STATEMENT OF
MICHAEL SHEPHERD, M.D.
PHYSICIAN, OFFICE OF HEALTHCARE INSPECTIONS
OFFICE OF THE INSPECTOR GENERAL, DEPARTMENT OF VETERANS AFFAIRS
BEFORE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ON
HEALTH CARE FOR VETERANS ON MAUI
WAILUKU, HAWAII
AUGUST 23, 2007

Mr. Chairman and Members of the Committee, thank you for the opportunity to testify today on access to health care for veterans on Maui.  I am accompanied by Julie Watrous, R.N., Director, Los Angeles Regional Office, Office of Healthcare Inspections, Office of Inspector General (OIG).  Today I will discuss the challenges and opportunities for providing health care to veterans on the island of Maui.  These challenges can be viewed as those concerns shared with Veterans Health Administration (VHA) facilities nationwide, those in common with other rural and/or remote areas, and those unique to Maui. 
Primary Care Staffing Issues at the Maui Community Based Outpatient Clinic (CBOC)
Staffing at the Maui CBOC has been a major concern since the departure of the full-time nurse practitioner, relocation of the full-time physician to the mainland, and the subsequent departure of a part-time contract primary care provider in 2006.  Despite efforts at recruitment, the Maui CBOC was without a full-time VA primary care physician for a 9 month period until May 2007.  During this time period, a full-time VA nurse practitioner who was hired in the summer of 2006 was the only consistent provider of primary care at the Maui CBOC.
During this period, the clinic relied on an informal triage system for scheduling patient appointments, based on urgency of medical complaint, service connection, Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) service, and lack of veteran financial means to access care elsewhere.  Non-service connected veterans with private insurance were encouraged to see providers in the private sector.  Some patients were co-managed by VA and non-VA providers depending on the type of service or care needed.  Wait lists accrued for non-urgent care such as semiannual or annual physical examinations, leading at times to frustration on the part of veterans and impacting, in turn, staff morale.  In the interim, part-time fee basis providers were utilized to provide care that was helpful, though continuity of care remained a significant issue.  A fee basis primary care physician was hired as a full-time VA employee at the CBOC in May 2007, and since then the wait list has reportedly been improving.  In addition to this now full-time VA physician, a part-time fee basis physician continues to see patients 3 times per week, and a second fee basis physician has been seeing patients twice a month.  In the near term, this second fee basis physician reportedly will be working weekly to see walk-in patients and OEF/OIF veterans. 
VHA Directive 2004-031, Guidance on Primary Care Panel Size, from July, 6, 2004, provides guidance on the maximum number of active patients (panel size) for whom a provider should deliver primary care with the aim of establishing a primary care system that balances productivity with quality, access, and patient service. The VHA directive recognizes that expected panel sizes will vary from site to site depending upon patient characteristics of the primary care population and the level of system support.  The directive also recognizes that panel sizes for specialized panels may need to be smaller than for undifferentiated primary care panels, and adjustments to panel size should be made at a local level, incorporating guidance from national programs where available. 
On Maui, primary care providers have a greater reliance on fee basis and consult specialty care in the absence of a full service VA, which impacts the real time availability of medical information and provider efficiency.  In addition, the generation of paperwork and arrangement of outside consultation, the absence of an in-house full service pharmacy, and the need for outside referral for certain radiology tests may also have a bearing on the appropriateness of panel size relative to a suburban mainland location. 
Replacing providers at rural facilities is generally difficult and may lead to prolonged gaps in continuity.  This challenge may be further exacerbated by relative real estate prices on Maui compared to many locations on the mainland.  For these reasons, in addition to panel size, in certain locations where there are unique geographic factors that impact access and where a high percentage of complex patients are in need of frequent appointments, expanded full-time primary care provider staffing may be a salient consideration that might assure greater continuity and minimize disruption to care in the event that a full-time provider leaves VA employment.  We found that the VA Pacific Islands Health Care System has proactively responded to the recent gap in primary care physician continuity by hiring a second full-time primary care physician for the Maui CBOC.  This physician will begin seeing patients at the Maui CBOC within the next month.
Access to Outpatient Mental Health Care on Maui
During the past year, the Maui clinic has had a full-time psychiatrist and psychologist.  The psychiatrist reported that the CBOC has been experiencing an ongoing increase in the number of patients seen for mental health visits.  The VA Pacific Islands Health Care System is presently recruiting applicants for several new positions at the Maui CBOC including a telehealth clerk, an addictions therapist, a psychology technician, and a psychologist to serve as a telehealth coordinator.  In addition, a clinical nurse specialist with a mental health focus, who is presently assigned to the Kona CBOC, will reportedly be assigned to the Maui CBOC to provide patient care. 
Cognitive behavioral therapies including prolonged exposure therapy are among the best evidence supported treatments for Post Traumatic Stress Disorder.  However, nationally, there is a relative shortage in both the VA and private sector of clinicians trained in specific cognitive behavioral techniques.  The VA Pacific Islands Health Care System reported having recently contracted with a psychologist from the University of Pennsylvania to train VA psychologists in prolonged exposure therapy. 
Access on Molakai and Lanai
In addition to serving veterans on Maui, the CBOC supports veterans on the islands of Molokai and Lanai.  A part-time physician and a mental health clinician are available a few days per week to see patients on Molokai.  At the U.S. Senate Committee on Veterans' Affairs field hearings in Hawaii in January 2006, VA representatives committed to funding for telehealth capabilities with non-VA providers and announced that Molokai veterans would get telehealth equipment.  VA Pacific Islands Health Care System primary care leadership reported having made contractual arrangements for veteran use of telehealth equipment that is owned and located at a non-VA clinic on Molakai.  The equipment will be utilized when the telehealth positions are filled, and staff at the non-VA clinic will assist veterans and VA staff with its use.  Service to veterans on Lanai was significantly impacted during the 9 month period in which the Maui CBOC was experiencing primary care staffing difficulties.  In response, the VA Pacific Islands Health Care System began sending providers from Honolulu to serve the 55 veterans residing on Lanai.  System leadership reports that subsequently a primary care physician has been seeing patients in Lanai on a regular basis.  System leadership is subsequently considering permanently supporting VA services on Lanai from the medical center in Oahu rather than via the Maui CBOC.  The VA Pacific Islands Health Care System has also recently begun partnering with a local hospital. 
Access to Non-Institutional Services Provided to Veterans on Maui
The Veterans Millennium Health Care and Benefits Act of 1999 clarified requirements for VHA to provide non-institutional care for veterans in response to the changing needs of aging veterans.  The Act directed VA to provide veterans eligible for medical services with certain services that are provided to veterans in their own homes or in community settings.  VHA implemented policies requiring medical facilities to provide non-institutional care services to all eligible veterans and to include the services in the VHA medical benefits package.  These services include: home based primary care; purchased skilled home health care; homemaker and home health aides (H/HHA); adult day health care; geriatric evaluation and management; respite care; and hospice and palliative care.  In addition, VHA measures facility use of care coordination and telehealth services (CCHT). 
In 2006, at the request of Senator Akaka, the OIG was asked to determine what restrictions were being placed on veterans for access to certain non-institutional care services and whether these restrictions were appropriate or were inconsistent with the intent of the Millennium Act.  The OIG report, Review of Access to Care in the Veterans Health Administration, found that the VA Pacific Islands Health Care System restricted contract adult day health care and H/HHA to highly service-connected veterans, provided no outpatient respite prior to June 2005, and offered home based primary care only to veterans living within a 50-mile radius of the VA Pacific Islands Health Care System or the Kona and Hilo clinics.  The OIG report specified the need for VHA to make sure that facilities eliminate local restrictions limiting eligible veteran access to non-institutional care and, where possible, expand coverage to geographic areas that currently do not offer non-institutional care services.  VA clinicians reported that subsequent to the time of the U.S. Senate Committee on Veterans Affairs field hearings in January 2006, both homemaker and home health aides and contract adult day health care services no longer have restrictions on service connection, and non-service connected veterans are eligible if they meet the medical qualifications for these programs. 

The VA Pacific Islands Health System primary care leadership reported that contract adult day health care is available on Maui, and additional funding has been allocated to bolster H/HHA services.  There are no restrictions to home based primary care, however, the VA Pacific Islands Health Care system is presently recruiting for a nurse practitioner to provide the home based primary care to medically eligible veterans.  CBOC staff report that purchased skilled home health services are available on Maui.  In addition, a gerontologist has resumed working at the Maui CBOC every other month to perform comprehensive geriatric evaluation and management, and there are no restrictions to access as long as patients meet the program criteria.  VA Pacific Islands Health Care System primary care leadership reported that they have begun consideration of "health buddies" and CCHT services for incorporation in future programming once the nurse practitioner to provide home based primary care is on board.  At present, respite care is only available on Oahu and on an inpatient basis. 
Access for Veterans to Non-VA Specialty and Hospital Care on Maui
Another challenge concerns veteran access to non-VA fee basis specialty or sub-specialty care.  Some specialty providers may have full practices and are no longer taking new patients or may not accept the reimbursement rate provided by VA fee basis.  Additionally, though the CBOC benefits from indirect access to specialty care through the sharing agreement with the Tripler Army Medical Center, the Maui CBOC does not derive the direct access benefit experienced from physical co-location experienced by veterans at the Matsunaga Medical Center.  To address this issue, the VA Pacific Islands Health Care System primary care leadership is examining possible future telehealth alternatives, such as tele-optometry and tele-dermatology to provide certain outpatient specialty care services.
A further challenge facing the VA Pacific Islands Health Care System is the limited medical infrastructure on Maui.  Maui Memorial Hospital is presently the only hospital on the island.  When veterans are admitted to the hospital, which is a state run facility, they are admitted on a rotational (on-call) basis to the service of local physicians at Maui Memorial Hospital.  VA staff reported that some non-VA health care entities have hired hospitalists to care for their patients admitted to Maui Memorial Hospital.  A hospitalist is a doctor who specializes in the care of hospitalized patients, whose focus is treating health conditions for which patients are often hospitalized, and whose office is usually located within the hospital.  Whether or not the number and medical complexity of veterans admitted to Maui Memorial Hospital would justify hiring or contracting for the services of a hospitalist is a question for further study by the VA Pacific Islands Health Care System leadership.  
Summary
Over the past year, the VA Pacific Islands Healthcare System leadership has taken actions to improve access to care for veterans on Maui and to enhance the consistency and continuity of care that will be provided.  Although staff recruitment and programming to enhance future access are in process, some obstacles to access remain for veterans on Maui.

Mr. Chairman, thank you again for this opportunity to testify.  I would be pleased to answer any questions that you or other members of the Committee may have.