Questions and Answers

Question

"What technical expertise is needed to develop national statistics on rural veteran populations? Does the VA have the technical capacity inhouse to develop national statistics on veteran populations residing various distances from VA medical facilities along the lines which the Togus VAM&ROC provided me regarding Maine veterans. If not, how would the VA acquire this capacity?"

Response: The Veterans Administration maintains a wide variety of population statistics on the number of veterans in civilian life. Among the data available are estimates and projections of the veteran population of each state and county nationwide. These figures are differentiated by period of military service, and are updated annually based on a March 31 reference date.

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The state and county veteran population data which we prepare are comparable statistics presented in the letter which Togus VA Medical Center Director John Bunger sent you on June 9, 1983. Our figures are available in somewhat greater detail, however. Enclosed for your information is a copy of our estimates of the veteran population for each county in Maine as of March 31, 1984. These figures are broken down by period of service.

In order to construct estimates of the veteran population residing exact distances from VA medical care facilities, we would have to develop an entirely new system. It is certainly possible for the VA, working with the Bureau of the Census to develop such a system. However, as Dr. Custis stated in testimony on April 11, 1984, such information would not be as important to us in planning as would be other determinants.

Question: "What would be the dollar costs to the VA of developing such statistics and what would be the value of such statistics to the VĂ in evaluating the availability of present VA health care delivery programs to rural veterans."

Response: The development of such a new system would undoubtedly be costly. At this time, however, we do not have a basis to provide a meaningful estimate of the cost involved.

Again, as we stated above, while such statistical data would be interesting, we do not believe it would be particularly valuable to the VA. We currently have statistical data on veterans by county which give us valuable information on how many veterans are living in remote rural areas.

Question: "Do you feel such statistics mentioned above could be used by this committee to target possible pilot VA program health-care delivery alternatives? What additional data would be helpful to the committee in this regard?"

Response: These statistics could theoretically be used as part of the criteria for conducting needs assessments studies for outreach clinics and other related VA health care initiatives. However, we would emphasize that the VA has developed and implemented a planning process called Medical District Initiated Program Planning

(MEDIPP). This new process has been very successful and we are committed to its continued use. We believe local need, as identified through the MEDIPP process, should be the determining factor for internal VA decision-making on where and how health care should be delivered to all veteran populations be they rural or urban.

Question: "Please provide more detail, with emphasis on the applicability of these projects to rural health care in Maine, on those alternatives which have been identified as having a current annual support in excess of $100,000 (St. Cloud VAMC: COPE; Hot Springs VAMC: Outreach to Rushville, Nebraska; Denver VAMC: Medivan; Salt Lake City VAMC: Outreach to Richfield and Roosevelt; and Tuscaloosa VAMC-Community Service Program)."

Response: As we stated earlier in this letter, medical centers throughout the country have used various methods to provide care, principally post-hospital follow-up care to veterans for nonservice-connected disabilities. The principal method used by the Togus facility, and it is certainly a good method, is the fee-basis contract care program. We would also note, however, that another approach being planned for providing care to veterans in Aroostook County, Maine, is a "sharing agreement" between Togus and the USAF Hospital at Loring Air Force Base, Loring, Maine. Under terms of this proposed agreement, the Air Force Hospital will provide services covering outpatient visits in general medicine and surgery, compensation and pension examinations and a limited amount of inpatient care.

Any option for service delivery is potentially available to VAMC Togus including these you mention. We rely upon the VAMC and the Medical District to plan the service delivery mechanisms to meet veteran health care demands based on a local determination of need.

Question: "Please advise me of any modifications to the operation of those outreach efforts from the descriptions provided by Salt Lake City Center Director Robert E. Lindsey in his prepared statement for the July 13, 1983, hearing (p. 126-137, S.Hrg. 98-456)."

Response: There have been no major modifications in operation of the rural health program at Salt Lake City since July 1983. Changes which have occurred have been related to improving the efficiency of management practices, enforcement of eligibility regulations, and cost containment. These changes are similar to those which have occurred within the medical center itself.

Question: "To what degree does the Salt Lake City VAMC find it necessary to rediagnose veterans referred by the Richfield and Roosevelt clinics?"

Response: The experience at Salt Lake City to date has not shown a need to rediagnose veterans who receive their care at the rural clinics. This is due to the close communication linkages between the Sale Lake City VAMC and the rural clinics and to the fact that most patients are receiving post-hospitalization care.

Question: "Have the operation of the clinics presented misleading impressions to nonservice-connected veterans regarding eligibility for VA treatment? What

problems has the VA encountered in making accurate eligibility determinations and properly monitoring the provision of quality care?"

Response: The rural health clinics are designed to provide post-hospital follow-up services so that eligibility in most cases has already been determined. To avoid giving misleading impressions to nonservice-connected veterans, Salt Lake City has instituted an educational program to inform rural veterans of eligibility requirements. Regarding the provision of quality care, outreach health clinic physicians and physician assistants work closely with the supporting VAMC medical staff to assure continuity of care for patients discharged from the hospital to be followed in the rural clinics. This allows closer monitoring of changes in the patient's medical condition and earlier referral to specialty clinics to avoid emergencies and the need for rehospitalization. The Salt Lake City VA Medical Center's quality assurance section monitors clinic costs, workloads and medical practices on an ongoing basis. It also conducts administrative audits, patient care evaluation and utilization review studies.

Question: "Can the VA provide me a detailed breakdown of expenditures associated with a diagnostic clinic which would result in a 3-year $980,000 expenditure that would be generated by enactment of S. 523?"

Response: The breakdown of the estimated three-year cost (proposed time period of the program) of operating the experimental program is:

2

Estimated by Space Management; assumes no structural renovations would be required.

Staff requirements at VA specifications estimated at $26,301 FTEE, FY 1984 EST. 3 Other costs include: travel and transportation; communications; supplies and materials; equipment; and costs associated with the Advisory Committee authorized by the bill.

Question: "At what date can we expect final approval of this project by the VA? Is it the impression of the VA that the $105,000 FY 85 funding estimate included for this project in response Ig will be sufficient? Is the VA committed to funding for the expected 5-year life of this study? If so, at what level of funding for each year?"

Response: The Health Services Research and Development (HSR&D) Service received proposal IIR #82-113 from VAMC Togus on April 10, 1984. It is being reviewed presently. Only scientifically acceptable proposals are considered for funding and each quarter the HSR&D Service's Awards, Appeals, and Appointments Council reviews all such proposals and rank orders them according to funding priority. Funding is contingent on the availability of resources. Thus, it is not possible to give a date by which the project would be funded. We expect to know whether or not the proposal is scientifically adequate by mid-July. If adequate, it would be considered at the Council's meeting that quarter, and if sufficient resources are available it would be funded effective October 1, 1984. The proposal requests $930,695 over five years, with $442,276 requested for Kennebec Valley Regional Health Authority (KVRHA). Once funded, it is HSR&D Service's policy to support a project to completion, if progress is satisfactory and funds are available.

Question: "Under the parameters of the study, would it be possible to include Aroostook County among the areas included in this study? Would a mandated inclusion of Aroostook County jeopardize the scientific validity of this study?" Response: We understand that Aroostook County is already included in the proposed study.

Question: "It is my understanding that as part of this research, veterans living in geographically remote areas of Maine will be encouraged to utilize the services of rural health clinics which have entered into "federation agreements" with Togus VAM&ROC. How would such "federation agreement" differ from the contractual agreement central to S. 523?"

Response: The proposed study would be of veterans eligible for outpatient care under the fee-basis program, and of veterans discharged from VAMC Togus and enrolled in the post-hopsital outpatient treatment program for nonservice-connected conditions. The KVRHA would coordinate the federation between VAMC Togus and each Rural Health Center. All Centers in Maine would be solicited for participation in this project. Contracts between VAMC Togus and each Center would state rights and responsibilities, centering on treatment plans, reimbursement levels, and in-service training. The primary difference between the study clinics, and a clinic such as that proposed by S. 523 is that the study clinics will only be providing care to veterans when eligibility for care for nonservice-connected conditions has been established.

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