We have, I believe, 
scheduled half of those people, and we are in the process of 
scheduling the other half for appointments, so that is being 
taken care fairly rapidly.
    Let me talk a little bit about supplemental funds. In the 
fourth quarter of 2002, Congress passed supplemental funds to 
the Veterans' Administration in the amount of $142 million. As 
a result of that, this hospital got approximately $1 million. 
And I would like to tell you what we have done with that money. 
If you look at primary care, we have hired two physician's 
assistants. Each one of those physician's assistants will take 
approximately 800 patients. And we are in the process of 
recruiting for a physician at the Twin Falls CBOC, which, like 
I said, should eliminate the 800-patient waiting list there.
    We feed in the community about 65 procedures in 
orthopaedics. These are patients that are on the waiting list. 
We also did about 150 patients that needed cataracts surgery, 
that was feed in the community. We took care of about 194 
patients in the urology clinic. These are patients that either 
needed clinic appointments or surgery. We took care of about 
182 patients for audiology exams and we increased EMT to take 
care of about 36 patients that either needed clinic 
appointments or surgery. So these funds were used to reduce the 
waiting list by feeding out most of the care to community 
providers. In order to continue this, of course, the 
supplemental funds need to be recurring or we will have to--we 
will not be able to do that.
    I am going to stop there, and those are all the comments I 
have. Thank you very much.
    Mr. Shays. Thank you, Mr. Tippets. Dr. Lee. I understand, 
Dr. Burger, you are also a Major General.
    Mr. Burger. Yes, sir.
    Mr. Shays. Yes. Hard to know which----
    Mr. Burger. Retired, sir.
    Mr. Shays. Retired. OK.
    Mr. Lee. Chairman Shays, Congressman Otter, it is indeed my 
honor as well to be able to testify to your committee. I just 
wanted to comment on a few clinical issues as a physician 
beyond the data that you have already heard from my colleagues. 
One that I think has already been made a matter of the record 
but just to emphasize it is that the waiting lists really are a 
matter of operational necessity, and we have heard that the 
high quality of care once you start receiving care is good and 
appreciated, and we value that. But the reason we can keep that 
quality high is because we do have to have the waiting lists in 
order to constrain the workload to something that can be 
manageable. It is a highly regrettable situation, however, and 
one thing I would like to say on behalf of the providers is 
that most of us went into health care because we were driven to 
help people. Most of us went into veterans health care because 
we love taking care of our veterans. And so it is very 
difficult and in fact even a bit corrosive, I think, at times 
for our providers to face veterans who have legitimate needs 
and not be able to meet them. So the voice in the face of the 
provider, I think, is something else that we should put on the 
table here.
    And then we heard eloquently, I think, from panel one the 
human cost to many of the patients. With a supplemental funding 
that Mr. Tippets alluded to earlier, I had a real chance to 
kind of experience up close and personal many of the people on 
the waiting list. And in fact probably about 90 percent of the 
people that we took off toward the end of the last fiscal year 
with the supplemental funding indeed wanted their medications. 
But some of those were heartrending stories of people whose 
medication bills exceeded their Social Security monthly income.
    And in addition to that, I wouldn't want it to be said that 
many of these people didn't have fairly serious health care 
needs. And just to paint that I saw two patients, one of whom 
had very uncontrolled hypertension, and in fact I would 
characterize as a stroke waiting to happen, and another patient 
who had gangrenous foot that we had to put in for a rather 
urgent vascular surgery. So there are many people on that 
waiting list with rather urgent health care needs that are not 
being met, and of course there is a very real human cost to 
that. I would be happy to respond to any questions, but I 
wanted to put a human face to those things.
    One last thing, since I have the opportunity, is that Mr. 
Smith, I think, raised a very good point, which is a policy 
issue. And that is many years ago we were able to use VA funds 
to copay Medicare or private insurance, but there is a general 
council opinion that we cannot copay Medicare, and I am told 
that general council opinions have the force of law. And there 
is a VA regulation that says we cannot copay private insurance. 
And so for those two reasons, we are sometimes I think 
restricted unreasonably from being able to provide local care 
while local specialty care might be available through one of 
those two mechanisms. And that is a policy that I would think 
that you gentleman could change. Thank you.
    Mr. Shays. Appreciate the testimony of all three of you and 
we will also thank all three of you for going the usual 
protocol, which is the government official goes first and then 
the so-called general witnesses go after. We have in this 
committee learned that it is very important to have the human 
face go first, and you touched on it, Dr. Lee, and you 
listened, all of you did, which is what we like, because then 
you can comment on that human face as you have already begun to 
have done. So I do want to thank you, though, because it is not 
a slight, it is just wanting to make sure that we have--you get 
the point. I don't have to go on. Congressman Otter.
    Mr. Otter. Thank you, Mr. Chairman. I guess I will start 
with you, Dr. Burger. In your region, has the reduction in cost 
per patient, is that fairly representative of what has happened 
in the entire region of what Mr. Tippets and Dr. Lee have had 
experience in Idaho? It seems to me there are $406 reduction in 
5 years not adjusted for inflation. Is that pretty 
representative of the entire region? Take your time.
    Mr. Burger. I believe it is, Congressman Otter. If you look 
in attachment B, as well, we tried to display the data the same 
way for the entire region and then for Boise. As you can see, 
the cost per veteran has basically gone down across the board 
for us as a network as well. Now, part of that has to do with 
efficiencies and trying to become more efficient, but, clearly, 
we can't keep up. No matter how efficient we get, we can't keep 
up with the fact that more and more veterans as we get older 
take more and more medications. That is true across the 
country, and the cost of pharmacy care has gone up 15 to 19 
percent. So we are losing ground in that regard. But, yes, sir, 
that is a general statement.
    Mr. Otter. How much of the supplemental--we heard what 
Boise got, $1 million of the $142 million, which I am going to 
have to look into that, but how much did the region get?
    Mr. Burger. We received several million dollars as part of 
the supplemental, and we allocated that money by bringing all 
of our medical center directors together and looking at how we 
would distribute those resources. Our start point is usually 
looking at the overall patients, the numbers of patients served 
across the system and where the greatest needs are. We actually 
probably two or three different times, it was about $7 million, 
but we two or three times went back to each of our facilities 
and looked at--because the money came to us so late in the 
fiscal year trying to spend that money became an issue, so we 
went back to the facilities and asked, ``If we gave you more 
money, could you, are the providers in the community willing to 
take our patients and do that in a timely way?''
    Mr. Otter. And their answer was?
    Mr. Burger. In some cases, yes; in some cases, no.
    Mr. Otter. Is that because there is a fixed national cost 
for some of these, standard?
    Mr. Burger. There is a demand for services across our 
region, and it is not so easy to find a cardiologist or an 
orthopaedic surgeon or a urologist that has openings, that can 
take our patients in a timely way.
    Mr. Otter. Or will provide openings if he doesn't think 
that he is getting his service paid for.
    Mr. Burger. That is true, but on the fee, the way we 
provide that by fee, that fee is not set in any particular 
amount, as was referred to about----
    Mr. Otter. So that can be regionally adjusted.
    Mr. Burger. That can be regionally adjusted.
    Mr. Otter. Well, it would seem to me that if you handle, 
and in your testimony I picked up on 17 percent of all vets?
    Mr. Burger. That is correct.
    Mr. Otter. Is that right?
    Mr. Burger. That is correct.
    Mr. Otter. Twenty-three percent of the land mass but 17 
percent of all vets.
    Mr. Burger. Right.
    Mr. Otter. It would seem to me that you should have 
received about $22 million--17 percent of $142 million 
supplement.
    Mr. Burger. That is one way of looking at it.
    Mr. Otter. Well, my concern is unless it was higher cost of 
delivering the service in some other area of the country, why 
didn't we receive our full rata share?
    Mr. Burger. I can't respond to that, Mr. Congressman. I 
don't know the answer to that question.
    Mr. Otter. If you could find the answer, would you provide 
the answer?
    Mr. Burger. I indeed will.
    Mr. Otter. Mr. Chairman, I would ask that answer that was 
provided be made part of the permanent record when we receive 
it.
    Mr. Shays. Absolutely.
    Mr. Otter. Let me ask you a question about the prescription 
drugs, and we heard in the testimony from when we were trying 
to put a face and a voice to the person that needs the care 
that why can't we provide drugs, filling prescriptions, whether 
it is eye or visual or whatever, from a physician? If the 
person has a doctor's degree and fills out a prescription, it 
would seem to me--and if they brought that prescription, No. 1, 
it would certainly reduce part of the workload of that waiting 
list that may be the care out of private insurance paid for the 
issuing of the prescription and all ours would be quite simple 
in just filling out the prescription. Why can't we do that? Is 
there something stopping us from doing that?
    Mr. Burger. I will respond, and I will ask the others to 
respond as well. I believe that is a policy decision that needs 
to be made. The Veterans' Health----
    Mr. Otter. Made or changed?
    Mr. Burger. Changed.
    Mr. Otter. Oh, OK.
    Mr. Burger. The Veterans' Health Administration thinks of 
itself as providing comprehensive, longitudinal care to the 
veterans it serves, as opposed to just filling a prescription 
for someone.
    Mr. Otter. I would yield on that.
    Mr. Shays. Yes. I think so we can have a candid 
conversation there is a part of me that believes it is a way of 
restricting the use of these facilities because there is the 
question of whether they could keep up with all the 
pharmaceutical demand. And there is also, I am wondering as 
well, not a concern that a doctor on the outside is just going 
to basically maybe be a little more lax in terms of deciding 
which type of prescription. In the VA, there are only certain 
prescriptions that are filled. I mean it is not all 
prescriptions, right, or is it all?
    Mr. Burger. If we have the medication in our formulary, 
yes.
    Mr. Shays. Yes. It has to be part of the formulary.
    Mr. Burger. The formulary.
    Mr. Shays. Yes. I mean there can be three drugs that 
provide the same service, and you may only provide one of them 
in the VA, and it sometimes raises the question to the doctor 
through advertising and others might decide that this other 
prescription is good, and then there is going to be pressure on 
the VA to provide that one. So I think there are other subtle 
things that they may not be good reasons but I think they are 
all--and I am suggesting that may be a factor and I am curious 
to have a more candid response.
    Mr. Burger. As you all know, the Department of Defense 
provides a pharmacy benefit to military retirees and military 
dependents. Using our formulary, the experiences that we have 
had in working with the providers in the community, I really 
don't believe that what you have just mentioned would be an 
overwhelming issue that we could not overcome.
    Mr. Shays. OK.
    Mr. Burger. By sharing our formulary--actually, our network 
formulary is on our Web site, it is on the Internet. It is very 
easy for providers in the community to know which of those 
drugs we do carry so they can prescribe those specific drugs 
for our patients. So I don't see that as really a major issue.
    Mr. Shays. Would the gentleman continue to yield?
    Mr. Otter. Yes.
    Mr. Tippets. Let me make just a couple, then I know Dr. Lee 
wants to address this issue. Our copay is $7, which has got to 
be the best prescription benefit that perhaps exists in the 
country, including any of us that have insurance. I pay more 
than $7.
    Mr. Shays. Yes. That one beats it.
    Mr. Tippets. And I guess the other thing I would say, and 
Dr. Lee will talk about a couple of the issues regarding this, 
we can do anything that the Congress wants us to do as long as 
we have adequate money to do it. The average patient that walks 
in our medical center, the average patient probably has, the 
last time we calculated, $800 to $1,000 worth of drugs. That is 
the average patient.
    Mr. Shays. Per?
    Mr. Tippets. Per patient, per year. Per patient, per year. 
And if we were to provide this benefit, we could certainly do 
that, but you are talking about--I have no idea how much, but 
you are talking about a lot of people that want this service 
and you are talking about a lot of money. With that, I will 
pass it to Dr. Lee.
    Mr. Lee. Yes. If I could respond, I think I would say that 
it really is not a clinical issue. I think that clinically that 
could be done. I think it is a policy and it is an economic 
issue. It is VA policy that they only provide care to those who 
are actively receiving care and that it be written by a VA 
physician.
    Mr. Shays. And I think your point, policy/economic, I think 
it has to do with just the incredible potential costs.
    Mr. Lee. Yes. But responding to the formulary piece, 
actually physicians in the private sector are very used to 
dealing with different formularies right now, and most health 
care plans have to do that. So I suspect that if we worked in 
combination with the private clinicians, that they would be 
able to adjust to our formulary.
    Mr. Burger. Yes. If I might make one other comment about 
that. We are very proud in our system of having a computerized 
patient record that is probably the best in the Nation, 
probably the best in the world, the CPRS system. And over the 
last several years now we are getting to the point where Dr. 
Lee for one of his patients has an icon on his screen and he 
can call up where that patient has been seen anywhere in the 
country, and we know the records. One of the real issues about 
receiving care outside our system is the idea of how do I know 
what that provider outside did to that patient, what was that 
lab test that was done, what was that copy of the x-ray or of 
the electrocardiogram and what have you? So the recordkeeping 
is really a major issue for us. It is an issue in dealing with 
the Department of Defense in how we are trying to share 
patients together, because we use two different computer 
systems. So the recordkeeping is really important. If we more 
and more allow our patients care in the private sector, which 
makes sense for them to have care--for all of us to get care 
locally, how do you get that record incorporated?
    Mr. Otter. Well, reclaiming my time, I also--you know, I 
recognize the importance of single provider in order to make 
sure that we don't oversupply a patient with needs. But it 
would seem to me that there is, besides the costs in terms of 
facilities and operation that we talk about here, it seems to 
me that there is also a human cost, and I sometimes wonder when 
I hear these veterans calling into my office and I get a chance 
to talk to some of them, my staff talks to all of them, that 
there is a--it would seem to me that there is always a stress 
level that goes up when they know they need the drug, they know 
that they need the--need to be provided their pharmaceuticals 
within 30 days because they are going to be out, and they say, 
``Well, we can't get you in for 90.'' And it would seem to me 
that if there were a way that we could facilitate the private 
prescription, the prescription outside the system, to be filled 
within the system and maybe an audit or maybe a check or 
something like that, you folks have to tell me. You tell me 
where to go, and I will start calling the cadence, as far as I 
am concerned, because you are the ones who are going to have to 
tell us what is going to work in this system.
    Let me go to the formulary. Now, does this mean that on the 
formulary there is a list of drugs that you can provide and 
then on that same list there may be some drugs you can't 
provide?
    Mr. Burger. There is a national formulary that lists all 
the drugs that are available across the whole system. We have 
within our network each of our facilities modifies that for its 
own special needs. Those are the drugs that are available 
through the formulary. If there is a medication that is needed 
outside, then the physician or the provider must ask--must make 
a request of that and actually goes to the chief of staff at 
each of our facilities to approve that to be purchased outside 
of the formulary system.
    Mr. Otter. Is the formulary that we use for the vets any 
different than the formulary that we use for active military?
    Mr. Burger. Yes, there is a difference.
    Mr. Otter. Why?
    Mr. Burger. Different populations, different contracts. You 
can get a drug better from one company than another. I believe 
we do very well with DOD in pharmacy and buying things 
together, and I believe Mr. Tippets is correct, we probably 
purchase drugs less expensively than anyone else in the 
country.
    Mr. Otter. No question about it. And we are grateful for 
that, because it is needed. Mr. Tippets, let me ask you around 
this whole question of the availability of pharmaceuticals. The 
new Regional Center for Pharmaceutical Dispersement, is that 
going to help us?
    Mr. Tippets. It should make the timing much better, because 
that is going to be up in the Seattle area. Will that help us 
take care of more veterans that want prescriptions? No, I don't 
think so.
    Mr. Burger. What we are concerned about with the 
consolidated mail order pharmacy is turnaround time. The 
quality--and it is an excellent product. I think we will give 
all of our veterans in the Northwest better turnaround time if 
we have such a facility, and we are also, as you probably know, 
working with DOD. There are also 1 million DOD beneficiaries in 
the Northwest. So if we can combine those two things 
geographically, that would make it far more efficient from a 
turnaround point of view. Right now we are using the Levenworth 
CMOP and I believe that our patients are fairly satisfied with 
that. We have had some problems, but I think we have had those 
turned around. The turnaround times are pretty good now.
    Mr. Otter. Dr. Lee.
    Mr. Lee. Yes, I would agree. we have actually had a very 
active and ongoing process with full formulary adherence and 
using the centralized mail pharmacy system at Levenworth, which 
has driven, to some degree, the cost per patient that Mr. 
Tippets alluded to. But that having been said, I think that 
when we get the new regional one here up in the Northwest, it 
will probably improve timeliness but probably won't change much 
else. I think the quality and the cost will still be about the 
same.
    Mr. Otter. Mr. Chairman, I appreciate your endurance here 
with me. Let me ask just one more question, Dr. Burger, about 
the facilities as a whole.
    [Changing microphone cords.]
    Mr. Otter. We do have utility in our Congressman from 
Connecticut; he can do anything. [Laughter.]
    Tell me about the facilities. We have talked about the 
delivery of care services and the locations where they are and 
where they are not, but what about the state of our facilities? 
Are we investing in the latest care service or are we going to 
have to continue to go to the local hospitals, the local 
caregivers in order to maintain our up-to-date delivery of 
health care services to our veterans?
    Mr. Burger. As to the facilities themselves, we have some 
really aging facilities across our network, I think you know 
that. Actually, Mr. Tippets is our chief facility management 
officer, and he really helps us, as we get funds from the 
Congress and from VHA, to renew our facilities and do 
construction. He has been very much a player in that. We are 
really faced with a seismic problem right now in the Northwest, 
the whole Pacific Rim, and we have some buildings that really 
need seismic improvement. VHA is addressing that as money 
becomes available, but that is a continuing issue.
    The operational dollars, the need to bring more and more 
veterans, I think Dr. Lee alluded to that, makes it very 
challenging in how one allocates the money that we have. We 
have this year, as we do each year toward the end of the year, 
look at where we are in buying the very latest in equipment and 
do the best we can to provide the latest equipment. I believe 
that when we think in terms of colonoscopes and endoscopes and 
radiology equipment, by and large we are doing a good job in 
having state-of-the-art equipment to take care of our patients. 
That matches what is available in the community. But there are 
pockets in places. As we get into digital imaging, for example, 
that is very expensive to do that, and the technology changes 
so often that when you make a capital purchase, 3 or 4 years 
later you are faced with doing the same thing again. Computers, 
we just made a choice to purchase--to replace 25 percent of our 
computers. Trying to keep in that cycle has been very 
challenging, but I think the answer is that we are keeping up 
but it is a challenge. Would you add anything to that?
    Mr. Lee. I think the facilities that we have in Boise, 
while aging, have been kept up exceptionally well, and I think 
they are really quite good. There really are not enough of 
them, and one of the things I have to face all the time is even 
if I got more clinical providers, I wouldn't have a space to 
put them. And so clinic space for more primary care is an 
urgent need.
    And a few of the other things that exist in Boise are very 
capital-intensive, and that includes things like cardiac 
catheterization laboratories and radiation therapy. And, again, 
Mr. Smith, I think was very eloquent about the fact that he had 
to wait before he could be transferred to Seattle for cardiac 
catheterization. And Boise simply does not have enough size at 
the VA to warrant that kind of a capital investment. Those 
sorts of things I think we would still need to continue to 
partner with our community.
    But I would say we heard from Mr. Smith about the 
difficulty of having a life-threatening illness, having to wait 
a bit, frankly because of nursing shortages in Seattle, to be 
transferred out there in a timely way, and then be out there 
away from his family when he is having a myocardial infarction. 
And similar with the radiation therapy, the necessity of 
transferring cancer patients who don't have long to live to a 
distance place away from their family and support systems in 
their last days. And, frankly, many of those clinicians regard 
it as nearly inhumane.
    Mr. Otter. Thank you, Mr. Chairman.
    Mr. Shays. Thank you. If the gentleman has more questions 
after, we can come back to you. I represent probably four-
fifths of a county, and in the county there are about 250,000 
veterans. I represent a wealthy district and candidly many 
choose not to use the VA facilities, some, simply because they 
would just as soon go to their neighborhood hospital or the 
community hospital, which is--in my congressional district, we 
have six hospitals. But what has started to happen is they may 
be paying $3,000 a year for--or $2,000 or $4,000 for their 
pharmaceuticals, and they are saying, ``My gosh, I can get the 
best deal in town.'' So they seem to feel guilty in one sense 
that they are not taking advantage of the program, in another 
sense, they say, ``Well, we have the resources, we have been 
able to deal with it.'' But it is just--after a while they 
think they are stupid not to take advantage of this service 
which they are entitled to as a veteran. So what has happened 
is they have started to really push the VA facility. Now, I 
know it is being pushed in a lot of places, but these are 
people in many cases who have some resources. My question to 
all of you is, all things being the same, if you did not 
provide a pharmaceutical benefit, just wasn't provided, I am 
not even suggesting we not, I am going to suggest the opposite, 
but if you didn't provide it, would there be a backlog?
    Mr. Burger. You will have to speak to Boise specifically, 
but as I mentioned in my testimony, 82 percent of our patients 
are priorities 1 through 6 already. We lead VHA in that regard.
    Mr. Shays. But 1 through 6 has nothing to do, forgetting 
even the wealthy, has nothing to----
    Mr. Burger. But the priority 7s are mainly the individuals 
that are seeking a pharmacy benefit or are more and more 
populating the waiting list. What I was trying to get at was 
that as we now take off the 50 percent service connected and 
soon we will be taking those seeking care for service-connected 
conditions, what is going to be left on the waiting list are 
really priority 7 veterans, and the vast majority of priority 7 
veterans are the ones that you describe are there for the 
pharmacy benefit. So that will become the case.
    Across our system, as we have grown----
    Mr. Shays. Let me just say, which would suggest, and then 
don't forget your thought, that if we dealt with it the way 
that Congressman Otter is suggesting, I mean if we could have 
all the prescription basically handled outside the VA, your 
backlog would disappear significantly, but then you would have 
to make sure your facility could handle the incredible amount 
of demand on the pharmaceutical.
    Mr. Burger. That is true.
    Mr. Otter. Would the gentleman yield?
    Mr. Shays. Sure, absolutely.
    Mr. Otter. What if we just did that for a certain period of 
time to reduce the list and go from first time service to 
ongoing maintenance? In other words, what if we just did that 
for 6 months? What if we just took the outside prescriptions 
for 6 months to reduce the folks that you have got on your 
list?
    Mr. Burger. That would get rid of the list, but there are 
lots of other people that are being added to the list. That is 
the idea of the supplemental kind of funding. It is a one-time 
solution, it would get the list down, but the other reasons why 
people are coming in the Northwest with HMOs not being 
available and those kinds of things, health care in general not 
being available, I think the list would grow again for us, 
specifically.
    Mr. Otter. Yield back.
    Mr. Shays. You wanted to respond as well, Dr. Lee.
    Mr. Lee. Yes. The other issue I think is the vast majority 
of the medications these people are seeking are actually 
chronic medications. Having had that window of time and looking 
at them toward the end of last year, they are mostly for 
diabetes, hypertension and heart disease. And at the end of 6 
months, those conditions will continue on, and so we wouldn't 
need to have a mechanism to continue to provide for those 
medications after the 6-month window.
    Mr. Otter. Excuse me, Dr. Lee. Perhaps I didn't make my 
question clear, which is not unusual for me.
    Mr. Shays. That is simply not an accurate statement. Be 
careful now, he is being very subtle here.
    Mr. Otter. I am just saying that looking at the total list 
in its totality, and it just seems sometimes overwhelming, and 
the stress that goes on with those names that are on the list, 
and I want to go back to the human cost in terms of not only 
the individual themselves but the family. And I am just 
suggesting that if we used a time period here where we said we 
are going to allow those people to bring in the prescription 
from their own doctor and for a certain period of time until we 
get them into our system and can get them off the list of 
waiting and get them on to the list of maintenance, is that 
still a problem?
    Mr. Lee. Oh, I couldn't agree you with more. You know, we 
have heard about the human costs. I just think we have to be 
very careful about making sure that we had capacity when the 6-
months ran out to make sure that we can handle it. We are all 
on the same wavelength here, we want to provide that care.
    Mr. Burger. If you were to suggest a pilot, and I know Mr. 
Tippets once before said he would be willing to raise his hand 
to try that to see, but I think, Dr. Lee, really, it is what 
happens at the end of 6 months? I wanted to just mention that 
through that last month in our 5 percent increase in total 
numbers of veterans, about 3 percent of that was in the 
category A, the 1 through 6s, and about 16 percent was in the 
priority 7 veterans. So, again, even in our network where the 
vast majority of patients are priority 1 through 6, it is the 
priority 7 veterans that are overwhelming our system for the 
drug benefit.
    Mr. Shays. And most they are interested in what is truly 
the best drug program in the country, if not the world.
    Mr. Lee. Yes, sir; that is exactly right.
    Mr. Tippets. Yes. A very high percentage of them are. I 
think if you did that, yes, you would--again, this depends on 
the facility, the hospital you are talking about. Yes, you 
would probably either greatly reduce or eliminate the waiting 
list but then you have to figure out what to do with those 
patients when they need to come into the hospital.
    Mr. Shays. In regards to--what neither of us want to do is 
screw up a program that is pretty outstanding--which is 
outstanding, but at the same time, when you hear Colonel 
Jaurena speak, he is service connected and yet he is having to 
wait, it blows my mind. I mean it is service-related, it is not 
an injury that he has had as a veteran afterwards but totally 
connected to the service in Vietnam. And by the way, our 
committee has had countless hearings on the whole issue of Gulf 
War illnesses, and we have learned that there are many who are 
in fact sick because of their service, and it has been a long 
struggle to get the VA kind of to sort it out themselves.
    Let me just ask you, as it relates--and I will get on 
beyond the pharmaceutical--but the pilot program, it seems to 
me, is a no-brainer that we should try seeing what is the 
impact of prescriptions being filled by outside physicians. 
Will they start to suggest more? Since they don't really--a VA 
doctor is going to focus on his patient, but he is also going 
to know the capabilities of the system, and so will there be 
more drugs per patient being prescribed versus what a VA doctor 
is going to do? Who knows. Maybe not, maybe there shouldn't be, 
but it would be interesting to know. And it would be 
interesting to know how the VA then fills in actually providing 
this greater supply now of pharmaceuticals, because you are 
going to have to be able to manage more drugs in and out.
    One of the things that has been a source of aggravation is 
that you can get a 30-day supply and you have to come in and 
pick them up. In some cases--I don't know, in some cases, are 
they allowed to be sent to the patient? They are being sent to 
the patient?
    Mr. Lee. Yes. The Department of Defense has the 30-day 
supply scriptures; the VA actually has 90-day supplies of 
medications and mail-out refills. So we are more user-friendly 
in that respect.
    Mr. Shays. So you are sending them out.
    Mr. Lee. Yes.
    Mr. Shays. OK. Well, that is interesting. Let me ask you 
the question of the supply of physicians, nurses, technicians, 
administrators. Is your biggest challenge nurses, biggest 
challenge doctors, biggest challenge technicians? Where is your 
biggest challenge?
    Mr. Tippets. It is not administrators, by the way. 
[Laughter.]
    Mr. Burger. That is my biggest challenge. Let me speak from 
a network perspective. You know, it is interesting that we are 
geographically isolated in the Northwest, and that really is an 
issue for us. When you actually look at the number of nursing 
schools or even medical schools, we only have two: One in 
Oregon, in Portland, and one in Seattle, in Washington, in our 
area if you look at the number of nursing schools and pharmacy 
schools and so on. So there is a restriction right there, and I 
have already heard from nurses that nursing schools are paying 
faculty enough to attract faculty, so they can't expand the 
size of their classes and so on.
    On the nurse side, it becomes very obvious, because nurses 
take care of patients that are in-patients, in bed. There is a 
dramatic shortage of nurses and that is going to continue to 
grow. Within VHA, the average age of our nurses is approaching 
50.
    Mr. Shays. This is all over the country. I just don't know 
what the--and I am told it is not just getting--well, you 
answer your question, I am sorry.
    Mr. Burger. And it is. It is a national issue, and it is 
getting worse as we all get older and need more care and so on. 
For us, specifically, in the Northwest, several of the medical 
specialties there is a dramatic shortage--medical 
technologists, informatic specialists, laboratory technicians. 
Imaging technicians are among those areas that have an absolute 
traumatic shortage. We have decided as a network, as VHA has 
decided, to start training its own. There are debt reduction 
programs now in people who are going to various schools. We are 
in the process now of trying to figure out how----
    Mr. Shays. Is this that debt forgiveness for graduate 
schools?
    Mr. Burger. Yes. So we are going to try to train our own 
people in medical technology or in imaging or as prosthetics 
managers and that kind of thing. It is a national issue that I 
believe requires a national solution.
    Mr. Shays. OK. I hear you.
    Mr. Burger. It is really getting to be--we are already in 
that crisis. I guess you hear that from your constituents.
    Mr. Shays. Right.
    Mr. Burger. People who drive ambulances drive around our 
cities, can't find beds. And I am not talking about the VA, I 
am talking about in general. I just saw a statistic that said 
the average wait for one of our Nation's citizens to see their 
physician with an acute problem is 7 days. That is a national 
issue, so it is a problem.
    Mr. Shays. Mr. Tippets.
    Mr. Tippets. We have a pretty severe problem with nurses 
going back--oh, it probably started a couple years ago, and I 
have been the administrator of the hospital here for just about 
10 years, and for the first time ever we actually had to go to 
the nurse registry and--you know what the nurse registry is, I 
am sure; yes, that is where you go to get contract nurses from 
a private agency to come into your hospital.
    Mr. Shays. And your costs go up about 30 percent?
    Mr. Tippets. Well, yes. Let me just give you an example. To 
get a nurse from the nurse registry costs us about $70 an hour, 
so we probably should have all gone to nursing school.
    Mr. Shays. It is not too late. [Laughter.]
    Mr. Tippets. We have increased our salaries. We have to be 
competitive with two major hospitals in town. We have increased 
our salaries, we are doing fairly well right now. In addition 
to that, in conjunction with the Idaho Hospital Association, we 
have met with the local university, Boise State, and they have 
agreed to increase their nurse class size by 30, and I believe 
that started this fall.
    Mr. Shays. But the bottom line is nurses are a concern. How 
about doctors?
    Mr. Tippets. I will let Dr. Lee address that.
    Mr. Lee. Yes.
    Mr. Shays. Dr. Lee, before you answer, if there is any--we 
are going to be set pretty soon to go to our open mic, and so 
if you would like to speak, Jason, would you raise your hand 
there? Jason has a mic, and what we will do is we will want you 
to fill out a form so we can give the transcriber your name and 
address and so on so we have it for the record. You won't be 
sworn in but you will be invited to address us. Yes, sir. I am 
sorry, Dr. Lee.
    Mr. Lee. Just a comment on the health professions in 
general. I regard it as an ecosystem, and you have to have just 
about all the species in the ecosystem to make the whole thing 
function. And so we have, from time to time, seen various 
things, like imaging technicians become mission critical 
because of near shortages. As far as physicians are concerned, 
we are actually not too unsuccessful in recruiting most primary 
care physicians, but several of the specialties we need most 
for aging veterans, like urologists and orthopaedic surgeons, 
are actually earning two to three times what the maximum VA 
salary is in the community. And, of course, that makes it much 
harder to recruit them, and that means that there are backlogs 
in some very critical specialties that our veterans need.
    Mr. Burger. And you can't buy those services either, 
because the demand is there in the community as well.
    Mr. Shays. Let me just--you talked about, Dr. Lee, 
listening to the face of the issue in terms of listening to 
what the veterans were saying, and when you heard Mr. Smith 
speak about the cardiac care, what would be the challenge and 
what is the logic against not having him receive cardiac care 
in Boise? I am sure that exists here, correct?
    Mr. Lee. Oh, yes. Our private medical community in Boise is 
absolutely wonderful. The specialists are good, well qualified, 
and actually we value a fairly close working relationship as 
far as the VA and the community----
    Mr. Shays. So let us just talk about that particular issue, 
the cardiac care. Is that going to be a subjective decision? 
Would he have had the right to petition to get it in Boise or 
would he not even have the right to do that?
    Mr. Lee. Well, he certainly could ask, and it is really 
largely an economic issue. We have talked about the fact that 
we have large waiting lists and we try to stretch the Federal 
dollars we get absolutely as far as we possibly can. And one of 
the ways we do that is to send cardiac specialty care to 
Seattle.
    Mr. Shays. Anybody else care to----
    Mr. Burger. I would echo that. I think it is an economic 
issue about how much care. We could attempt to contract with a 
group to try to negotiate prices, but, again, the demand for 
the care in the community for cardiology care in the community 
is such that there is an unwillingness to enter in any----
    Mr. Shays. So bottom line is you would be paying top 
dollar.
    Mr. Burger. We would be paying top dollar.
    Mr. Shays. And so I am reading into your answer that if 
some of these fairly expensive procedures, if you contracted 
for the cardiac care but then added all the others that you 
could logically include with that, I mean different services, 
your budget would disappear real quick.
    Mr. Burger. Sure.
    Mr. Shays. OK. Is there anything that you all--Congressman 
Otter, is there anything you want to ask before we get to the 
floor?
    I know we are going to have to--in order to make that 
flight, we are going to have to----
    Mr. Shays. Let me just say, we will stay and take the next 
flight if we have to, but I am just curious to know if there is 
anything you have to add.
    Mr. Otter. Yes. I would just like to ask Dr. Lee one 
question about his ecosystem, which I thought was very 
analogous to what our needs are. But one of the things when I 
take a look at the inventory of our assets, and being prior 
military, my prior military was in the 116th Armored Cat. I 
joined initially 139th engineers and then we were reorganized 
during the Vietnam into the 116th Armored Cat. And we had 
several medical units attached to us, and it wasn't unusual 
during our summer, our 2 months--or I should say our 2 weeks in 
the summer or our monthly meetings it wasn't unusual for a 
medical unit to come in, provide us with the necessary 
physicals that were required for that year and that sort of 
thing. But it also wasn't unusual, though I wasn't part of the 
medical group, I was in reconnaissance, for them not to have 
much to do.
    And I wonder if we have even taken a look at maybe perhaps 
tapping that into asset for an occasional reduction or maybe a 
review of some of those lists. Is there any way we can take 
these assets and work them together and maybe have a Guard 
medical unit come in for a weekend or something like that when 
they are on their weekend drill and maybe work on part of this 
list, because they are highly professional folks, and every one 
of them have a physician?
    Mr. Burger. Can I address that, actually. Well, go ahead, 
David.
    Mr. Lee. Well, I will briefly address and then turn it to 
Dr. Burger. Yes, I think there is a lot of promise to that, and 
in fact some of that happens, and we have a number of people 
who do their Reserve duty, or at least part of it, by coming 
out to us. In fact, we have one physician from Emmit who comes 
to us on a regular basis, and he has helped a great deal with 
some of the workload and the backlog, and we do have other 
units that come in on the weekend. And during those weekend 
drills, they do provide us with substantial help, although it 
takes a while to orient them and get them up to speed and 
working with us.
    Mr. Burger. Just a technical point there. When the military 
restructured itself, the vast majority of the medical units are 
in the Reserve, not the Guard, actually, and I don't know what 
USAR units or other--well, Reserve units might be here but not 
in the Guard.
    May I please respond to the question, you caught me unaware 
when you said 17 percent before, and it has been rattling on 
me. It is not 17. Seventeen percent is our market share. The 
$142 million was distributed by VERA by workload, and we did 
get our fair share. So that----
    Mr. Otter. We got a per capita.
    Mr. Burger. We got a per capita. We got like everybody 
else. The 17 percent relates to our market share of our million 
veterans.
    Mr. Otter. There is no sense in us leaving any money laying 
on the table.
    Mr. Burger. No. We did get our fair share of that money.
    Mr. Otter. Thank you. Thank you, Mr. Chairman.
    Mr. Shays. Let me invite the three of you to stay, and I am 
going to let you have closing comments. We may have just one or 
two veterans, participants, here who may want to make some 
comments. So if you could just--so if you would identify 
yourself for the record. I know you have given us a sheet, but 
identify yourself.
    Mr. Harris. Good morning.
    Mr. Shays. Good morning.
    Mr. Harris. Representative Shays and Otter, I am Eldon 
Harris. I am a retired Navy chief petty officer. I retired in 
1958, enlisted in 1938. I have seen many changes in health care 
to losing lifetime health care in the Navy. I then go into 
civilian life and I have a company promise of lifetime health 
care; later, lose that. So I am almost appalled at the 
arguments we have or what we have to present regarding 
basically the pharmaceutical plan, or what we don't have as a 
plan, available for our veterans down at the VA hospital.
    I have gone through pharmaceutical plans that you won't 
believe. At the present time, I am just about as good as I can 
get. We get our prescription filled through DOD, the wife and I 
both, and we also have available through Fred Meyer's, a local 
chain store here, we can get prescription drugs filled here for 
$3 a prescription, and that is for your regular prescriptions 
if they are generic and $9 for the others. So to me, we are 
missing an awful lot someplace. I think we need to go back 
clear up to where this ball starts to roll and go to these 
pharmaceutical companies.
    Another appalling thing is that if you go to our borders in 
Mexico and Canada, 40 percent, or maybe more, of the people 
going across the border to fill their prescriptions are either 
retired farmers or retired military that don't have a medical 
plan or they are not qualifying for it. This is sickening. If 
these pharmaceutical companies can go to Mexico or go to 
Canada, sell the plant and sell these drugs for that price 
outside of losing their lobbying policies here in the United 
States, there is no reason they can't do it here. We have got 
to be as good a country for the companies as anybody is.
    Mr. Shays. Let me say we had a hearing in Boston on the 
whole issue of the pharmaceutical program, and if you leave 
your address with us, we will send you the--should we send the 
transcript--yes, we can send you the transcript of that and be 
interested in your comment. One of the challenges that exists 
for pharmaceutical companies, you know that they are basically 
price controls in both. I wager to say there has been no major 
medical breakthrough of any pharmaceutical company in Mexico 
because of it. And I would say to you there is one company in 
California that has invested $1 billion in hoping to retard the 
deterioration into Alzheimer's. They thought they were going to 
have a major breakthrough, had a lot of investors in, but right 
now it has not proved successful. That $1 billion is out the 
window. So we are trying to find the way you get the 
pharmaceuticals to create the new drugs and invest and risk and 
so on, get a return far more than what it costs to produce but 
for all they are investing.
    What we did do was we did vote in the House for legislation 
to say that if you could get a drug cheaper in Mexico or 
Canada, as long as it was FDA-approved, that you could import 
it in as a way to see if we could kind of level pricing in the 
United States. It is very controversial. Your program that you 
get, though, you are not getting from the VA, you are getting 
through the Department of Defense.
    Mr. Harris. This is true, what they call the TriCare type 
thing.
    Mr. Shays. And your testimony is that you are content with 
that program.
    Mr. Harris. Yes. This is a fantastic deal.
    Mr. Shays. Yes.
    Mr. Harris. But here, again, you have to be over 65.
    Mr. Shays. Right.
    Mr. Harris. One other thing on this, I noticed in the 
conversation there is a difference between minimum copay 
through the VA and what I can get it at Fred Meyer's. 
Evidently, Fred Meyer's is getting paid for the difference 
through Medicare, but the DOD or VA should be getting----
    Mr. Shays. What the VA, I don't know if DOD does as well, 
is we buy in bulk, and we are able to basically pass on that 
savings to the veteran.
    Mr. Harris. Well, this rings in another problem, just to 
touch on it in a minute. My wife has a condition that takes a 
special pill. When we first moved here 3 years ago from 
Washington State we went to Mountain Home Pharmacy, and it got 
to the point where she could not get her prescription filled 
there, because they had no generic, no crossover. And then we 
come to find out that the small pharmacies they only order 
enough of this one pill for prescriptions for their local 
people on the base. So here again you have a cost breakdown. I 
did forget when I introduced myself, I am the president of the 
Fleet Reserve Association Branch 382. I have been a member for 
49 years, so I have seen a lot of changes and have followed 
this man the last 3 years too. The man sitting behind me and I 
have run across a few years, so I am watching all of you. I 
haven't got many years to go but I am watching. I thank you for 
this opportunity.
    Mr. Shays. Thank you. It is an honor to have you testify 
before the committee. Thank you very much. Mr. Smith, I think 
you also wanted to make a comment.
    Mr. Smith. I am Tom Smith, of course. The comment I had to 
make was that the medical flights to Seattle. On the Cardiac 
Unit, if you are in there on an emergency, they do fly you up. 
They fly you up with a medical plane, a nurse's assistant and 
the pilot. And the plane, I am sure that costs a bunch, and 
when we start figuring things out, the copay with my insurance 
would have been far cheaper than to have the medical procedure 
done in Seattle. So I don't understand why that there is a 
regulation here that stops the VA from paying a copay with my 
private insurance when my private insurance took care of 
everything but. And it is just a fine line here, and I don't 
understand what it is and why it should be there.
    Mr. Shays. You know, I should know the answer to the 
question. I understand why it exists in Medicare because it is 
the same thing: It is the government paying the government. So 
whether the government is VA or the government is Medicare, to 
get a copayment from Medicare is just taking one part of the 
government to the other, but I don't know the private side and 
why we are not able to do it on the private side. Can you speak 
to that at all? Mr. Smith, you should sit down, I am sorry, 
because the transcriber has the mic.
    Now we have one other person who is going to--OK. And we 
will go to the next person afterwards.
    Mr. Lee. Yes. I am very well-versed on that one. The 
copayment of the private insurance is a matter of VA 
regulation, and I am told I can be disciplined if I ignore VA 
regulations.
    Mr. Shays. No, I understand you have got to follow 
regulations. Usually when something seems absolutely absurd 
there is a reason, and you may not agree with it, yes, but 
there is a reason why, and I wish I had why we don't do it 
because it seems like a no-brainer.
    Mr. Lee. Yes. I don't understand the rationale either. I 
agree with Mr. Smith. By the way, the cost of the air ambulance 
is about $4,000.
    Mr. Smith. The copay on that would have been less.
    Mr. Shays. Right. But how much is an operation in a 
hospital, what would that have been in a private hospital?
    Mr. Lee. You are looking right around $45,000.
    Mr. Shays. Right, 45. And at the facility, how much at your 
facility?
    Mr. Burger. Probably well under $25,000.
    Mr. Shays. Right. So you are getting your--you are looking 
at total costs. But in the end, we have got to decide there is 
a point that even costs notwithstanding there should be a 
critical mass of service provided for a veteran, and I don't 
think anyone here is denying that. We put these administrators 
in a difficult circumstance. We give them a certain amount of 
money, we have a lot more veterans each year, and we could yell 
at them, but it really rests on Congressman Otter's and my 
shoulder to just keeping running out more benefits for--more 
money for the hospitals, which we do every year, but it is 
never quite enough.
    Mr. Smith. I agree that there is not much money to go 
around, that is No. 1. And the only thing that I can't 
understand and still don't understand is why that they wouldn't 
be able to have a copay that would pay with my insurance if----
    Mr. Shays. I don't have the answer to your private--why the 
private insurance, and you have--I am going to leave this as a 
requirement of my committee staff. You are looking at the 
Director, Larry Halloran. Larry will make sure you get an 
answer and Butch and I get an answer as to why there is not the 
private copay and then if there is anyone in the audience who 
could answer, I would love it. But I should know it, I think I 
was told and I think I have forgotten. But it may make sense or 
may not, and we will look into it, and this is one of the 
values of the hearing. So you have made a number of 
contributions today, and I thank you.
    I think we will get to our last witness, not our witness 
but our last person invited to make comments. And you have 
given a form to--OK, yes.
    Mr. Williams. My name is Gordon Williams, and I am combat-
wounded Marine, and I am 6-year paratrooper, 22 years active 
service. And unlike the rest of the people that testified, I, 
like a commander, see the people in action at the VA hospital 
because my wife and I volunteer there 2 or 3 days a week. We 
work there to supplement the people that get paid. I can tell 
you that this is one of the best hospitals that I have ever 
been in. I have been in a few. They have the best medical staff 
and they are overworked and in most cases underpaid. Mr. 
Tippets runs a tight ship. There are no wall-leaners, there are 
no clipboard carriers, they work. Anytime you--and they always 
go the extra mile. If you need a question answered by a doctor 
and you are in there, he will take the time to do it, although 
many people sit out there. And I guess I am beating a drum for 
this hospital, and I damn sure am.
    Mr. Shays. Well, you know what? I was going to ask if any 
of the gentleman want to have a closing comment, but I think 
you would be foolish to respond. [Laughter.]
    And we are going to let your comment be the last word, how 
about that?
    Mr. Williams. How about that.
    Mr. Shays. OK.
    Mr. Williams. Semper fi.
    Mr. Shays. Thank you very much. We will close this hearing. 
Thank you very much. Oh, excuse me, before we close, I want you 
to sit down. I do want to thank very much the people who worked 
hard on arranging this hearing. Cheryl Miller, Business Manager 
of VWF Post 63, thank you very much, Cheryl. We thank Jim 
Adams, Congressman Otter's district staff, from his staff, and 
Mark Warbiss, Communications Director as well from the staff of 
Congressman Otter. And also Gayle Ruts, Northwest Transcripts 
Court Reporter. Thank you Gayle. Is there anyone else we should 
thank?
    Well, I just want to thank all of you for participating. It 
has been a wonderful hearing, very educational. I am delighted 
that the committee came out. I just apologize to Butch that we 
didn't come out sooner, but we will back on other issues as 
well. And thank you all very much. Butch, do you have anything?
    Mr. Otter. No. I thank everybody for being here. I really 
want to thank Congressman Shays, Chairman Shays and the entire 
staff, Larry, everybody, for coming out, because I know how 
important, and I think you too, know how important it is to 
these folks that were here in this room here today, and I thank 
you very much, Mr. Chairman.
    Mr. Shays. Thank you very much. This hearing is adjourned. 
This first adjourn didn't happen.
    [Whereupon, at 12 p.m., the subcommittee was adjourned.]