Statement of
James Hastings, M.D.
Director, VA Pacific Islands Healthcare System
Veterans Health Administration (VHA)
Department of Veterans Affairs (VA)
before the
United States Senate Committee on Veterans’ Affairs
Field Hearing Oahu, Hawaii
April 10, 2012

Senator Akaka, mahalo for the opportunity to discuss VA health care and services in Hawaii and the Pacific region.  Today, I will describe the VA Sierra Pacific Network, which includes Hawaii and the Pacific region, and give the Committee an overview of the VA Pacific Islands Health Care System (VAPIHCS), with particular emphasis on VA facilities here on Oahu.  Finally, I will highlight some issues of particular interest to Veterans residing in Hawaii. 

The Department thanks you for your leadership and advocacy on behalf of our Nation’s Veterans and your strong support of VA.    You have consistently demonstrated your commitment to Veterans by introducing legislation designed to meet their needs.  Your vision and support have led to an unprecedented level of health care services now available to Hawaii’s Veterans and those living on other islands across the Pacific.   Among notable achievements is the construction of state-of-the-art facilities here in Honolulu and remarkable improvements in access to health care services for Veterans residing in American Samoa and Guam. 

VA Sierra Pacific Network (VISN 21)
The VA Sierra Pacific Network is one of 21 Veterans Integrated Service Networks (VISN), in VHA.  The VA Sierra Pacific Network, or VISN 21, provides services to Veterans residing in Hawaii and the Pacific region, including the Philippines, Guam, American Samoa, and Commonwealth of the Northern Marianas Islands (CNMI).  In addition, the VISN includes a mainland region encompassing northern Nevada and north central California.  As of last year, there were an estimated 1.1 million Veterans living within the boundaries of the VA Sierra Pacific Network.

The VA Sierra Pacific Network includes six major health care systems and they are based in Honolulu, Hawaii; Palo Alto, San Francisco, Sacramento, and Fresno, California; and Reno, Nevada.  There is also an Independent Outpatient Clinic in Manila, Republic of the Philippines.  In fiscal year (FY) 2011, the VISN provided services to 281,000 Veterans out of a total of 400,000 Veterans who are enrolled.  There were about 3.1 million clinic visits and 27,817 inpatient discharges.  We had a cumulative level of 11,064 full-time employee equivalents and an operating budget of approximately $2.4 billion.

The VA Sierra Pacific Network is remarkable in several ways.  The Network hosts the highest number of VA Centers of Excellence and also receives the largest research funding allocation in VHA.  VISN 21 also operates one of five Polytrauma Rehabilitation Centers in VHA that serves the clinical needs of the most severely wounded Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans as well as the needs of other Veterans requiring acute medical and rehabilitation care.

VA Pacific Islands Health Care System (VAPIHCS)
As noted above, VAPIHCS in Honolulu is one of six major health care systems in VISN 21.  In 2011, there were an estimated 118,000 Veterans living in Hawaii, and at least 10,000 additional Veterans living outside Hawaii in the VAPIHCS catchment area.  VAPIHCS is unique in that its catchment area includes 2.6 million square miles and encompasses Hawaii, Guam, American Samoa and CNMI.  The region’s vastness presents many challenges, such as providing access to services for Veterans living on remote islands a great distance from population centers.  There are benefits as well, such as the richness of the culture of Pacific Islanders and the ethnic diversity of our patients and staff. 

In FY 2011, VAPIHCS provided services to more than 27,000 Veterans, an increase of over 6.7 percent from the previous fiscal year.  Of that number, 22,000 reside in Hawaii.  There were 206,000 clinic visits in Hawaii during FY 2011.  The cumulative Full-Time Equivalent Employees (FTEE) in FY 2011 for the VAPIHCS was 775.  The operating budget increased by 4.7 percent from $190 million in FY 2010 to $199 million in FY 2011.  

VAPIHCS currently provides health care services to Veterans through numerous facilities in Hawaii and beyond.  There is an Ambulatory Care Center (ACC) and a Community Living Center (CLC) on the campus of the Tripler Army Medical Center (AMC) in Honolulu and Community-based Outpatient Clinics (CBOC) in Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii), Hagatna (Guam), and Pago Pago (American Samoa).  VAPIHCS has Outreach Clinics in both Molokai and Lanai in Hawaii, and also in Saipan, CNMI.  The inpatient post-traumatic stress disorder (PTSD) residential rehabilitation unit is currently located on the campus of Tripler AMC, pending construction and activation of a new VA facility, also at Tripler, that was funded in the FY 2008 Budget.  VAPIHCS constructed a new replacement CBOC in Guam in FY 2010 with expanded capacity.  VHA operates six Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue, Wailuku, Kailua-Kona, Hilo, and Guam that provide counseling, psychosocial support, and outreach.

In addition to these sites, we are proud that VAPIHCS is expanding existing facilities and building new ones to continue to provide quality health care in the future.  VAPIHCS will open a new CBOC to serve Leeward Oahu Veterans, later this year.  A larger, shared facility between VAPIHCS, VA’s Regional Office in Honolulu, and the Army, Navy, and Coast Guard medical care programs has also been included in the FY 2013 Budget as a VA major lease project for the Leeward Oahu area.  If approved, the design phase will begin in FY 2013.  VAPIHCS also received funding for two projects to build a joint VA/Department of Defense (DoD) Ambulatory Surgery and Endoscopy facility on the grounds of Tripler AMC.  These projects are nearing design completion and construction will begin later this year.  Adding to the six existing Vet Centers mentioned above, two more, in Kapolei, Oahu and the other in American Samoa, will open later this year. 

VAPIHCS provides or contracts for a comprehensive array of health care services.  VAPIHCS directly provides primary care, including preventive services and health screenings, and mental health services at all locations.  VAPIHCS does not operate its own acute medical-surgical hospital, but has significantly improved access to specialty services by hiring specialists in endocrinology, infectious diseases, nephrology, neurology, orthopedics, ophthalmology, pain management, rheumatology, urology, women’s health and inpatient medicine (“hospitalists”) who work within Tripler AMC, our DoD partner.  These specialists, in addition to specialists from the University of Hawaii , provide selected specialty care in Honolulu and in our CBOCs, via island visits and by use of telemedicine.  Veterans continue to be referred to DoD and community facilities.  Veterans with spinal cord injuries (SCI) receive care from VAPIHCS dedicated staff, including a full-time dedicated SCI physician.

Inpatient long-term and acute rehabilitation care is available at the CLC.  Inpatient mental health services are provided by VA staff on a 20-bed ward within Tripler AMC and at the 16-bed PTSD Residential Rehabilitation Program (PRRP).  This latter unit also supports active duty and recently deployed Reserve and National Guard personnel requiring care through our VA/DoD sharing agreement.  VAPIHCS contracts for care with DoD at Tripler AMC and Guam Naval Hospital and at community facilities for inpatient medical-surgical care.

Oahu facilities
VA operates the Spark M. Matsunaga VA Medical Center in Oahu, located on the campus of Tripler AMC in Honolulu.  The medical center includes both the ACC and the CLC.  Additionally, VA operates the 20-bed acute psychiatry inpatient unit and a 16-bed PRRP both at Tripler. The VA Regional Office Honolulu is co-located with VHA on this campus.  The Honolulu Vet Center is located nearby in Honolulu.

The VA facilities in Oahu serve an estimated island Veteran population of 88,500.  In FY 2011, 34,000 Veterans on Oahu were enrolled for care, out of a total of 45,000 enrollees in the VAPIHCS.  Of these Veterans, identified as “Oahu users”, 18,070 received VA care in FY 2011.  The market penetrations, or percentages of Veteran enrollees and users compared to the Veteran population, are 38 percent and 21 percent, respectively, and compare favorably with rates within VISN 21 and VHA.

The average FTEE level on Oahu in FY 2011 was 620.  With this staff, VAPIHCS provides a wide range of outpatient services, including primary care, several medical subspecialties (e.g., cardiology, gastroenterology, geriatrics, nephrology, neurology, orthopedics, endocrinology and women’s health), mental health and dental care.  In addition, VAPIHCS provides diagnostic services such as laboratory, echocardiography and radiology.  If Veterans require services not available at the ACC or CLC, VAPIHCS arranges and pays for care at Tripler AMC, or by use of community providers.  Some Veterans are also referred to VISN 21 facilities in California if specialized care is needed.

In FY 2011, VA facilities in Oahu recorded 154,000 clinic visits.  The combined average daily census was 9 in the mental health ward and 48 at the CLC.  VAPIHCS spent about $20 million for clinical services for Veterans at Tripler AMC and another $35 million for non-VA care in the community.

Special Issues
VAPIHCS has played a facilitative role in the potential establishment of a Veterans Court system in Hawaii.  VA recently organized a symposium involving VA, State of Hawaii and other legal and government entities to address the need for a special Veterans Court system for Hawaii, and to identify key resources and implementing steps.  To date, Hawaii State legislative actions are proceeding. Generally, there is support and recognition of the positive outcomes that would be created by such a special court.

The Integrated Disability Evaluation System (IDES) Program, a joint VA/DoD program was implemented in FY 2010 in Hawaii.  VA and all branches of the military are participating and involved in the IDES program.  VAPIHCS, VA Regional Office Honolulu, and Tripler AMC are the largest stakeholder participants/deliverers of service. The program seeks a permanent co-located presence at Tripler AMC, which will involve the moving some VBA employees and programs from Tripler to the newly approved Leeward Oahu VA/DoD Outpatient Clinic, creating space for the permanent configuration.

VAPIHCS still faces several challenges, including timely access to health care services, an aging Veteran population, and the special needs of our newest OEF/OIF/OND Veterans.  Timely access to service is influenced by several factors:  the geography of its catchment area; challenges in recruiting healthcare professionals; and the availability of specialized care services in remote locations.  VAPIHCS will meet these challenges by working with DoD and community partners to increase Veterans’ access to care, activating the FY 2013 approved ambulatory surgery and endoscopy center, continuing to enhance the use of telehealth technologies, and assessing the need for new or replacement clinics.  I am proud of what VA has accomplished in Hawaii and the Pacific Islands region, and look forward to our future endeavors on behalf of Veterans.

Conclusion
With the support of Congress and the Hawaiian congressional delegation, VA is providing an unprecedented level of health care services to Veterans residing in Hawaii and the Pacific region.  VA has state-of-the-art facilities and enhanced services in Honolulu, as well as robust staffing on the neighboring islands and VA has expanded or renovated clinics in many locations.  VA continues to enhance its staff and programs to meet Veterans’ needs.  VA’s services are also available to eligible Hawaii National Guard and Army reserve members.

This concludes my prepared testimony.  My colleagues and I would be pleased to answer any questions.