[Senate Hearing 107-793]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 107-793
 
               MENTAL HEALTH CARE: CAN VA STILL DELIVER?
=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION




                               __________

                             JULY 24, 2002

                               __________

      Printed for the use of the Committee on Veterans' Affairs 






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                     COMMITTEE ON VETERANS' AFFAIRS

            JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida                  ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont       STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii              FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota            BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington             LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia                 TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska         KAY BAILEY HUTCHISON, Texas

        Kim E. Lipsky, Deputy Staff Director for Health Programs

      William F. Tuerk, Minority Chief Counsel and Staff Director

                                  (ii)

  
?

                            C O N T E N T S

                              ----------                              

                             July 24, 2002

                                SENATORS

                                                                   Page
Jeffords, Hon. James M., U.S. Senator from Vermont, prepared 
  statement......................................................    45
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia, 
  prepared statement.............................................     2
Wellstone, Hon. Paul, U.S. Senator from Minnesota, prepared 
  statement......................................................     6

                               WITNESSES

Alarcon, Renato D., M.D., Professor of Psychiatry, Emory 
  University, representing the American Psychiatric Association..    61
    Prepared statement...........................................    64
    Response to written questions submitted by Hon. John D. 
      Rockefeller IV.............................................    71
Armstrong, Moe, Director of Family and Consumer Affairs, Vinfen 
  Corporation, Representing the National Alliance for the 
  Mentally Ill on Behalf of the National Alliance for the 
  Mentally Ill...................................................    87
    Prepared statement...........................................    90
Evans, Colleen, Staff Nurse, Acute Schizophrenia Unit, VA 
  Pittsburgh Health Care System, Highland Drive Division, and 
  Chief Steward, American Federation of Government Employees.....    73
    Prepared statement...........................................    75
Frese, Frederick, Vice President Emeritus, National Alliance for 
  the Mentally Ill, and Assistant Professor of Psychology in 
  Clinical Psychiatry, Northeastern Ohio Universities College of 
  Medicine.......................................................    79
    Prepared statement...........................................    82
Ibson, Ralph, Vice President for Government Affairs, National 
  Mental Health Association......................................    55
    Prepared statement...........................................    57
    Response to written questions submitted by Hon. John D. 
      Rockefeller IV.............................................    60
Losonczy, Miklos, M.D., Co-Chairman, Committee on Care of 
  Veterans With Serious Mental Illness, Assistant Chief of Staff 
  for Mental Health and Behavioral Sciences, New Jersey Health 
  Care System, and Associate Professor, Department of Psychiatry, 
  Robert Wood Johnson School of Medicine.........................    31
    Prepared statement...........................................    33
    Response to written questions submitted by Hon. John D. 
      Rockefeller IV.............................................    41
Roswell, Hon. Robert H., M.D., Under Secretary for Health, 
  Department of Veterans Affairs; accompanied by Laurent Lehmann, 
  M.D., Chief Consultant, Mental Health Strategic Health Care 
  Group..........................................................     8
    Prepared statement...........................................     9
    Response to written questions submitted by:
        Hon. John D. Rockefeller IV..............................    15
        Hon. Arlen Specter.......................................    16

                                 (iii)
                                APPENDIX

American Association for Geriatric Psychiatry, prepared statement    98
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
  prepared statement.............................................    97


               MENTAL HEALTH CARE: CAN VA STILL DELIVER?

                              ----------                              


                        WEDNESDAY, JULY 24, 2002

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:36 a.m., in 
room 418, Russell Senate Office Building, Hon. John D. 
Rockefeller IV (chairman of the committee) presiding.
    Present: Senators Rockefeller, Jeffords, Wellstone, and 
Nelson.
    Chairman Rockefeller. Good morning, everyone. Senator Ben 
Nelson has to leave at 10, so I am going to make my statement, 
then I will ask him to make his and to ask any questions that 
he might want to ask.
    In this committee, we have looked for some time at the 
quality of VA health care, and that is obviously our job. One 
of the facets of that is mental health care, which is broadly 
ignored in our country and broadly ignored by public policy. 
Today, we are going to discuss it in the Department of Veterans 
Affairs.
    We debate quite a bit here in Congress. What we actually 
get done is questionable, but we certainly do debate. That 
debate about mental health and the parity of mental health has 
increased in its intensity. On the surface, there is parity for 
mental health care in the Department of Veterans Affairs. 
Veterans are technically not subjected to arbitrary limits on 
the number of visits to clinicians. So the foundation seems to 
be in place. But I worry that in actuality, VA may not be doing 
all it can to help those who are suffering.
    Virtually all families in America face mental illness in 
one way or another. Veterans face it in higher proportions and 
more painfully in many cases. So my focus is simple: To make 
sure that VA is doing everything possible to guarantee that 
each and every veteran who needs mental health care, whether 
that is in the great State of Nebraska or the even greater 
State of West Virginia, or wherever it might be.
    Why am I so adamant about this? Because so often, the 
battle wounds that veterans come home with are not visible. 
They may not be missing a limb. There may not be scars or 
shrapnel.
    I have never seen anything as devastating as PTSD. Most 
Members of Congress could not tell you what the letters stand 
for, but the people that have PTSD suffer in ways which we are 
just beginning to understand. This does not have just to do 
with wars, but it has to do with life experiences too. But this 
is the Veterans' Committee, and we are talking about veterans 
and what they have been through and, therefore, mental health 
has to be taken very, very seriously. So that is why I am 
adamant about mental health.
    So we are talking about PTSD and mental health. It is not 
just a headache. It stays and it stays, and it can get worse. 
It has to be treated and has to be dealt with. Most of American 
society chooses not to admit that they have such things, and 
because of this they do not deal with them or do not know how 
to deal with them. But in the VA, we are meant to be able to 
address the problem.
    VA has a long-term care health policy. The rest of the 
country does not; so we are ahead in theory. We have mental 
health parity; so we are ahead in theory. Are we ahead in fact? 
That is what this hearing is about.
    Hypertension, heart disease affect so many people, but 
mental health is not far behind. Cancer and depression affect 
roughly the same number of veterans.
    But is VA reaching all veterans who need care? VA's own 
Advisory Committee has in the past found that mental health 
services have not been maintained, per a congressional mandate. 
I just want to know what the facts are.
    In my own State, a unilateral decision had been made to 
close the inpatient psychiatric unit at the Clarksburg VA 
hospital. That decision was made in spite of the fact that 
mental illness is one of the most prevalent diagnoses there. 
So, without an inpatient unit, veterans would have been 
required to leave their families and friends in the community 
and travel hours for care.
    Whereas I am very happy to report the decision to close the 
psychiatric unit was reversed, I am very unhappy that it might 
have been closed. So, again, I fear that those needed inpatient 
programs are not being spared in other parts of the country.
    Dr. Roswell, I know that managing a strong mental health 
network in times of overwhelming budget constraint is daunting. 
I said to you in your confirmation process, that yours is one 
of the world's toughest jobs. I am glad you are here and look 
forward to your testimony.
    [The prepared statement of Chairman Rockefeller follows:]

 Prepared Statement of Hon. John D. Rockefeller IV, U.S. Senator From 
                             West Virginia

    Good morning.
    This Committee has looked at the quality of VA health care 
and the need for more to be done on long-term care. Today we 
will examine what I believe is just one more facet of veterans' 
health care--that of mental health.
    Here in Congress, the debate continues about mental health 
parity. On the surface, there is parity for mental health care 
in VA. Veterans are technically not subjected to arbitrary 
limits on the number of visits to clinicians. But I worry that 
in actuality, VA may not be doing all it can to help those who 
are suffering.
    My focus is simple--to make sure that VA is doing 
everything possible to guarantee that each and every veteran 
who needs mental health care--whether in West Virginia or 
Nebraska or Arkansas--is receiving that care.
    Why am I so adamant about this? Because so often battle 
wounds do not manifest in physical illness, but in quiet and 
equally debilitating mental illness. These wounds are revealed 
as PTSD with effects that linger and symptoms that can be 
brought on years after combat.
    While hypertension and heart disease afflict vast numbers 
of veterans, mental illness is not far behind. Cancer and 
depression affect roughly the same number of veterans.
    But is VA reaching and treating all veterans who need care? 
VA's own Advisory Committee has in the past found that there is 
a lack of evidence that mental health services have been 
maintained--per a Congressional mandate. I hope to learn if 
this has improved.
    In my own State, a unilateral decision had been made to 
close the inpatient psychiatric unit at the Clarksburg VA 
hospital. This decision was made in spite of the fact that 
mental illness is one of the most prevalent diagnoses there. 
Without an inpatient unit, veterans would be required to leave 
their families and friends in the community and travel several 
hours to reach the next available inpatient mental health bed.
    While I am happy to report the decision to close the 
psychiatric unit was reversed--I fear that these needed 
inpatient programs are not being spared in other parts of the 
country.
    Dr. Roswell, I know that managing a strong mental health 
network in times of budget constraints and a move toward 
primary care is not easy. As I told you at your confirmation 
hearing just four months ago, you would not have an easy job.
    I welcome your testimony.

    Senator Nelson. Thank you very much, Mr. Chairman. I 
appreciate the courtesy today. I have to preside at 10, so it 
gives me the opportunity to participate in still a meaningful 
way and fulfill my obligations.
    First of all, I, Mr. Chairman, would like to submit my 
complete statement for the record, but to start by thanking the 
witnesses for being here today. As the Chairman said, yours is 
a daunting task with sometimes too few resources and too many 
requirements to be able to matching things, and in the area of 
mental health, that is obviously one of the things that you 
face today.
    A review of the numbers indicate that veteran satisfaction 
with the mental health programs of the VA has declined by 15 
percent and the VA is spending 23 percent less on these 
programs since 1996. I am not against spending less money if 
you are getting more results or you are achieving better 
results in the process, but a recent Federal study found that 
the Department's cost containment policies are having a 
profound impact on clinical practice, one of the most important 
areas of the VA, with a strikingly high number of VA staff 
psychiatrists across the country reporting that they do not 
feel that they have the freedom to prescribe anti-psychotic 
medicines of their choice for patients.
    So Dr. Roswell, Mr. Secretary, in your view, do not these 
practices, particularly those that interfere with the 
physician's clinical judgment, actually increase the use of 
psychiatric hospital services, inpatient services, due to 
greater patient failure rates? Does this not further exacerbate 
the VA's capacity problems for veterans, and in some areas 
where there is not really any real capacity for this kind of 
inpatient care? I guess maybe I would like to have you respond 
to that.
    Dr. Roswell. Thank you very much, Senator Nelson. You bring 
up some excellent points, and in general, I agree with you. We 
have been extremely challenged with growth in new veterans 
seeking care. Fortunately, most of the new users coming into 
our system today are veterans who do not have serious mental 
illness but rather have less serious problems that, while not 
as difficult to manage, do cause competition for very scarce 
resources.
    We have had some reduction in staffing. We have been quite 
successful, based on clinical outcome measures, in shifting a 
variety of mental health services from an inpatient location to 
an outpatient delivery mode, but we have also distributed our 
delivery system from a hospital-based system to a clinic-based 
system. What we have not yet been entirely successful with is 
being able to move the entire mental health team to a small 
satellite clinic.
    So the 23 percent reduction you spoke of in resources, I 
believe, alludes to the number of mental health care staff 
working, particularly psychologists, as we have shifted a lot 
of programs. We are very resource- and staff-intensive on an 
inpatient basis to an outpatient basis, then distributed that 
outpatient care across not 165 hospitals, but over 1,200 
locations of care. We have not been able to move those staff to 
those locations as effectively as we would like. We are working 
on that, and I will talk about telemedicine and some other 
plans we have to try to address that need later.
    With regard to the anti-psychotic medications, I am a very 
strong advocate of atypical anti-psychotics. I have spoken on 
several occasions since my confirmation before this committee 
on the importance of using atypical anti-psychotics to enhance 
clinical outcomes. We have been adamant that there is no fail-
first policy nor do we advocate a particular medication in 
management of mental illness, but rather defer that to a 
clinician's judgment.
    Senator Nelson. It is strange, though, that the clinicians 
are now saying that they do not feel the freedom to prescribe 
what they feel and believe in their medical judgment would be 
the best prescription drug, and I think that is what raises 
questions, not that--I applaud your efforts to try to find a 
more effective and efficient way to treat these veterans, but 
if the clinicians raise questions about their ability to 
prescribe what they believe is the right kind of medication, 
how does that further advance good care? I do not want to 
suggest that they are always right. I do not think we ought to 
suggest that they are never right, either, so----
    Dr. Roswell. No, I understand. I think there are two 
dimensions to the thorny question you pose. One is we have an 
obligation--and this is one of the strengths of the VA health 
care system--to provide the latest scientific evidence, side 
effect profiles, and efficacy studies on any medication to our 
clinicians. We can do that through our computerized patient 
record system.
    So our challenge is to make sure that every clinician 
prescribing anti-psychotics has the latest information on their 
effectiveness, as well as their cost, what their side effects 
might be, and where they have a particular therapeutic 
advantage over a different medication. We have attempted to do 
that. If that is construed as constraining their practice, that 
is not the intent because it is intended only to be a 
guideline, a clinical practice guideline.
    Senator Nelson. Can we get that word back to them so that 
they are not raising the question and they do then feel the 
freedom to make the prescriptions that they choose?
    Dr. Roswell. I will certainly make sure that as I speak on 
the subject, which I do--I mean, it is a very important issue 
in my mind--that I continue to advocate for that and I will 
ensure through our Deputy Under Secretary for Operations and 
Management that there are no restrictions, once again, on any 
particular drug.
    Senator Nelson. And if we find that there are continuing 
concerns, I assume it would be OK if we brought them to your 
attention.
    Dr. Roswell. I would very much appreciate that.
    Senator Nelson. I appreciate it.
    Thank you very much, Mr. Chairman.
    Chairman Rockefeller. Thank you, Senator Nelson.
    Senator Nelson. Thank you, Secretary.
    Chairman Rockefeller. Senator Wellstone?
    Senator Wellstone. Thank you. I apologize, Mr. Chairman. I 
have to be at the floor in 10 minutes to speak about disaster 
relief and we have a markup in the Health Committee. I am going 
to try to come back. I am so interested in this testimony, and 
thank you for having this hearing.
    Very quickly, a full statement in the record, please. Dr. 
Roswell, I am glad--on the Comprehensive Homeless Veterans' 
Assistance Act, we call upon each VA primary care facility to 
have a plan for dealing with the mental health services. 
Senator Rockefeller was talking about this. I cannot say I am 
100 percent satisfied with the progress, but you have got it on 
the radar screen and I am glad you are moving in the right 
direction.
    I will tell you what bothers me about the testimony here 
today is you basically have made a lot of cuts and put into 
effect a lot of savings in mental health services, but the most 
damning statistic I see in today's testimony is that only 17.8 
percent reinvestment rate of the savings from the mental health 
services you put back into mental health for veterans, while 
the mental health services workload has increased 25 percent. 
That is completely unacceptable--unacceptable. That reinforces 
the very stigma that outrages me toward people who are 
struggling with mental health issues.
    Now, I care a lot about Priority 7 veterans and a lot of 
this money, I think, has gone to them, but here is really the 
point. I do not think we should be cannibalizing the mental 
health and the substance abuse programs to use this to pay for 
other veterans. I do not think one group of veterans should be 
pitted against another group of veterans.
    I do not think there should be a zero-sum game, and I would 
call on you, because I know you care about this, and I would 
call on the Secretary, whom I thoroughly enjoy working with, to 
come to us with a realistic budget that lets you do your 
mission, because you do not have that at all--at all. And for 
us, all of us here in the Senate, we are now back into 
deficits, and we can go over the tax cuts and all the rest. The 
only thing I am going to tell you is I am not prepared--I am 
not showboating here--I am not prepared to balance the budget 
on the back of veterans. That is the kind of budget that we are 
talking about here. It is unacceptable.
    We have all worked too hard, yourself included, to overcome 
the stigma to basically--that is exactly what this budget is 
and that is exactly what is going on here, so we have got a lot 
of work to do, a lot of oversight, a lot of staying close to 
what is going on, Senator Rockefeller, and I want to be a part 
of that, believe me, you.
    I am going to try to come back. I hate making a statement 
like that and then running out, but I am going to run back 
unless I cannot because of the markup in committee.
    Chairman Rockefeller. There are no doubts that you really 
care about this issue.
    Senator Wellstone. Thank you.
    [The prepared statement of Senator Wellstone follows:]

 Prepared Statement of Hon. Paul Wellstone, U.S. Senator From Minnesota

    Mr. Chairman, thank you for calling this hearing. Mental 
health parity is a critically important topic for me, both with 
regard to veterans and for Americans generally.
    I've had a chance to review some of the written testimony 
and unfortunately it just seems to confirm that the Department 
of Veterans Affairs is increasingly losing ground in dealing 
with mental illness and substance abuse among veterans. It 
simply reinforces the testimony we heard last year when the 
Committee held hearings on homelessness among veterans--a 
majority of whom battle with mental illness--that veterans were 
not getting the mental health care that they needed.
    As an aside, I would say to Dr. Roswell that you mentioned 
in your testimony some of the initial steps that VA is taking 
to be in compliance with provisions of the Comprehensive 
Homeless Veterans Assistance Act we passed last year that 
required each VA primary care facility to develop and carry out 
a plan for providing mental health services. I will have some 
questions for the record on VA's progress--but I'm glad that 
it's at least on the radar screen.
    But back to my larger point--failure to provide veterans 
with adequate mental health services is especially unfortunate 
given that many veterans who struggle with mental illness--
particularly those affected by PTSD--do so as a result of their 
service to their country. So if these veterans aren't getting 
the treatment that they need, it's just that much more of a 
scandal.
    The testimony before us today suggests that the VA is 
essentially cannibalizing it's mental health and substance 
abuse programs to pay for other veterans services. To me one of 
the most damning statistics from today's testimony is that 
there is only a 17.8% reinvestment rate of the savings from 
changes in mental health services back into mental health care 
for veterans. At the same time that the mental health service 
workload increased by 25%!
    So either the VA has happened upon some kind of magic 
formula to dramatically reduce the cost of quality mental 
health care--in which case I hope they'll share it with us 
today--or the quality and accessibility of this care must be 
declining. Again, the testimony today suggests that it's the 
latter.
    Most troubling is the charge that this decline in mental 
health and substance abuse services is occurring because 
veteran is being pitted against veteran within the VA in terms 
of what kind of care is delivered and which veterans are being 
served. We all know that the current challenge for the VA is to 
deal with dramatically rising demand especially among priority 
7 veterans. This was also during a period where Congress and 
the Clinton administration--wrongly--were asking the VA to do 
more things with less money.
    I don't think anyone's suggesting that these other services 
aren't worth while and important--it's not like it's just being 
frittered away. But it's telling that mental health services 
and substance abuse treatment seem to be bearing a significant 
brunt of the cost cutting.
    The stigma against people with mental disorders has 
persisted throughout history, and it persists in the VA system 
as well. As a result, people with mental illness are often 
afraid to seek treatment for fear that they will not be able to 
receive help, a fear all too often realized when they encounter 
outright discrimination in health coverage. Why is it that 
because the illness is located in the brain, and not the heart 
or liver or stomach, that such stigma persists?
    One of the most serious manifestations of stigma is 
reflected in the discriminatory ways in which mental health 
care is paid for in our health care system. We need to fix this 
problem in private insurance--which everyone on this committee 
knows of my interest in--and we need to ensure that veterans 
get decent mental health care.
    In closing Mr. Chairman, let me say this: I don't think the 
VA should have to pit veteran against veteran and I don't think 
Congress should either. This shouldn't be a zero sum game. For 
the VA's part, I would say to Dr. Roswell, you need to come to 
us with a realistic budget that lets you do your mission.
    For Congress's part: We know that now that were back into 
an era of deficits that Congress will have to make some hard 
choices. But I reject making them on the backs of veterans. We 
can find other places within the budget for savings or for 
sources of revenue.

    Chairman Rockefeller. Senator Jeffords?
    Senator Jeffords. Thank you, Mr. Chairman. Thank you for 
holding this hearing.
    The VA is in the right place to deliver this kind of care. 
It has some of the nation's top medical expertise and years of 
clinical experience and we appreciate that. most importantly, 
the VA has the trust of the veterans and it is high time that 
the program was provided with the funding it needs and 
attention that it deserves and I intend to try to help you with 
that respect.
    While we will not have time to focus specifically on PTSD 
treatment and research today, I would like to bring my 
colleagues' attention to the important contributions of VA's 
National Center for Post-Traumatic Stress Disorder. This 
center, headquartered in White River Junction, Vermont, is 
dedicated to improving the quality of VA treatment provided for 
veterans with PTSD.
    The center's research, educational, and consultation 
services have unquestionably promoted better clinical treatment 
for veterans. The center has made significant contributions to 
our scientific understanding about the causes, diagnosis, and 
the treatment of this potentially incapacitating disorder that 
affects thousands of service-connected veterans, which you are 
well aware of.
    The center has been innovative in its efforts to get 
information about PTSD into the hands of practitioners, who can 
put the information to good use with their patients. For 
example, the center has developed some unique resources for 
mental health professionals, such as an award-winning website 
and the largest and most comprehensive bibliographic data base 
in the world, called PILOTS, the Published International 
Literature on Traumatic Stress.
    As a central authority on PTSD, the National Center has 
frequently served as a consultant to VA policymakers as well as 
other governmental and international officials on matters of 
concern in this area. The center has played an important role 
in developing practice guidelines for individual treatment and 
for early intervention in major disorders. Detailed information 
on the center is included in the latest annual report, which 
has been distributed to members of this committee.
    I want to take this time today to acknowledge the important 
work of VA's National Center for PTSD. Strong support for this 
center is an important part of the effort to improve the VA 
mental health and improve treatments for our veterans.
    Mr. Chairman, once again, I appreciate your holding this 
hearing today. I hope that these efforts will highlight the 
areas in which important improvements must be made and 
underline the critical importance of doing so immediately.
    I apologize for not being able to stay for all the 
testimony, but I have another hearing I am in charge of that 
will take place shortly. Thank you very much, and thank you all 
for all you do.
    Chairman Rockefeller. Thank you, Senator Jeffords, very 
much.
    I also want to mention, before I introduce the panel, that 
Senator Specter wanted to be here, but he has an absolute 
conflict. He regrets it. He specifically asked me to apologize 
to our panels, because he wants to be here but cannot.
    Dr. Roswell, I have introduced you. You are accompanied by 
Dr. Larry Lehmann. Also testifying is Dr. Miklos Losonczy, who 
is the Co-Chair of the Committee on Care of Veterans with 
Serious Mental Illness. We welcome you and await your 
testimony.

STATEMENT OF HON. ROBERT H. ROSWELL, M.D., UNDER SECRETARY FOR 
HEALTH, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY LAURENT 
LEHMANN, M.D., CHIEF CONSULTANT, MENTAL HEALTH STRATEGIC HEALTH 
                           CARE GROUP

    Dr. Roswell. Thank you, Mr. Chairman. I appreciate your 
chairing the hearing today on VA's mental health programs. Our 
mental health clinical programs are designed to provide the 
highest quality, most cost-efficient care across a continuum of 
services designed to meet the complex and changing needs of our 
patients.
    Last year, in fiscal year 2001, 886,000 veterans received 
mental health care and over 700,000 of them were treated in 
specialized mental health programs. VA expended over $2.2 
billion on clinical care for these patients and an additional 
$375 million for psychotropic medications. VA has developed 
special emphasis programs designed to serve particular target 
populations, including veterans with serious mental illness, 
homeless veterans with mental illness, veterans suffering from 
post-traumatic stress disorder, and veterans with substance 
abuse problems.
    VA has committed itself to expanding state-of-the-art 
treatment of serious mental illness using an assertive 
community treatment model and now operates the largest network 
of such programs in the country. Our Mental Health Intensive 
Case Management Program, or MHICM program, is an assertive 
community treatment model, and as of April of this year, VA had 
65 active MHICM programs and several others in various stages 
of development.
    As I have already alluded, VA is committed to using state-
of-the-art medications, such as the new generation of atypical 
anti-psychotic medications, in treating seriously mentally ill 
veterans. Use of these medications results in improved clinical 
outcomes, a decreased incidence of side effects, increased 
compliance with the prescribed medication, improved 
functioning, and increased patient satisfaction, and no one 
supports their use more strongly than I do.
    VA operates the largest national network of homeless 
outreach programs. VA's homeless programs serve not only 
homeless veterans, but they play a role in destigmatizing 
mental illness in the homeless population. Last December, the 
President signed P.L. 107-95, the Homeless Veterans 
Comprehensive Assistance Act of 2001, and this law was designed 
to enhance and increase VA's ability to serve the homeless 
veterans. I am happy to say that we are well on our way in our 
efforts to implement the provisions of that law.
    Secretary Principi recently convened the first meeting of 
VA's Advisory Committee on Homelessness among veterans. The 
council will greatly assist VA in improving the effectiveness 
of our programs.
    VA operates 147 specialized programs for the treatment of 
PTSD. In fiscal year 2001, VA's specialized outpatient PTSD 
programs saw over 57,000 veterans, an increase of 8.6 percent 
over the previous year. Overall, inpatient PTSD care is 
declining, while the alternative, residential care, is 
increasing. This reflects our commitment to moving from costly 
inpatient programs to less costly but equally effective 
outpatient programs.
    In 2001, VA treated 125,000 veterans in specialized 
substance abuse treatment programs. The number of veterans 
receiving inpatient care for substance abuse is decreasing, as 
a part due to the shift to outpatient care. To accommodate for 
this shift, services are increasingly being developed on a 
residential and outpatient basis. In 2001, VA saw a 9.5 percent 
decrease in the number of veterans treated in its in-house 
specialized substance abuse programs, but at the same time, a 
number of networks instituted contracts for residential 
substance abuse treatment services. Consequently, VA has begun 
a process to determine where these veterans are now being 
treated and the adequacy of the treatment in residential 
settings.
    Section 8(a) of P.L. 107-95 requires VA health care 
facilities to develop and carry out plans to provide mental 
health services for substance abuse disorders and VA is fully 
prepared to implement those plans this year with quarterly 
monitoring.
    Our educational programs are significant. VA's educational 
programs involve traditional programs, and recently, VA 
developed an innovative psychiatry resident primary care 
education model to enhance the educational effort.
    Our research programs encompass both basic science as well 
as essential scientific findings. VA's Mental Illness Research, 
Education, and Clinical Centers, or MIRECC's, are excellent 
examples of the fusion of these three tasks. Currently, VA has 
eight MIRECC's located all across the country.
    Perhaps the most exciting aspect of VA's mental health 
programs as we look to the future is its National Mental Health 
Improvement Plan, which uses validated data collection, expert 
analysis, and active intervention by an oversight team to 
continuously improve the access, outcomes, and function of 
mental health patients.
    Mr. Chairman, our mental health system is strong and 
effective, but no system is perfect. Quality improvement 
activities, such as the National Mental Health Improvement 
Plan, symbolize VA's commitment to continuing improvement in 
the delivery of comprehensive, high-quality care. It is 
imperative that high-quality mental health services be 
available across the VA health care system and we are committed 
to that. Mr. Chairman, thank you.
    Chairman Rockefeller. Thank you, Dr. Roswell.
    [The prepared statement of Dr. Roswell follows:]
Prepared Statement of Hon. Robert H. Roswell, M.D., Under Secretary for 
                 Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee:
    The Department of Veterans Affairs (VA) provides mental health 
services for veterans across a continuum of care, from intensive 
inpatient mental health units for acutely ill persons to residential 
care settings, outpatient clinics, day hospital and day treatment 
programs, community-based outpatient clinics (CBOCs), and intensive 
community case management programs. VA views mental health as an 
essential component of overall health and offers comprehensive mental 
health services, including programs for substance abuse, as part of its 
basic benefits package.
    In FY 2001, VHA saw 4,153,719 patients for all health care 
services; 886,019 (21.3 percent) of these received mental health care. 
Of those who received mental health care, 712,045 veterans were treated 
in specialized mental health programs. The remaining 173,974 received 
mental health care in general medical care settings. Of the overall 
total number of patients receiving mental health care, 285,161 met 
criteria for inclusion in the Capacity Report, i.e., an inpatient 
admission or six or more outpatient visits.
    The 712,045 unique veterans treated in specialized mental health 
programs represent a 4.9 percent increase from the previous year, over 
four times the increase for the period from FY 1999 to FY 2000. Only 
10.1 percent of these patients required an inpatient stay, 
demonstrating VA's emphasis on providing care in the least restrictive, 
most accessible way that meets patients' needs, which includes 
enhancing our capability to provide mental health services in CBOCs. 
Over 85 percent of veterans who use VA mental health services are in 
Priority Groups 1-6, our ``core mission'' patients. The clinical care 
costs for specialized mental health services in FY 2001 were 
approximately $2,400,000,000. For FY 2002, it is estimated that VA will 
provide care in mental health programs to 729,400 unique patients at a 
cost of more than $2,484,000,000.
    The clinical care costs mentioned above cover major expenses such 
as staffing, but do not include the costs of psychotropic medications. 
Pharmacy costs for psychotropic medications in FY 2001 were 
$375,117,569, an increase from $304,696,503 in FY 2000. The figure for 
FY 2001 includes prescriptions for both patients who were treated in 
specialty mental health services and patients who received care from 
non-specialty providers such as primary care clinicians.
    This statement describes VA's mental health clinical services, 
education and research initiatives, program monitoring efforts, and 
special programs for homeless veterans.
                         clinical care services
    Treatment for mental illnesses in VA rests essentially on two main 
approaches, pharmacotherapy and psychosocial rehabilitation (including 
psychotherapy). It is our practice to provide the latest medications 
for mental disorders to veterans who need these drugs and to prescribe 
them in accordance with the best medical evidence. VA's formulary for 
psychotropic medications is one of the most open in organized health 
care. It includes virtually all of the newer atypical antipsychotic and 
anti-depressant drugs.
    In most cases, medications alone are not enough to bring patients 
with serious mental illnesses to their optimal level of functioning and 
well-being. The application of psychosocial rehabilitation techniques, 
designed to optimize patients' strengths and promote recovery, is 
essential. These interventions include patient and family education, 
cognitive behavioral therapy, working and living skills training, and 
intensive case management. Treatment is provided in both inpatient and 
outpatient settings and can include supervised living arrangements in 
the community.
    Assisting veterans to engage in meaningful and productive work 
activities is an important part of their therapeutic rehabilitation. 
VHA accomplishes this primarily through the Compensated Work Therapy 
(CWT) program and Compensated Work Therapy/Transitional Residence (CWT/
TR) program.
    In FY 2001, 22,053 veterans had contact with the CWT program and 
13,700 worked through the program. There currently are more than 105 
individual CWT operations connected to VA medical centers nationwide. 
Through CWT programs with companies and government agencies, veterans 
earned $33.4 million.
    The CWT/TR program includes 34 sites at 26 currently operational 
programs with 55 residences and 433 operational beds in FY 2001. Nine 
program sites with 17 residences are designated to exclusively serve 
homeless veterans. The average length of stay is approximately six 
months. Increased competitive therapeutic work opportunities are 
occurring each year. At discharge from the CWT/TR program, 41 percent 
of the veterans were placed in competitive employment and four percent 
were in training programs.
    Additionally, VHA offers a vocationally oriented program, the 
Incentive Therapy (IT) program. Veterans working in IT provide direct 
services to VA Medical Centers, for which they receive remuneration. 
Such work is done usually in preparation for transfer to CWT, or direct 
job placement. In FY 2001, 8,806 veterans were served by IT. Some 
stations sponsor Incentive Therapy On the Job Training programs (IT/
OJT) in which veterans learn vocational skills while providing services 
to the host Medical Center. The IT program operates at over 80 Medical 
Centers.
    VA's clinical services are increasingly being structured to 
accommodate mental health participation in medical and geriatric 
primary care teams and medical capabilities in mental health primary 
care teams. Best practice models have been identified in the field 
based on criteria that included patient clinical improvement, 
prevention, screening activities, and patient satisfaction. We have 
data showing that when medical primary care services are integrated 
with mental health care, clinical outcomes, as measured by standard VA 
indicators (e.g., Preventive Disease and Chronic Disease Indices), are 
improved, as is patient satisfaction.
    Section 8(a) of Public Law 107-95 requires that each VA primary 
care health care facility develop and carry out a plan to provide 
mental health services, either through referral or direct provision of 
services. Section 8(c) also requires that each VA medical center 
develop and carry out a plan to provide treatment for substance use 
disorders, either through referral or direct provision of services. 
Treatment for substance abuse disorders is to include opioid 
substitution therapy, where appropriate. In the first two quarters of 
FY 2002, all VISNs prepared plans to implement this section of the law. 
VHA HQ has approved all plans and is monitoring their implementation 
quarterly.
    Innovative uses of technology such as tele-mental health are also 
being implemented to enhance mental health services to distant sites 
(e.g., CBOCs) and provide psychiatry support to Veterans Outreach 
Centers. In addition there are 10 tele-mental health demonstration 
projects either operational or in development. By disseminating 
information about best practices across the system, program development 
is encouraged, and higher quality, more cost-efficient care will be 
delivered to VA patients.
                mental health special emphasis programs
    VA has identified several particular target populations and has 
developed special emphasis programs designed to serve those 
populations. They include veterans with serious mental illness (e.g., 
those suffering from schizophrenia and other psychoses); homeless 
veterans with mental illness; veterans suffering from Post-traumatic 
Stress Disorder (PTSD); and those with substance abuse disorders. A 
significant percentage of all veterans receiving mental health services 
are seen in the following special emphasis programs.
Serious Mental Illness
    Since 1996, the number of veterans seen with serious mental illness 
has increased by six percent while the cost has increased by four 
percent, reflecting decreased hospital days of care counterbalanced by 
increased spending on outpatient care. The average length of stay for 
general inpatient psychiatry decreased from 29.9 to 17.0 days 
nationally, and the average number of days of hospitalization within 
six months after discharge (reflecting readmissions) dropped from 12.4 
to 6.7. The percent of discharged general psychiatry patients receiving 
outpatient care within 30 days of their discharge has increased from 50 
percent in FY 1996 to 59 percent in FY 2001. These indicators suggest 
more effective hospital treatment and aftercare, including intensive 
case management services. A 17 percent decrease in the number of 
general psychiatric patients hospitalized in FY 2001 compared to FY 
1996 was accompanied by a 29 percent increase in general psychiatric 
patients receiving specialized mental health outpatient care, resulting 
in a net 28 percent increase in individual veterans treated in 
specialty mental health. These data suggest an effective move from 
inpatient to community-based mental health treatment nationwide.
    VA has committed itself to expanding state-of-the-art treatments of 
serious mental illness, using the Assertive Community Treatment (ACT) 
model. VA now operates one of the largest networks of such programs in 
the country, the Mental Health Intensive Case Management (MHICM) 
program. As of April 2002, VA had 65 active MHICM programs with another 
10-12 in various stages of development, a 33 percent increase in this 
fiscal year alone. VISN plans for expansion of MHICM teams are reviewed 
quarterly.
    Another aspect of VA's care for veterans with seriously mental 
illness is our commitment to using state-of-the-art medications, which 
result in improved clinical outcomes, decreased incidence of side 
effects, and increased compliance with prescribed medications. Patient 
functioning and patient satisfaction are increased. In FY 2001, of the 
78,210 veterans with a diagnosis of schizophrenia who received 
antipsychotic medications, 72 percent received the new generation of 
atypical antipsychotic medications, such as olanzapine, clozapine, 
risperidone, quetiapine, or ziprasidone.
Homeless Veterans
    VA operates the largest national network of homeless outreach 
programs. VA expects to spend $144 million on specialized programs for 
homeless veterans this year. In FY 2001, VA initiated outreach contact 
with 44,845 veterans. VA's Health Care for Homeless Veterans (HCHV) 
program incorporates:
     outreach to serve veterans with serious mental illness who 
are not currently patients at VA health care facilities;
     linkage with services such as VA mental health and medical 
care programs, contracted residential treatment in community-based 
halfway houses, and supported housing arrangements in transitional or 
permanent apartments; and
     treatment and rehabilitation provided directly by program 
staff.
    These activities serve not only to help homeless veterans; they 
play a role in de-stigmatizing mental illness in the homeless 
population.
    Secretary Principi recently convened the first meeting of VA's 
Advisory Council on Homelessness Among Veterans. The Council's mission 
is to provide advice and make recommendations on the nature and scope 
of programs and services within VA. This Council will greatly assist VA 
in improving the effectiveness of our programs and will allow a strong 
voice to be heard within the Department from those who work closely 
with us in providing service to these veterans.
Post-Traumatic Stress Disorder
    VA operates an internationally recognized network of 147 
specialized programs for the treatment of PTSD through its medical 
centers and clinics. This figure includes new specialized programs 
funded by the Veterans Millennium Health Care and Benefits Act that are 
operational and seeing new patients. In FY 2001, VA Specialized 
Outpatient PTSD Programs (SOPPs) saw 57,783 veterans, an increase of 
8.6 percent over the previous year. Of these, the number of new 
veterans seen was 23,082. For SOPPs, continuity of care, measured as 
number of visits across 2-month intervals (a marker for quality of 
care), was maintained between FY 2000 and 2001.
    Specialized Inpatient and Residential PTSD Programs had 5,012 
admissions in FY 2001. Overall inpatient PTSD care is declining while 
the alternative, residential care, is increasing. Outcomes for 
outpatient PTSD treatment (e.g., continuity of care) and for 
Specialized Inpatient PTSD Programs (e.g., PTSD symptoms at four months 
post discharge) were maintained or improved in FY 2001 over FY 2000.
    These specialized Mental Health PTSD programs act in collaboration 
with VA's 206 Vets Centers, which are community-based operations 
staffed by a corps of mental health professionals, most of whom have 
seen active military service, including combat.
Substance Abuse
    In FY 2001, 429,032 VA patients had a substance use disorder 
diagnosis. Of these, 125,660 were seen in specialized substance abuse 
treatment programs. Most of the rest of these veterans were seen in 
non-substance abuse mental health care settings or received non-mental 
health services. The number of veterans receiving inpatient care for 
substance use disorders is decreasing, as part of the shift to 
outpatient care. Studies show that for many patients residential and 
outpatient substance abuse treatment can be as effective as inpatient 
services. To accommodate this shift, services are increasingly being 
developed on a residential and outpatient basis. From FY 2000 to 2001, 
VA saw a 9.5 percent decrease in the number of veterans treated in its 
in-house specialized substance abuse programs. At the same time, a 
number of networks instituted contracts for residential substance abuse 
treatment services. Consequently, VA has begun a process to determine 
where these veterans are now being treated and the adequacy of that 
treatment. As of January 2002, in the 31 new Substance Abuse programs 
established to implement the requirements of Sec. 116 of Public Law 
106-117, 1500 additional patients had been seen. VHA is also reviewing 
its capacity to provide opiate substitution services and the need to 
expand these services.
                          maintaining capacity
    Under 38 U.S.C. Sec. 1706(b), VA is required to maintain its 
capacity to meet the specialized treatment and rehabilitative needs of 
certain disabled veterans whose needs can be uniquely met by VA. Mental 
health encompasses four of the designated populations, veterans with 
severe, chronic mental illness, veterans suffering from post-traumatic 
stress disorder (PTSD), homeless veterans with mental illness, and 
veterans with substance abuse disorders.
    From FY 1996 to FY 2001, VA has maintained or increased capacity to 
treat veterans in both the SMI and PTSD categories in terms of patients 
served. Although overall capacity has increased, there has been a 
decrease in the number of veterans with substance abuse who meet SMI 
criteria and were served in specialized programs by the system as a 
whole, from 105,898 in FY 1996 to 89,963 in FY 2001. The Networks 
completed an initial review of variation in April 2002, the results of 
which are being analyzed. Based on this ongoing analysis, VHA will 
identify areas for improvement. Several performance monitors are in 
place to ensure our ability to maintain capacity to treat specialized 
mental health disorders.
                           program monitoring
    To track its progress and enhance its performance in mental health 
services, VA has one of the most sophisticated mental health 
performance monitoring systems in the nation. To monitor the care 
provided in mental health programs to over 700,000 veterans per year, 
VA uses measures of performance, quality, satisfaction, cost, and 
outcomes (e.g. PTSD symptoms; homeless veterans who are domiciled). The 
results published annually in VA's National Mental Health Performance 
Monitoring System report indicate that quality of care, as indicated by 
performance monitors associated with quality and patient satisfaction, 
is essentially being maintained or is improving. Lengths of inpatient 
stay (LOS) have increased slightly from 16.6 days in FY 2000 to 17.0 in 
2001, but there has been an overall 39 percent decrease in LOS since FY 
1995. Readmission rates and days hospitalized after discharge decreased 
slightly from FY 2000 to FY 2001. There have been slight decreases in 
measures of outpatient care in the past year, mostly by less than four 
percent. However, the number of outpatient visits is down by 8.5 
percent, from 17.2 to 15.7 average visits per year for general 
psychiatry patients.
    The Seriously Mentally Ill Treatment Research and Evaluation Center 
(SMITREC) created a Psychosis Registry, a listing of all veterans 
hospitalized for a psychotic disorder since 1988. This registry tracks 
the health care utilization of these veterans over time. Over 70 
percent of these veterans are still in VA care. The percentage of 
patients with long inpatient stays (over 100 days) is decreasing while 
the number of patients receiving atypical antipsychotic medications has 
increased. SMITREC is studying aspects of patients' adherence to 
treatment regimens, a key element in maintaining patients in the 
community with optimal good health.
    To support its mental health programs and to ensure acquisition of 
the most current knowledge and dissemination of best practices, VA has 
undertaken a number of activities. These include development of 
practice guidelines, educational programs, and partnering with other 
organizations involved in mental health services.
    VHA has also published up-to-date, evidence-based practice 
guidelines for major depressive disorders, psychoses, PTSD, and 
substance use disorders. The International Society for Traumatic Stress 
Studies used VA's initial PTSD guidelines as a start for their 
guideline development. Earlier this month, work started on a new stand-
alone VA/DOD PTSD Clinical Practice Guideline. The Major Depression 
guidelines, revised in collaboration with the Department of Defense 
(DOD), were published in FY 2001. A new ``stand-alone'' Substance Abuse 
guideline created with DOD has been published, and the revised 
Psychoses Guidelines are currently in review. Automated clinical 
reminders are in development to assist clinicians in following the 
practice guidelines and document and track compliance.
    Last year, MHSHG inaugurated a new quality improvement program - 
the National Mental Health Improvement Program (NMHIP). NMHIP uses 
validated data collection, expert analysis, and active intervention by 
an oversight team to continuously improve the access, outcomes, and 
function of patients in need of our mental health programs. The program 
draws upon existing MHSHG resources such as the Northeast Program 
Evaluation Center (NEPEC), and the Mental Illness Research, Education 
and Clinical Centers (MIRECCs), as well as resources in VHA's Health 
Services Research and Development Service, including existing 
initiatives in the Quality Enhancement Research Initiative (QUERI), and 
the Office of Quality and Performance. Currently NMHIP is reviewing 
general assessment measures for patients with mental disorders, 
focusing on the Global Assessment of Functioning Scale (GAF) and the 
SF-36 functional status survey instrument. NMHIP is also beginning to 
look at diagnosis-specific assessment tools starting with those for 
schizophrenia.
                               education
    VA has been a leader in the training of health care professionals 
since the end of World War II. More than 1,300 trainees in psychiatry, 
psychology, social work, and nursing receive all or part of their 
clinical education in VA mental health programs each year. Recently, VA 
has developed an innovative Psychiatry Resident Primary Care Education 
program with involvement of over thirty facilities and their 
affiliates, representing approximately 11 percent of VA's more than 700 
psychiatry residents who receive training in VA facilities each year. 
In addition, 100 psychology and psychiatry trainees are involved in the 
highly successful Primary Care Education (PRIME) initiative, which 
provides mental health training within a primary care setting. This 
type of activity is changing how VA is training mental health providers 
and preparing them to meet the primary care needs of mentally ill 
patients. It serves and improves the mental health of veterans seen in 
medical and geriatric primary care in both VA and the nation.
    In addition, VHA's Office of Academic Affiliations, in 
collaboration with the Mental Health Strategic Health Care Group and 
the Committee on Care of Seriously, Chronically Mentally Ill Veterans, 
has recently introduced a new interdisciplinary fellowship program in 
Psychosocial Rehabilitation. This program will train fellows from 
Psychiatry, Psychology, Social Work, Mental Health Nursing, and 
Rehabilitation in the latest state of the art approaches to treating 
and reintegrating those with serious mental illnesses into the 
community.
    VA's educational efforts involve both traditional programs and 
innovative distance learning techniques. Face-to-face workshops serve a 
useful purpose for certain kinds of demonstrations (e.g., Prevention 
and Management of Disturbed Behavior Training) and for networking. 
Distance learning such as satellite broadcasts, Internet training, and 
teleconferencing, offers accessible, cost-effective training.
                                research
    VA's National Center for PTSD, established in 1989, is a leader in 
research on PTSD. Its work spans the neurobiological, psychological and 
physiological aspects of this disorder. Women's sexual trauma and 
mental health aspects of disaster management are also addressed by the 
National Center, which has become an international resource on 
psychological trauma issues.
    VA's Mental Illness Research, Education and Clinical Centers 
(MIRECCs), which began in October 1997, bring together research, 
education, and clinical care to provide advanced scientific knowledge 
on evaluation and treatment of mental illness. The MIRECCs demonstrate 
that the coordination of research with training health care 
professionals in an environment that provides care and values results 
in improved models of clinical services for individuals suffering from 
mental illness. Furthermore, they generate new knowledge about the 
causes and treatments of mental disorders. All of the MIRECCs have 
active projects that are of direct benefit to veterans. In order to 
help create a new generation of mental health scientists, the MIRECCs, 
with the support of the Office of Academic Affiliations, have 
established Special Mental Health Fellowships to train young 
psychiatrists and psychologists for research careers. Their 
videoconference curriculum is accessible by non-MIRECC VA trainees as 
well. VA currently has eight MIRECCs located across the country, from 
New England to Southern California.
    Mental health currently has two projects in the VHA Quality 
Enhancement Research Institutions (QUERI) program. These include the 
Substance Abuse QUERI project, associated with the Program Evaluation 
Resource Center (PERC), and the Mental Health QUERI project. The Mental 
Health QUERI actually has two sets of activities: the Major Depression 
QUERI associated with the VISN 16 MIRECC, and the Schizophrenia QUERI 
associated with the VISN 22 MIRECC. The goal of QUERI is to promote the 
translation of research findings into practice and observe their impact 
on quality of care.
    VHA has established an interagency Memorandum of Agreement (MOA) 
with the Substance Abuse and Mental Health Services Administration 
(SAMHSA) and Bureau of Primary Health Care (BPHC) of the Health 
Resources and Services Administration (HRSA). This MOA will support a 
cross-cutting initiative to determine if there are statistically 
significant differences over a full range of access, clinical, 
functional, and cost variables between primary care clinics that refer 
elderly patients to specialty mental health or substance abuse services 
(MH/SA) outside the primary care setting and those that provide such 
services in a integrated fashion within the primary care setting. It 
will also address improving the knowledge base of primary health care 
providers to recognize MH/SA problems in older adults.
    VA is also a partner with the National Institutes of Mental Health 
and the DOD in the National Collaborative Study of Early Psychosis and 
Suicide (NCSEPs). This ongoing project is designed to better understand 
the clinical and administrative issues of service members who suffer 
from psychotic disorders during military service, their course of care, 
and the transition from DOD to VA care in such a manner that continuity 
of care is maintained.
    In FY 2001, VA Research Service funded 379 mental health projects 
at a cost of $53,756,149. VA investigators also were awarded 
$131,600,314 from other sources that funded an additional 1,189 mental 
health projects.
                               conclusion
    VA Mental Health programs provide a comprehensive array of 
clinical, educational and research activities to serve America's 
veterans. Our clinical programs are designed to provide the highest 
quality, most cost-efficient care, across a continuum of care designed 
to meet the complex and changing needs of our patients. Our educational 
programs train a significant proportion of our nation's future mental 
health care providers and ensure that our employees remain on the 
cutting edge of knowledge about the best clinical practices using 
traditional as well as innovative educational approaches. Our mental 
health research programs encompass both basic science as well as the 
essential translation of scientific findings into clinical practice. 
The Mental Illness Research Education and Clinical Centers (MIRECCs) 
are excellent examples of the creative fusion of all three of these 
tasks.
    Mr. Chairman, our mental health care system is strong and 
effective, but no system is perfect. Quality improvement activities 
such as NHMIP and QUERI symbolize VA's ongoing commitment to continuing 
improvement in the delivery of comprehensive, high quality clinical 
services to those veterans who need our care. It is imperative that 
high quality mental health services be available across the VA health 
care system. We are continuing our efforts to assure availability of 
appropriate services and the implementation of evidence-based practices 
in real world clinical settings.
    Mr. Chairman, I will now be happy to answer any questions that you 
or other members of the committee may have.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
                       to Robert H. Roswell, M.D.
    Question 1. VA is embarking on an expedited effort to restructure 
and realign how VA delivers services--the CARES effort. How will the 
CARES process take into account the needs of the seriously mentally 
ill, now and in the future?
    Answer. The CARES process is dedicated to providing a framework for 
identifying and addressing the needs of veterans in the future through 
the development of market-specific planning initiatives for the next 20 
years. The needs of veterans who are users of VA mental health care, 
especially those with serious mental illness, are incorporated and 
considered in the planning model at several levels. First, veterans 
with mental disorders are being considered in the enrollment pool of 
veterans as projected into the future. Many veterans use VA mental 
health services because non-VA mental health resources, especially 
public mental health resources, may be lacking in their communities. 
This can be particularly true for conditions where VA has unique 
expertise such as war zone related PTSD or co-morbidity of substance 
abuse disorders with other mental disorders. Second, since these 
veterans, especially those with Serious Mental Illness (SMI) tend to 
rely heavily on the VA for all of their health care needs; this 
reliance is factored into the model in predicting utilization. Third, 
the current inpatient and outpatient utilization of veterans with 
serious mental disorders is being used to predict future needs for 
services. Also, the projections of future needs are adjusted, using 
diagnosis-based methods, to reflect the fact that veterans tend to have 
greater episodes of illness than private sector health care users. 
Finally, the basic planning categories for the CARES process include 
both inpatient and outpatient treatment provided by multidisciplinary 
teams including psychiatrists, psychologists, and other mental health 
providers. Moreover, prior to approval, the draft CARES plan will be 
reviewed by a group of clinical experts in health care, including 
mental health clinicians, and by the CARES Commission, to ensure that 
the criteria of health care needs and quality of care are met.
    Question 2. As discussed in the hearing, please develop, together 
with the Committee on Care of Veterans with Serious Mental Illness, a 
budget estimate of the costs to fully fund on a national level a 
complete comprehensive continuum of care for veterans with serious 
mental illness, including PTSD and Substance Abuse Disorder. This 
continuum of care, as discussed at the hearing, should specifically 
include elements that would provide all aspects needed for optimal 
rehabilitation for these veterans. This should include those programs 
needed to fully address work restoration, supported housing, family 
supports, access to Community Based Outpatient Clinics where feasible, 
and Mental Health Intensive Case Management (MHICM) programs for all 
veterans needing these services. This estimate should also take into 
account the geographic challenges to serving the SMI population, and 
where it would not be reasonable to have a full MHICM team, a 
comparable program with similar intensity of treatment and 
rehabilitation should be estimated. In addition, this continuum of care 
should also include complete substance use disorder treatment, 
including opioid substitution treatment where necessary. Such estimates 
should be provided by VISN and program type. We understand that these 
are estimates only to give us insight into the approximate funding that 
would be needed for full implementation of addressing the unmet needs 
of these disabled veterans. For the purposes of this estimate, please 
use the SMI population defined in the FY2001 capacity report, as your 
current drafts may indicate. Please provide a response to this 
Committee no later than November 1, 2002.
    Answer. The President's FY 2004 Budget will be the Administration's 
plan to support the medical care needs of all veterans, including their 
mental health requirements. This budget will be submitted to the 
Congress the first week of February 2003. While final decisions of the 
FY 04 budget are still to be made, we will work closely with OMB to 
assure that this budget will be adequate to deliver the defined benefit 
package of health care to all enrolled veterans, especially those that 
are service connected, medically indigent, and those with special 
needs. I understand and share your particular interest in mental 
health. It is my responsibility as Under Secretary for Health to insure 
the capability of the Veterans Health Care program to provide a 
balanced and complete comprehensive range of services to all enrolled 
veterans.
    The Mental Health Strategic Health Care Group (MHSHG) is continuing 
to work closely with the SMI Committee to respond to your question. The 
group has been working since August to provide an analysis of potential 
gaps in services, best practices and programs, and their respective 
costs. As you can imagine, this is a very complex process. The MHSHG 
has now received the SMI Committee's recommendations and those are 
currently under review. VHA is engaging the services of an external 
contracting group with experience in healthcare management modeling to 
verify VHA's analyses of the mental health population's service 
requirements as described in their report. Completion of the review is 
expected early next year.
    We will, of course, need to reconcile these plans with the final 
budget approved by Congress and the Administration. We would anticipate 
that our final response will be available February 2003.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Arlen Specter to Robert 
                            H. Roswell, M.D.
    Question 1a. I am advised that--as is the case with respect to 
other forms of VA health care--treatment of mentally ill veterans has 
shifted from a predominately inpatient to a predominately outpatient 
setting. I am told that in Pennsylvania, for example, inpatient 
psychiatric beds have been reduced by over 60%--from 884 (in 1996) to 
334 (in 2002). Is this correct?
    Answer. VISN 4 facilities have decreased psychiatry beds from 884 
in FY 1996 to 344 in FY 2001 for a decrease of 61 percent. Within 
Pennsylvania, the decrease was from 616 beds to 252 beds (a 59 percent 
decline). Alternatives to inpatient psychiatry beds have produced an 
increase in domiciliary beds for homeless veterans (up 69.6 percent 
from 115 to 195 beds), all of which are in Pennsylvania. Homeless Grant 
and Per Diem beds, Community Residential Care beds on medical center 
grounds and Health Care for the Mentally Ill (HCMI) beds have increased 
from 0 such beds in FY 1996 to 258 in FY 2002, all of which are in 
Pennsylvania. Specific efforts have been made to develop these 
alternative levels of care, some of which are community-based, others 
of which remain on medical center grounds. VISN 4 plans to conduct a 
needs assessment for acute psychiatry beds, as will as evaluate the 
need for additional residential and/or general domiciliary beds. The 
cost for establishing a geropsychiatry brief evaluation and treatment 
unit will also be evaluated.
    Question 1b. To what do you attribute this drop in the overall 
number of inpatient psychiatric beds? Do fewer veterans need mental 
health services from VA? Or are you treating a more-or-less constant 
need in different settings?
    Answer. For the most part, the 67 percent decrease in the average 
daily census of VA psychiatric hospital bed sections since 1983 has 
paralleled or, at times, lagged behind the trends in both private and 
non-VA public sector mental health care. The roots of this shift go as 
far back as the Community Mental Health legislation of the mid-1950s, 
when the concept that patients with a mental illness were best managed 
in isolated asylums was challenged by evidence that, with new 
antipsychotic medications, patients who had been hospitalized for 
decades could now recover sufficiently to go home. Long-term studies of 
patients with schizophrenia in the 1980s revealed that many patients 
recover with time and most improve to the extent that they can engage 
again in their life's progression. As the psychotropic medications have 
progressively improved over the years, the need for long-term 
hospitalization has progressively diminished.
    This is particularly true with the recent advent of newer 
antipsychotic medications with less severe side effects. These 
medications also permitted patients to engage in progressively more 
sophisticated psychosocial approaches in the community, including 
assertive community treatments, work programs with supported 
employment, and newer rehabilitation concepts that promote self care 
and improved self-esteem.
    Currently, the empirical literature supports treating those with 
serious mental illnesses in the least restrictive environment with the 
full spectrum of community oriented psychosocial rehabilitation 
treatments, including psychotropic medications. This is designed to 
assist those with serious mental illness to achieve the maximum 
functional recovery so that they can attain the highest level of 
functioning possible. VA's outpatient and residential psychosocial 
rehabilitation programs are designed to do this, and treatment in an 
inpatient setting is used sparingly and only when needed.
    Thus, clearly, fewer veterans need inpatient services from VA. 
However, while the number of veterans requiring at least some hospital 
care dropped 60 percent (from 180,408 in 1996 to 72,252 in 2001), the 
number of veterans needing mental health services from VA has increased 
22 percent, from 581,624 in 1996 to 712,045 in 2001, primarily in the 
outpatient arena.
    Question 1c. Has a reduction in the number of psychiatric care beds 
resulted from a decrease in the need for inpatient services? Or has the 
reduction in the number of patients being treated in an inpatient 
setting been driven by budget-driven bed closures?
    Answer. It is clear that the need for psychiatric beds has been 
drastically reduced. Both the VHA-wide shift from a hospital-based 
system to one providing access through primary care-based outpatient 
clinics, and budgetary, compromises have probably played a role in 
individual instances. However, anecdotal responses from VA facilities 
suggest that a decreased demand for beds is the primary factor. New 
therapeutic modalities, including medications and psychosocial 
interventions, have resulted in more patients being successfully 
treated in an outpatient setting, reserving the inpatient setting for 
those patients who truly need acute episodes of care.
    Question 1d. Where are the patients who used to get inpatient care 
in Pennsylvania now getting care? Can you demonstrate to me that the 
care they are getting now is better care?
    Answer. There has been an increase in the total number of patients 
receiving care within Pennsylvania and VISN 4. Workload data for VISN 4 
(ARC, 4/29/02) revealed a 3.7 percent increase in the total number of 
seriously mentally ill (SMI) patients treated in IFY 2001 when compared 
to IFY 1996. Within Pennsylvania, during this same time period, total 
SMI patients increased by 1.8 percent. These increases were most 
evident in the treatment of homelessness and PTSD. Inpatient and 
outpatient substance abuse treatment did show a decline of 19.2 percent 
(from 7,140 patients treated in FY 1996 to 5,767 in FY 2001). Within 
Pennsylvania, the decrease was 22 percent (from 6,490 to 5,064 patients 
treated). The Northeast Program Evaluation Center (NEPEC) located in 
West Haven, Connecticut, reports that, from FY 1996 to FY 2001, the 
number of unique veterans receiving mental health outpatient services 
in VISN 4 increased by 16.7 percent (from 31,365 to 36,590). Patients 
who were once treated on an inpatient psychiatric unit are now 
receiving services in outpatient settings. Many of these patients are 
now residing in VA-approved Community Residential Care (CRC) programs, 
one example of which is the 52-bed CRC program located on the grounds 
of VAMC Coatesville.
    A number of VACO-approved and VISN planned enhancements will be 
implemented in FY 2003 to address deficiencies and enhance other 
services to the SMI veteran. In the area of substance abuse, opioid 
replacement services will be enhanced at Pittsburgh and Philadelphia 
VAMC's, and outpatient services will be expanded at five medical 
centers where the decline in substance abuse treatment services was 
most in evidence (Butler, Coatesville, Lebanon, Pittsburgh and Wilkes-
Barre). PTSD treatment services were expanded in FY 2001 and FY 2002 at 
four medical centers (Erie, Philadelphia, Pittsburgh and Wilkes-Barre). 
In FY 2003, mental health services will be made available at all VISN 4 
CBOCs with greater than 100 unique veterans served. There are also 
planned expansions of outpatient services to the seriously mentally ill 
veteran through enhancement of existing Mental Health Intensive Case 
Management (MHICM) services at Coatesville and Pittsburgh, and 
establishment of new MHICM teams at Clarksburg, Lebanon, Philadelphia 
and Wilkes-Barre VAMC's. NEPEC has documented that the incorporation of 
MHICM teams has produced significantly positive outcomes as related to 
the care and treatment of the SMI patient. This outpatient model, in 
conjunction with adequate supportive housing, has been proven to have 
greater outcome potential than a traditional inpatient psychiatric unit 
alone. VISN 4 is actively following this model of care through current 
and planned initiatives as noted.
    Question 2. In Pennsylvania, the Coatesville VA Medical Center 
provides care to a significant number of geriatric patients who suffer 
with mental illness. In particular, the Coatesville VA operates an 
extensive Alzheimer's care program. Do you believe that some 
diagnoses--such as those treated in Coatesville's Alzheimer's program--
still require inpatient services? Are there not some veterans--those 
with Alzheimer's or other diagnoses--who must be treated in an 
inpatient setting?
    Answer. In general, patients who have Alzheimer's dementia, a 
slowly progressive disorder, go through a series of phases that can 
last from months to years. A comprehensive system of dementia care 
includes a full continuum of services, including in-home, community-
based, and institutional-based acute and extended care services, as 
well as support for family caregivers. Depending on the veteran's 
needs, VA services may include home-based primary care, homemaker/home 
health aide, respite, adult day health care, outpatient clinic, 
inpatient hospital, or nursing home care.
    Care needs at a given stage, as well as over the course of the 
disorder, are highly individualized and influenced by a variety of 
factors including the presence of co-morbid illnesses, presence of 
family or other caregivers, and the psychological, emotional, and 
social resources of both the person with dementia and his or her 
caregivers. With appropriate training and supportive services, some 
families desire and are able to care for the veteran with dementia at 
home virtually throughout the course of the disorder. For example, with 
training in behavior management and environmental safety issues, 
families may be able to manage difficult behaviors (e.g., wandering, 
aggressiveness, resistance to care) at home. With training and in-home 
services, families may be able to provide palliative care for persons 
with advanced dementia who prefer to die at home. In some cases, 
individuals with dementia may require short-term inpatient 
hospitalizations in order to stabilize behavior or manage co-morbid 
illnesses, with eventual return to the home setting. In other cases, 
families may be unable or unavailable to continue care at home at some 
point in the course of the disorder, and a longer-term institutional 
inpatient setting may be needed.
    VA continues to seek ways to improve systems of care for veterans 
with dementia. Two major activities in this area include the Chronic 
Care Networks for Alzheimer's Disease (CCN/AD) initiative, co-sponsored 
by the National Chronic Care Consortium and the Alzheimer's 
Association; and the VA Advances in Home-Based Primary Care for End of 
Life in Advancing Dementia (AHEAD) rapid-cycle quality improvement 
project.
    The bottom line is that there is no ``one size fits all'' approach, 
and more can be done in the home and community with appropriate 
training and support if that is what the patient and or their family 
wants. Inpatient settings are one important part of the full continuum 
of dementia care, but not all patients or families will want or need 
that level of care.
    Question 3a. The Veterans' Health Care Eligibility Reform Act of 
1996, Public Law 104-262, requires that VA maintain, at 1996 levels, 
its ``capacity'' to provide care to veterans in need of specialized 
services such as mental health services. I am advised that, since 1996, 
VA has reduced its average daily census of mental health inpatients 
from 12,500 to 3,800. Does VA believe that it is in compliance with the 
requirements of the Public Law 104-262? Is VA maintaining its 
``capacity'' to treat mentally ill veterans? Please explain.
    Answer. During the years immediately following 1996, VA lost some 
of its capacity to treat veterans with serious mental illness but we 
have worked hard in subsequent years to restore that capability. Data 
collection and analysis have been completed for the 2001 ``Capacity 
Report,'' and the data indicate that for 2001, VHA has returned to its 
1996 level of capacity to treat veterans with serious mental illnesses. 
In the area of substance abuse treatment however, we have not 
maintained this capability, and we are working to correct this 
deficiency.
    Question 3b. In your view, does this statutory mandate compel VA to 
maintain a historical number of inpatient treatment beds? Or does it 
require that VA maintain the capability to provide treatment to 
historical numbers of patients--at whatever level of care is affordable 
or appropriate?
    Answer. Public Law 104-262 did not define what was meant by the 
maintenance of capacity. Determining a definition was left to VA, and 
VA determined that capacity to treat veterans should be measured by the 
number of veterans treated each year in each of the special disability 
populations, and by the amount of money spent for that treatment. With 
the passage of Public Law 107-135, the Department of Veterans Affairs 
Health Care Programs Enhancement Act of 2001, the requirements for 
measuring capacity have become more focused and specific. However, with 
the exception of measuring capacity for substance abuse disorders, the 
statute does not require VA to maintain a certain number of inpatient 
beds, and we believe this is appropriate. The empirical literature 
supports treating those with serious mental illnesses in the least 
restrictive environment with the full spectrum of community-oriented 
psychosocial rehabilitation treatments, including psychotropic 
medications. This is designed to assist those with serious mental 
illness to achieve the maximum functional recovery and attain the 
highest level of functioning possible. VA's outpatient and residential 
psychosocial rehabilitation programs are designed to do this; treatment 
in an inpatient setting is used sparingly and only when needed.
    Question 4a. During routine oversight visits, the Committee's staff 
has been told by VA clinicians that outpatient-based treatment for 
psychiatric care requires much greater VA ``community coordination'' to 
assure success. Is this so? If so, please explain for the record the 
sort of ``community coordination'' VA must undertake to achieve greater 
success.
    Answer. Community coordination can mean working cooperatively with 
community agencies, families, and caregivers for planning and 
developing new programs as well as coordinating treatment and 
rehabilitation plans for individual veterans living in the community. 
Both are needed.
    One of the best examples of coordinating services with the 
community involves VA's Community Homelessness Assessment Local 
Education and Networking Groups (CHALENG) for Veterans. As required by 
law, all VA medical centers and Regional Offices meet with 
representatives from other Federal Agencies, state and local 
governments, and non-profit organizations to assess the unmet needs of 
homeless veterans and develop action plans to meet those needs. For the 
last two years, 100 percent of VA medical centers have coordinated 
local CHALENG meetings. The FY 2001 CHALENG Report indicated that, 
across the nation, over 3,300 people participated in the CHALENG 
process. Approximately 16 percent of the participants were VA staff and 
84 percent were participants from the community, including homeless 
veterans. The CHALENG process allows for a coordinated approach to 
determining the best methods for delivering those services.
    In addition, VA's support of community-based residential programs 
through funding under the Grant and Per Diem Program fosters 
coordination and collaboration between VA and the community. An 
important aspect of this collaboration involves VA clinicians who 
conduct outreach to homeless veterans and provide case management 
services for veterans in community residential programs. Their constant 
presence in the community encourages coordination of care.
    Community coordination for individual patients is best seen in 
VHA's mental health intensive case management (MHICM) program, in which 
individual counselors coordinate with family and community agencies to 
provide intensive day-by-day assistance in community living to recently 
discharged veterans with a severe and persistent mental illness.
    Care coordination by mental health nurses and social workers for 
elderly veterans discharged from medical wards with co-morbid 
depression and anxiety was recently evaluated in a nine-site, six-year 
demonstration project called UPBEAT (Unified Psychogeriatric 
Biopsychosocial Evaluation and Treatment). One of the major roles of 
the care coordinators was to work with the veterans and their families 
in coordinating appointments with VA and community agencies as well as 
transportation to and from the appointments. The coordination and 
resource linkage services provided by the UPBEAT team varied broadly, 
ranging from provision of home-care services to procurement of legal 
and financial counseling. Care focused on optimizing outpatient 
interventions such as referral to community resources, outpatient 
clinic visits, focused group therapy, and home visits by UPBEAT staff.
    Question 4b. What community-based resources or services does VA 
need to tap to assure success in an outpatient-based care setting? 
Please give me examples.
    Answer. Community partnerships can enhance the services that VA 
provides to veterans receiving mental health services. VA staff 
regularly make referrals to community agencies for veterans in need of 
transitional housing, permanent housing, transportation, legal 
services, food stamps, and employment. We work with other federal 
agencies to ensure that veterans who qualify can access services and 
benefits from the Social Security Administration, Department of Housing 
and Urban Development, Department of Labor, Department of 
Transportation and the Department of Health and Human Services. VA was 
a voluntary participant in the President's New Freedom Initiative, 
partnering with other federal agencies to identify and remove barriers 
to community living for persons with disabilities. The VA New Freedom 
Initiative Report highlighted the services and programs for disabled 
veterans that have knocked down barriers to living and prospering in 
the community.
    The VHA Community Residential Care program provides placements in 
VA?approved residential care homes for veterans in need of a structured 
living environment. Although VA does not pay for these services, VA 
social workers negotiate reasonable rates with residential care home 
operators. Veterans living in residential care homes receive lodging 
and meals in a safe, supervised environment. They are also provided 
with social and recreational activities and assistance with managing 
their medications. VA social workers visit veterans in the homes and 
conduct joint inspections of the facilities with VA life safety 
engineers. Before the Community Residential Care Program was 
established, many of these veterans would have been placed in nursing 
homes or would have remained in long-term psychiatric hospitals. The 
biggest limitation to fully utilizing community residential care homes 
is that veterans need to have sufficient income to offset the costs. VA 
currently has no legislative authority to pay for community residential 
care, even though it is less costly than inpatient admissions or 
community nursing homes and provides a better quality of life for 
veterans.
    Among the community based resources or services essential to 
maintain patients discharged from hospital and outpatient VA mental 
health care programs, are the partnerships that can be developed with 
community businesses through VHA's Compensated Work Therapy (CWT) 
Program. These partnerships represent a part of the continuum of care 
to assist veterans in the transition to independent and productive 
lives in their local communities. They should be expanded and made 
available to under-served veterans among the special disability groups, 
including substance abuse, serious mental illness, PTSD, and homeless 
veterans. Women veterans could also benefit greatly from this service 
and should be included.
    CWT is authorized by 38 U.S.C. Sec. 1718 to provide a supportive, 
stable, structured program utilizing work-based rehabilitation. 
Veterans in CWT are placed in work opportunities on a transitional 
basis with local employers or in a variety of federal agencies, 
including VA, to strengthen vocational identity and regain work skills. 
By working, veterans establish a source of income, structured use of 
time, and improved self-esteem.
    In FY 2001, there were over 105 CWT programs that treated nearly 
13,700 veterans. These veterans earned more than $33 million, and 41 
percent of those completing the program were placed in competitive 
employment with another four percent placed in training. An additional 
$10 million dollars was received from participating companies and 
government agencies and used for program operating expenses, making 
this an extremely cost effective program for VA.
    There is an innovative partnership with State chapters of the 
National Alliance for the Mentally Ill. There are nine State pilot 
projects working with VA and the local Alliance for the Mentally Ill to 
bring the Family-To-Family program to the VA veterans' families. This 
is a structured 12-week self-help course facilitated by persons trained 
in the Family-to-Family course who are usually family members 
themselves. This is directed at families of veterans with serious 
mental illness. It provides information about the illness, coping 
strategies and mutual support.
    The Vietnam Veterans of America have offered a twelve-step recovery 
program called ``Coping with the Aftermath of Vietnam'' to veterans who 
suffer from PTSD. In some areas the local VHA Vet Center coordinates 
the referral.
    The National Depressive and Manic-Depressive Association has been 
working with VHA Mental Health programs to provide information on the 
support groups that they sponsor. This is a program where clinicians in 
the VA refer veterans suffering from depression to one of the local 
support groups.
    In the Northeast, the Bedford VA Medical Center and the Boston VA 
Outpatient Clinic have hosted a mental health peer support project that 
trains veterans with mental illness. Many people from the Peer 
Educators Project self help groups have gone on to be public educators. 
They also teach staff in our mental health programs about new ways of 
interacting with veterans who have mental illness.
    The National Mental Health Association has several innovative 
models of care for people with schizophrenia and their families. The 
Partners in CARE (Community Access to Recovery and Empowerment) has 
several model programs that can be replicated. The programs represent a 
continuum of high-quality services, from low-intensity consumer self-
help and support programs, to a fully integrated model of community-
based service delivery that includes medication, social support 
services, employment, and rehabilitation.
    For veterans with substance abuse problems, VA has contracted for 
years with community-based halfway houses to provide aftercare from 
more intensive, hospital-based rehabilitation programs. In a number of 
moderate-size cities VA facilities have referred veteran patients to 
local opioid substitution programs where there are insufficient numbers 
of heroin users to create a VA program. For decades, VA also has used 
Alcoholics Anonymous, Narcotics Anonymous, and other self-help 
organizations as major supports for veterans with addiction problems.
    In North Carolina, which is fortunate to have a well-developed 
state-run community mental health program throughout the rural areas, 
many of our veterans who use VA for needed hospital care have also been 
able to receive outpatient care from local community programs. In 
Montana, VA has contracted for assertive community treatment (MHICM in 
VA) with a state funded non-profit organization.
    Question 4c. Is such ``coordination'' not necessary when formerly-
hospitalized patients are released to the community? Is ``community 
coordination'' more important to patients treated primarily in an 
outpatient setting than it is to patients treated in an inpatient 
setting?
    Answer. Depending upon the availability of mental health resources 
in specific communities, coordination with local agencies, 
organizations, and families is very helpful for both veterans 
discharged from inpatient settings and veterans treated on an 
outpatient basis. Coordination of VA and non-VA services is the key 
element in the rehabilitation of individual veterans discharged from a 
VA psychiatric inpatient setting. However, since most of our patients 
are served through a continuum of care, including both hospital and 
outpatient settings, community coordination, as part of the veteran's 
comprehensive treatment plan, cannot really be separated into inpatient 
or outpatient components.
    Question 4d. Has VA central office devoted any resources, or 
developed any guidance for field clinicians, to increase local 
``coordination'' by VA provider and local community service providers? 
Please explain.
    Answer. VA's Office of Social Work Service oversees the practice of 
approximately 3,800 masters' prepared social workers in VHA facilities 
across the country. One of the primary functions of VHA social workers 
is to develop and maintain community linkages and to serve as the 
liaison between the VHA medical center and providers and staff in 
community agencies and organizations. Social workers serve as case 
managers for veteran patients, assuring coordination and continuity of 
care across all treatment settings and in the home and community. They 
develop and foster strong, regular communication with family members. 
Social workers make home visits and assess the family, social and 
community systems available to their veteran patients. They also keep 
current on the programs and services available from community agencies 
and organizations and help veterans and families access these services. 
Social workers coordinate VA community nursing home, community 
residential care, respite care, adult day health care, and homemaker 
and home health aide programs. These coordination functions include 
matching the needs of veterans with the various programs, making 
referrals, inspecting the homes and programs, providing case management 
services to veterans served in these programs, and keeping each 
patient's interdisciplinary treatment team informed about the patient's 
progress and the services he or she is receiving in the community.
    VHA social workers assure the coordination of home and community 
services and the case management of veterans receiving outpatient 
Mental Health treatment. Such coordination and case management has led 
to reduced hospital admissions and reduced emergency visits, and better 
quality of life for veterans.
    Social Work Service in VA Central Office has published VHA Social 
Work Practice Guidelines on case management, psychosocial assessment, 
psychosocial treatment, and discharge planning coordination. All of 
these guidelines include expectations for active community involvement 
and coordination. Social Work Service has also published standardized 
position descriptions, scope of practice statements, and a VHA 
directive outlining community coordination functions for social workers 
and social work leaders.
    The VHA Office of Geriatrics and Extended Care has issued handbooks 
and directives providing guidance on community coordination of services 
provided in community nursing homes and community residential care 
homes, as well as adult day health care, respite care, homemaker/home 
health aide, hospice and palliative care services provided in veterans' 
homes and in the community.
    The VA Employee Education Service (EES) has produced four 
videotapes on case management, highlighting ``best practices'' in VA 
medical centers. They have also developed a case manager position 
description, a tool kit of resources for VHA case managers and an 
assessment tool for case managers to use with veteran patients. Copies 
of the videotapes and other materials were provided to each VHA medical 
center. All of the case management products developed by EES stress the 
importance of the continuum of care in the community and homes of 
veterans and the key function of VHA case managers in coordinating care 
with community providers.
    VHA's Mental Health Program Guidelines provide descriptions and 
definitions of various levels of case (or care) management including 
``linkage with other providers and services as needed and coordination 
of care among them.''
    Question 5a. I am told that many mental illnesses--even very 
serious mental illnesses such as schizophrenia--can be successfully 
treated on an outpatient basis with medications. Is this correct? If 
so, how do you assure that patients take their ``meds'' if they are not 
in the hospital?
    Answer. That is correct. The great part of our treatment of 
veterans with a serious mental illness has been on an outpatient basis 
for many decades. Congress authorized VA Mental Hygiene Clinics, Day 
Treatment Centers, and Day Hospitals in the early 1950s. Before 1970, 
VHA had several dozen hospitals that provided long-term psychiatric 
hospital care and approximately 140 hospitals with psychiatric beds 
that provided short-term hospital care and outpatient care. With better 
medications, psychosocial treatments, and expansion of outpatient care 
nationally, the shift away from long-term hospital-based care to 
community care accelerated both within and outside of VHA. Hospitals 
are now seen primarily as a necessary place to stabilize patients, but 
the primary treatment setting is now in the community. In FY 2000 (the 
latest year for which data are available), VHA provided care to 192,982 
veterans with a psychosis; over 102,000 of these had a diagnosis of 
schizophrenia and nearly 62,000 had a diagnosis of bipolar disorder. Of 
these patients, 20 percent received some inpatient psychiatric care, 
averaging 20.6 days per year, but only 2.4 percent (4,630 patients) 
stayed over 150 days. Ten percent of the overall number received either 
some residential rehabilitation domiciliary, vocational or nursing home 
care. In FY 2000, 98.8 percent of veterans with a psychosis used 
outpatient care.
    The issue of medication ``compliance'' has been researched since 
antipsychotic medications were developed in the mid 1950's, and 
hundreds of articles have been published showing the efficacy of these 
new ``anti psychotic'' medications. In fact these medications have made 
it possible for many patients who had previously been hospitalized for 
years to go back home or find a supportive living arrangement in the 
community. In VA, outpatient follow-up has been a key to maintaining 
compliance with taking medications. Generally, outpatients take their 
medications when they trust their physician, have family support, are 
not substance abusers, are seen in the clinic regularly, and see some 
benefit in doing so in spite of the inconvenience and often some 
unpleasant side effects. Influence of families is very important. For 
those patients who respond favorably to medications, the incentive to 
avoid a recurrence of their psychotic state is compelling. Outpatients 
who are unable to comply are seen at appropriate intervals in the 
clinic, where they may be given an injection by a nurse that will last 
for a week or more. Some states have experimented with ``outpatient 
commitment'' to improve compliance. Even in the hospital, patients have 
been known to ``cheek'' their medications and fool the nurses for days 
at a time. Blood tests have been used to check for medication levels 
but are generally not found to be necessary.
    Question 5b. When seriously mentally ill patients do not take their 
``meds,'' what happens? Is it necessary to hospitalize them? After they 
are stabilized and back on their meds, are they then released? If so, 
is the cycle then repeated--perhaps endlessly?
    Answer. Re-hospitalization is often necessary when patients do not 
take their medications, unless they are followed closely as outpatients 
by clinicians and family members where the recurrence of symptoms gives 
an early warning. In earlier studies, the monthly re-hospitalization 
rate of patients who stopped taking their medications was generally 
lower than the ``controls'' (who were given placebo medications), but 
higher than those who did continue to take their medications. Currently 
the relapse rates for patients with schizophrenia are estimated to be 
3.5 percent per month for patients who take antipsychotic medications 
regularly over the long term and 11.0 percent for patients who have 
discontinued their medications. Relapse due to the lack of efficacy of 
the anti?psychotic medications is estimated to account for 60 percent 
of the considerable costs of re-hospitalization. Relapse due to non-
compliance accounts for the remaining 40 percent of the costs, 
particularly in the second year. The readmission cycle referred to is 
mitigated by close outpatient follow-up where medication doses can be 
changed or new or additional medications added to achieve better 
outcomes. The addition of assertive community treatment (e.g., VA's 
MHICM program) has very effectively broken the readmission cycle even 
for veterans with the most serious mental illnesses.
    Question 6a. VA has unique resources at its disposal that could 
assist States and other local providers in their provision of mental 
health services to veterans and others. For example, the Butler VA 
Medical Center is now attempting to execute an enhanced use lease with 
the local county to provide space on hospital grounds for the county to 
use for care of local citizens with mental illness. Do you favor this 
sort of cooperative effort between VA and its ``host'' localities?
    Answer. Enhanced-Use Leases (EUL) provide a unique mechanism to 
meet the Department's mission requirements, and VA strongly encourages 
their use. The proposed enhanced-use business plan for the Butler VA 
Medical Center, which would establish a residential intermediate care 
mental health facility for the community, would be the Department's 
first use of an EUL for this purpose.
    Question 6b. In this particular case, the process of VA 
headquarters approval of the enhanced use lease is caught up in VA 
bureaucracy. If it is not approved soon, many citizens in Western PA 
could suffer the consequences. Please report on the status of VA 
central office review of the enhanced use lease application submitted 
by the Butler VA Medical Center.
    Answer. The proposal is for the development of a Butler County 
Human Services Mental Health Intermediate Care facility on underused 
land at the VA Medical Center in Butler, PA. The conceptual business 
plan was submitted to the Veterans Health Administration (VHA) on April 
15, 2002.
    During June and July 2002, additional information was requested by 
and submitted to the VHA Office of Facilities Management, which 
subsequently concurred with the proposal, and forwarded it for further 
Department-level review.
    County officials who are responsible for development of the 
proposed intermediate care psychiatric facility have expressed concern 
about the possibility of losing state funding. Assuming Department-
level approval is forthcoming, VA staff will work with local officials 
to resolve any potential scheduling issues.
    Question 6c. Please outline the steps for VA central office review 
of the enhanced use lease applications. What is the purpose of each 
step? Is each step necessary? How long does it typically for VA central 
office to process its review of an enhanced use lease application?
    Answer. VA's EUL authority is a capital asset management program 
that is unique to the Department. The program provides a proven method 
of leveraging VA's diverse real estate portfolio with private and other 
public sector markets. The typical milestones for enhanced-use lease 
authority include:
     Submission of the Conceptual Business Plan, with 
endorsement by the Network Director, to the appropriate Administration;
     Internal Administration Concept Plan Scoring for 
prioritization--14 days;
     Administration and OAEIVI approval of the Concept Plan--
approximately 30 days after submission;
     Public Hearing--approximately 30-45 days after approval;
     Congressional Notification of the Department's Intent to 
Designate the site for an EUL (minimum 90 calendar days for 
congressional review before VA can execute the enhanced-use lease)--
submitted approximately 30 days after the public hearing;
     Solicitation and selection of Developer/Lessee, if 
required--90 days;
     Developer preparation and finalization of Development 
Plan--60 days;
     VA approval of Development Plan--45 days after submission;
     Strategic Management Council and OMB Clearance, if 
required;
     Congressional Notification of the Department's Notice of 
Designation and Intent to Execute the EUL (30 calendar days required by 
statute)--30 days after all clearances;
     Execution of Enhanced-Use lease--30 days after submission 
of Notice of Intent to Execute;
    The milestones and timeline presented above allow VA to present 
EULs in 12-18 months. It should be emphasized that we are reviewing the 
EUL process to determine how we might improve and shorten this 
timeline.
    Question 7. Testimony presented by Colleen Evans, RN, states that 
VA has closed too many inpatient substance abuse treatment beds in 
Pittsburgh. Is this contention accurate, in your estimation? What is 
VA's policy on providing inpatient substance abuse treatment? Is it 
possible that VA has gone too far in closing inpatient substance abuse 
treatment beds in an effort to save the system money?
    Answer. The VA Pittsburgh Healthcare System (VAPHS) transitioned 
the substance abuse program from an inpatient unit to an outpatient 
continuum of care in June 1998. This change was in response to a low 
census on that unit, and this change paralleled the standard of 
treatment provided in the private sector.
    Within the current continuum of care, there are 15 beds (with the 
availability of 5 additional beds) in the Domiciliary for patients in 
the entry level for substance abuse treatment. If we compare program 
utilization for FY 1998, which was the last year of the inpatient 
program, to the current outpatient model with the availability of Dom 
beds, the program meets patient needs to a greater extent.

------------------------------------------------------------------------
                                        FY 1998          FY 2002 (YTD)
------------------------------------------------------------------------
Average Daily Census............  13.2..............  16.2
Occupancy Rate..................  43.6%.............  107% (for 15 beds)
Average Length of Stay..........  10.8 days.........  13.9 days
------------------------------------------------------------------------

    Question 8. Ms. Evans also testified that changes in policy at the 
medical center level have made it practically impossible for a patient 
to obtain substance abuse treatment while he or she is an acute 
psychiatric inpatient. She suggests that because patients are not 
permitted to walk to the outpatient treatment sessions on their own--
and there is too little staff to escort them--these patients are 
essentially going without treatment. Are Ms. Evans' contentions valid? 
Should more staff be hired? Should patients in acute psychiatric care 
be allowed to walk unescorted to the outpatient treatment sessions? If 
not, should hospital management see to it that such patients either get 
appropriate escorts? Or should it assure that treatment services are 
brought to the inpatient setting?
    Answer. On any given week, there are 2 patients who are referred to 
the substance abuse program during their inpatient stay. To begin 
entry-level work with these patients prior to discharge, the substance 
abuse program provides a motivational group three times a week on the 
inpatient unit. This is an approach which is patient centered, bringing 
the treatment program to the patient in a safe environment. The staff 
comes to the patients; therefore, escorting is not necessary.
    Question 9a. A report issued by VA's Advisory Committee on the 
Readjustment of Veterans expresses concerns about the reduction of 
inpatient PTSD programs. In 1993, there were approximately 20 inpatient 
programs providing care to veterans suffering from PTSD. Today, there 
are seven. What has occurred over the last 9 years that has allowed VA 
to significantly reduce its capacity for inpatient treatment of 
veterans suffering from PTSD?
    Answer. As with other health care generally, including mental 
health care, treatment of PTSD is increasingly being provided on an 
outpatient basis. Although providing care on an outpatient basis 
reduces costs, there are other important reasons why health care 
continues to shift to the outpatient settings. Health care providers 
and patients themselves recognize that health care should be provided 
in the least restrictive environment possible. Inpatient care must be 
available when needed but should be reserved for those situations where 
outpatient care alternatives are either unavailable or clinically 
inappropriate. Further, there is no evidence to suggest that providing 
care in an outpatient setting, where clinically appropriate, in any way 
compromises the quality of care or adversely affects clinical outcomes. 
VA has developed a continuum of outpatient and residential psychosocial 
rehabilitation programs designed to help veterans achieve the highest 
level of functioning possible. Although acute inpatient capacity has 
diminished in VHA, specialized residential and outpatient treatment 
programs have grown.
    Question 9b. Is there any data to suggest that caring for veterans 
suffering from PTSD in an outpatient setting is more appropriate than--
or yields better outcomes than--inpatient care?
    Answer. There are no data to suggest that outpatient care for 
veterans suffering from PTSD is more appropriate or yields better 
outcomes than inpatient care. On the other hand, there are also no data 
to suggest that outpatient outcomes are inferior to inpatient outcomes. 
It should be recognized that most PTSD treatment has always been 
delivered on an outpatient basis through specialized outpatient clinics 
and Vet Centers. Especially with the development of Post Traumatic 
Stress Disorder Clinical Teams, clinical staff have learned a great 
deal about treating PTSD in the outpatient setting. Data on the 
clinical outcomes of VA's specialized intensive PTSD programs show that 
these programs have maintained their effectiveness in reducing 
symptoms, substance abuse, and violent behavior. In addition, non-
experimental outcome studies of specialized VA PTSD inpatient and 
outpatient programs show that they have similar patient outcomes during 
the year following program entry.
    Question 9c. Do you believe that VA is capable of providing 
inpatient PTSD services to all veterans in need of such care?
    Answer. Although specialized acute inpatient PTSD capacity has 
declined in recent years, PTSD patients have access to acute inpatient 
care services on general mental health units for short-term 
stabilization, crisis intervention, and for other medical reasons. Most 
networks have residential rehabilitation capacity to treat PTSD, and 
all networks have some capacity to provide specialized treatment 
services on either an inpatient or outpatient basis.
    Public Law 106-117, the ``Veterans Millennium Health Care and 
Benefits Act'', provided an opportunity to expand programming for PTSD 
in order to fill gaps in services. In July 2000, 21 Networks, 
encompassing 69 facilities, submitted proposals to develop additional 
specialized treatment for PTSD. The total amount of funds requested was 
$13,975,686. Eighteen proposals were ultimately funded in the amount of 
approximately $5.5 million, leaving a documented unmet need of almost 
$8.5 million. This may be a significant underestimate of the overall 
additional need, however, for a number of reasons. Proposals were only 
funded to support recurring funding needs. Additional one-year startup 
costs are not included in the $5.5 million. More significantly, not all 
program needs within each network were submitted for national review. 
Many networks conducted an internal prioritization exercise and only 
submitted their highest priority needs. Had more money been available, 
we believe that the total number of submissions and the cost per 
submission would have been considerably higher.
    Question 10a. On July 12, 2002, Secretary Principi sent Chairman 
Rockefeller and me a letter detailing the waiting times veterans face 
at VA Medical Centers around the country. In my home state of 
Pennsylvania, the data showed an alarming number of veterans--over 
26,000--are waiting for care. What are the waiting times currently 
facing veterans for outpatient mental health services?
    Answer. Attached is an excel spreadsheet with waiting time data for 
mental health (MH) clinics in the state of Pennsylvania.

                                                       July Wait Times Mental Health Clinic Stops
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                     Average
                                                                                                   Number of                           New      Percent
                                                                                          Total      Appts     Number    Average     Patient     of ALL
 State  VISN    Sta5a           Name            PRIMARY DSS STOP      Type of CBOC/       Appts     That are   of New      Next     Wait Time    Appts
                                                                         Division       Scheduled     Next     Patient  Available   (recoded   Scheduled
                                                                                                   Available    Appts   Wait Time    as next     in 30
                                                                                                                                   available)     days
--------------------------------------------------------------------------------------------------------------------------------------------------------
    PA    4      646A5  Pittsburgh HCS-Highl  ACT DUTY SEX TRAUMA  VA PROVIDED........         50          0         0        0.0        7.9      100.0%
    PA    4        562  Erie................  DAY TRMT-GRP.......  VA PROVIDED........        210         35         0        0.0        0.0      100.0%
    PA    4      646A5  Pittsburgh HCS-Highl  DAY TRMT-GRP.......  VA PROVIDED........          8          0         0        0.0       19.0      100.0%
    PA    4        503  James E. Van Zandt..  DAY TRMT-IND.......  VA PROVIDED........         69          0         0        0.0       66.2      100.0%
    PA    4        642  Philadelphia........  HCHV/HMI...........  VA PROVIDED........         86         26         3        0.2        0.4      100.0%
    PA    4      693B4  Allentown...........  HCHV/HMI...........  VA PROVIDED........         63          0         0        0.0        7.0      100.0%
    PA    4      693GB  Williamsport........  MEN HILTH RESID      VA PROVIDED........          1          0         0        0.0       10.0      100.0%
                                               CARE.
    PA    4      646A5  Pittsburgh HCS-Highl  MENT HILT INT        VA PROVIDED........          1          0         0        0.0        0.0      100.0%
                                               (MHICM).
    PA    4        503  James E. Van Zandt..  MENTAL HEALTH-IND..  VA PROVIDED........        285         56        22       38.9       35.4       78.6%
    PA    4        529  Butler..............  MENTAL HEALTH-IND..  VA PROVIDED........       1021         15         9       19.9       36.1       99.4%
    PA    4        542  Coatesville.........  MENTAL HEALTH-IND..  VA PROVIDED........        148          1         0        7.0       16.6       98.6%
    PA    4        562  Erie................  MENTAL HEALTH-IND..  VA PROVIDED........        831          0         0        0.0       29.1      100.0%
    PA    4        642  Philadelphia........  MENTAL HEALTH-IND..  VA PROVIDED........        841        203        12       18.9       11.7       95.8%
    PA    4        693  Wilkes Barre........  MENTAL HEALTH-IND..  VA PROVIDED........        189         13        11       24.1       41.0       73.8%
    PA    4      542GA  Media...............  MENTAL HEALTH-IND..  VA PROVIDED........         29          0         0        0.0        0.0      100.0%
    PA    4      542GC  Reading/Berks.......  MENTAL HEALTH-IND..  VA PROVIDED........         48          0         0        0.0       14.6       97.9%
    PA    4      542GE  Spring City.........  MENTAL HEALTH-IND..  VA PROVIDED........         79          0         0        0.0        1.8      100.0%
    PA    4      693B4  Allentown...........  MENTAL HEALTH-IND..  VA PROVIDED........        481        157        41       72.3       57.8       65.9%
    PA    4      693GA  Sayre...............  MENTAL HEALTH-IND..  VA PROVIDED........         61          0         0        0.0       89.7       58.0%
    PA    4      693GB  Williamsport........  MENTAL HEALTH-IND..  VA PROVIDED........        144          5         4        3.6       43.7       97.9%
    PA    4        503  James E. Van Zandt..  MENTAL HYG-GRP.....  VA PROVIDED........        125          0         0        0.0       47.2      100.0%
    PA    4        529  Butler..............  MENTAL HYG-GRP.....  VA PROVIDED........        193          1         0       92.0        5.5       92.0%
    PA    4        542  Coatesville.........  MENTAL HYG-GRP.....  VA PROVIDED........         10          0         0        0.0        0.0      100.0%
    PA    4        562  Erie................  MENTAL HYG-GRP.....  VA PROVIDED........         54          0         0        0.0        0.0      100.0%
    PA    4        642  Philadelphia........  MH INV BIOMED CARE-  VA PROVIDED........         31          1         0       20.0         0.      100.0%
                                               IND.
    PA    4        646  Pittsburgh HCS-Univ.  MH INV BIOMED CARE-  VA PROVIDED........        109         35        23       20.1       19.4       91.6%
                                               IND.
    PA    4        595  Lebanon.............  MH PRIM CARE TEAM-   VA PROVIDED........         12          0         0        0.0        0.0      100.0%
                                               GRP.
    PA    4      646A5  Pittsburgh HCS-Highl  MH PRIM CARE TEAM-   VA PROVIDED........        748          0         0        0.0       29.9       99.9%
                                               GRP.
    PA    4        595  Lebanon.............  MH PRIM CARE TEAM-   VA PROVIDED........       1260         26        11       10.1       35.9       89.7%
                                               IND.
    PA    4        642  Philadelphia........  MH PRIM CARE TEAM-   VA PROVIDED........        867        270        56       45.8       48.5       79.1%
                                               IND.
    PA    4        646  Pittsburgh HCS-Univ.  MH PRIM CARE TEAM-   VA PROVIDED........        180          6         4       45.3       17.6       95.4%
                                               IND.
    PA    4        693  Wilkes Barre........  MH PRIM CARE TEAM-   VA PROVIDED........       8711          5         4       14.7       63.5       92.2%
                                               IND.
    PA    4      595GA  Camp Hill Outpatient  MH PRIM CARE TEAM-   VA PROVIDED........        482          6         0        8.8       26.7       98.3%
                                               IND.
    PA    4      646A4  Pittsburgh HCS-Aspir  MH PRIM CARE TEAM-   VA PROVIDED........          2          0         0        0.0        5.0      100.0%
                                               IND.
    PA    4      646A5  Pittsburgh HCS-Highl  MH PRIM CARE TEAM-   VA PROVIDED........       2720        116        27       21.4       25.8       98.3%
                                               IND.
    PA    4      693GC  Tobyhanna...........  MH PRIM CARE TEAM-   VA PROVIDED........         14          1         1      114.0      137.0       85.7%
                                               IND.
    PA    4        562  Erie................  MH RISK FAC RED EDU  VA PROVIDED........         88          0         0        0.0       23.0       95.7%
                                               GRP.
    PA    4        542  Coatesville.........  MH TEAM CASE MGT...  VA PROVIDED........         14          0         0        0.0       26.7      100.0%
    PA    4        595  Lebanon.............  MH VOCAT ASSIST....  VA PROVIDED........        269         13         1        0.9        2.5       99.6%
    PA    4        642  Philadelphia........  OPIOID SUBSTITUTION  VA PROVIDED........      24632          0         0        0.0        0.2       99.9%
    PA    4      646A5  Pittsburgh HCS-Highl  OPIOID SUBSTITUTION  VA PROVIDED........       1531          0         0        0.0        3.0      100.0%
    PA    4        542  Coatesville.........  PCT PTSD-GRP.......  VA PROVIDED........        122         10         0        0.0        0.0       99.2%
    PA    4        642  Philadelphia........  PCT PTSD-GRP.......  VA PROVIDED........          7          3         0        9.0        0.0      100.0%
    PA    4      646A5  Pittsburgh HCS-Highl  PCT PTSD-GRP.......  VA PROVIDED........        164          2         0        7.5       21.3      100.0%
    PA    4        642  Philadelphia........  PHONE GENERAL PSYCH  VA PROVIDED........         10          0         0        0.0        0.0      100.0%
    PA    4      693B4  Allentown...........  PSY/SOC REHAB-GRP..  VA PROVIDED........         18          0         0        0.0       14.1      100.0%
    PA    4        595  Lebanon.............  PSYCHIATRY CONS....  VA PROVIDED........         35          0         0        0.0       10.8      100.0%
    PA    4        503  James E. Van Zandt..  PSYCHIATRY-IND.....  VA PROVIDED........        529         86        28       24.9       31.3       91.1%
    PA    4        542  Coatesville.........  PSYCHIATRY-IND.....  VA PROVIDED........        731         14         6       11.6       11.7       97.7%
    PA    4        562  Erie................  PSYCHIATRY-IND.....  VA PROVIDED........        102          0         0        0.0        9.7      100.0%
    PA    4        642  Philadelphia........  PSYCHIATRY-IND.....  VA PROVIDED........       2406        885       143       31.0       21.7       80.4%
    PA    4        693  Wilkes Barre........  PSYCHIATRY-IND.....  VA PROVIDED........        194          1         0       49.0       63.8       86.8%
    PA    4      542GA  Media...............  PSYCHIATRY-IND.....  VA PROVIDED........        160          1         0        0.0       34.4       83.1%
    PA    4      542GC  Reading/Berks.......  PSYCHIATRY-IND.....  VA PROVIDED........         51          0         0        0.0       27.6       88.1%
    PA    4      542GD  Lancaster...........  PSYCHIATRY-IND.....  VA PROVIDED........         47          2         0        3.0       17.0       97.9%
    PA    4      542GE  Spring City.........  PSYCHIATRY-IND.....  VA PROVIDED........        134          2         0       23.5       39.5       98.5%
    PA    4      542GG  Philadelphia........  PSYCHIATRY-IND.....  VA PROVIDED........         69          3         0       35.3       11.6       94.2%
    PA    4        595  Lebanon.............  PSYCHOLOGICAL        VA PROVIDED........         32          1         0       21.0       17.6        100%
                                               TESTING.
    PA    4      595GA  Camp Hill Outpatient  PSYCHOLOGICAL        VA PROVIDED........          2          2         2       41.0       41.0        0.0%
                                               TESTING.
    PA    4        542  Coatesville.........  PSYCHOLOGY-GROUP...  VA PROVIDED........        178          0         0        0.0       48.7       98.1%
    PA    4        693  Wilkes Barre........  PSYCHOLOGY-GROUP...  VA PROVIDED........        332          0         0        0.0       32.6      100.0%
    PA    4     693134  Allentown...........  PSYCHOLOGY-GROUP...  VA PROVIDED........         17          0         0        0.0        0.0      100.0%
    PA    4        503  James E. Van Zandt..  PSYCHOLOGY-IND.....  VA PROVIDED........        245         47        17       31.3       23.2       73.3%
    PA    4        542  Coatesville.........  PSYCHOLOGY-IND.....  VA PROVIDED........         99         16         6        7.9       11.9      100.0%
    PA    4        562  Erie................  PSYCHOLOGY-IND.....  VA PROVIDED........         26         25        21       23.8       25.7       84.6%
    PA    4        595  Lebanon.............  PSYCHOLOGY-IND.....  VA PROVIDED........         46          2         2       22.0        9.7       95.7%
    PA    4        642  Philadelphia........  PSYCHOLOGY-IND.....  VA PROVIDED........         90         44        16       20.1       17.3       90.8%
    PA    4        693  Wilkes Barre........  PSYCHOLOGY-IND.....  VA PROVIDED........        218         11         4       88.5       44.9       86.3%
    PA    4      542GA  Media...............  PSYCHOLOGY-IND.....  VA PROVIDED........        105          0         0        0.0        0.0      100.0%
    PA    4      542GE  Spring City.........  PSYCHOLOGY-IND.....  VA PROVIDED........         73          1         0        1.0       19.7       86.3%
    PA    4      542GG  Philadelphia........  PSYCHOLOGY-IND.....  VA PROVIDED........         95          0         0        0.0        5.0      100.0%
    PA    4      595GA  Camp Hill Outpatient  PSYCHOLOGY-IND.....  VA PROVIDED........         11         11        10       40.4       40.1        9.1%
    PA    4      646A5  Pittsburgh HCS-Highl  PSYCHOLOGY-IND.....  VA PROVIDED........         80          0     0 0.0       16.2     100.0%
    PA    4      693B4  Allentown...........  PSYCHOLOGY-IND.....  VA PROVIDED........        100         28         7      130.0      116.9       69.8%
    PA    4        542  Coatesville.........  PTSD CL TEAM-PCT...  VA PROVIDED........        271         38         6        8.4       12.9       99.3%
    PA    4        642  Philadelphia........  PTSD CL TEAM-PCT...  VA PROVIDED........        908        361        26       26.1       12.5       90.6%
    PA    4      542GA  Media...............  PTSD CL TEAM-PCT...  VA PROVIDED........         55          5         1        5.0        6.6      100.0%
    PA    4      542GC  Reading/Berks.......  PTSD CL TEAM-PCT...  VA PROVIDED........         22          1         1       13.0        9.5      100.0%
    PA    4      542GD  Lancaster...........  PTSD CL TEAM-PCT...  VA PROVIDED........         50          7         0        6.1        0.0      100.0%
    PA    4      646A5  Pittsburgh HCS-Highl  PTSD CL TEAM-PCT...  VA PROVIDED........        280         14         4       24.9       30.6       98.1%
    PA    4        503  James E. Van Zandt..  PTSD GROUP.........  VA PROVIDED........        111          0         0        0.0        0.0      100.0%
    PA    4        562  Erie................  PTSD GROUP.........  VA PROVIDED........         38          0         0        0.0        0.0      100.0%
    PA    4        595  Lebanon.............  PTSD GROUP.........  VA PROVIDED........         66          1         0        6.0        0.0      100.0%
    PA    4        562  Erie................  PTSD-INDIVIDUAL....  VA PROVIDED........         93          0         0        0.0       10.7      100.0%
    PA    4      693GB  Williamsport........  PTSD-INDIVIDUAL....  VA PROVIDED........          8          3         3        2.7        2.7      100.0%
    PA    4        562  Erie................  SUBST ABUSE-GRP....  VA PROVIDED........          7          0         0        0.0        0.0      100.0%
    PA    4        595  Lebanon.............  SUBST ABUSE-GRP....  VA PROVIDED........          7          6         6        4.3        4.6      100.0%
    PA    4        642  Philadelphia........  SUBST ABUSE-GRP....  VA PROVIDED........        130         12         2        1.5       14.0      100.0%
    PA    4      646A5  ....................  Pittsburgh HCS-      SUBST ABUSE-GRP VA         227          8         0        0.0        0.0       96.9%
                                               Highl.               PROVIDED.
    PA    4        529  Butler..............  SUBST ABUSE-IND....  VA PROVIDED........          4          2         0       21.5        0.0       75.0%
    PA    4        542  Coatesville.........  SUBST ABUSE-IND....  VA PROVIDED........         46          3         3        7.3        5.7      100.0%
    PA    4        562  Erie................  SUBST ABUSE-IND....  VA PROVIDED........         82          0         0        0.0       19.3      100.0%
    PA    4        642  Philadelphia........  SUBST ABUSE-IND....  VA PROVIDED........        936        162        72        7.4        9.8       99.9%
    PA    4      542GE  Spring City.........  SUBST ABUSE-IND....  VA PROVIDED........         28          0         0        0.0       20.8      100.0%
    PA    4      646A5  ....................  Pittsburgh HCS-      SUBST ABUSE-IND VA         146          0         0        0.0        7.4      100.0%
                                               Highl.               PROVIDED.
    PA    4        646  Pittsburgh HCS-Univ.  SUBST/PTSD TEAMS...  VA PROVIDED........         15          0         0        0.0        0.0      100.0%
    PA    4      646A5  Pittsburgh HCS-Highl  SUBST/PTSD TEAMS...  VA PROVIDED........        287          0         0        0.0       19.8      100.0%
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Question 10b. Are these waiting times so long that VA, in effect, 
is simply refusing care to seriously mentally ill veterans who need 
such services?
    Answer. VA is not refusing care to any veteran with serious mental 
illness. All patients with urgent or emergency needs are seen 
immediately. For routine, non-urgent MH appointments, the average next 
available appointment ranges from 3.6 to 130 days. During the past 
year, we have monitored access to MH services in Community-Based 
Outpatient Clinics during the Network Directors' quarterly performance 
reviews. Discussions have emphasized the need to have MH services 
available either directly on site or by referral to the parent 
facility. VISN 4 also has had an initiative with Murray/Tantau 
Associates over the past year to decrease waiting times and MH clinics 
are included in this initiative. With time, we should see a decrease in 
waiting times for MH clinics.
    Question 10c. How does VA ``triage'' its waiting list to assure 
that veterans in need of immediate care are moved to the ``front of the 
line''?
    Answer. Patients with urgent or emergency needs are seen 
immediately in VA emergency areas or are referred within the community 
for emergency care. Once seen in that setting, the patient can then be 
referred for continuing care. If a patient requiring routine, non-
urgent care has been placed on a wait list, he or she will be removed 
from the wait list as openings occur on a first on, first off basis. If 
the patient's need subsequently becomes urgent or an emergency, he or 
she will be seen immediately.
    Question 11. A report in the June 9, 2002 edition of the Hudson 
Valley (NY) Times Herald Record detailed cases of four mentally ill 
veterans who were allegedly given poor care at, or were prematurely 
discharged from, the Montrose VA Medical Center. One veteran allegedly 
murdered his girlfriend, another apparently overdosed on drugs, and two 
others killed themselves. Has VA investigated these cases? Please 
report on the care afforded to these patients.
    Answer. VA has investigated these cases. The VISN 3 Network 
Director authorized his own investigation, and the Office of Inspector 
General is also reviewing the cases, and plans on issuing two separate 
reports, one in October and one in November.
[Redacted]:
    [Redacted] was discharged from Montrose VAMC on February 21, 2001. 
Mental health staff had worked extensively preparing the veteran for 
community transition including visiting several different community 
homes. The patient elected the [redacted]. In addition to the housing 
plan, the veteran was accepted to the VA MHICM program. The MHICM case 
manager called to check on whether [redacted] was adapting to the new 
environment, and visited him on February 23, at which time the veteran 
reported he was adjusting. A root cause analysis was completed on 5/01/
02. Recommendations have been implemented to improve the monitoring of 
high-risk discharges to the community. The current pending policy 
ensures that treatment providers participate in and are in agreement 
with the discharge plan. Staff on the chronic psychiatric unit has been 
educated on the level of care and function of the community residences 
and the role of intensive case managers.
[Redacted]:
    [Redacted] completed the 45-day [Redacted] program. Prior to 
entering this program the veteran violated conditions of parole and was 
going to be sent to jail due to the determination of law enforcement 
officials. Montrose staff had agreed to screen [Redacted] for the PTSD 
program upon the completion of his jail sentence, although he had been 
treated for PTSD at Montrose on three previous occasions (1997, 1998, 
and 2000). It is the written policy of the program not to accept 
patients to this intense program while there are pending legal issues. 
Although the patient was anxious about imminent incarceration, 
[Redacted] denied any suicidal ideation and was discharged to his home 
while awaiting imprisonment. [Redacted], the police report indicated 
acute morphine intoxication, consistent with past substance abuse 
behavior. This occurred while the patient was at home in bed with his 
wife. The report further stated, ``Due to the past history, this 
incident was not considered suspicious''.
[Redacted]:
    [Redacted] requested to be discharged from the [Redacted] program 
after being denied an increase in [Redacted], which he was receiving 
while detoxing from alcohol and heroin intoxication. Although staff 
encouraged him to stay, he was granted his request for discharge since 
there was no evidence of suicidal or homicidal ideation. Staff 
attempted to refer [Redacted] for shelter, which he refused. There is 
no entry in the patient's medical record indicating that the patient 
should not have been discharged, [redacted]. The Metropolitan Transit 
Authority police report stated that the engineer operating the train 
that hit [Redacted] witnessed [Redacted] stumble to get out of the way 
of the train. This is consistent with the autopsy report indicating an 
elevated level of alcohol in his system. The autopsy report maintained 
that the death was of an accidental nature.
[Redacted]:
    [Redacted] was last seen at the Montrose facility for mental health 
treatment in January 1997. At that time he had scheduled outpatient 
visits that he did not keep. He participated in volunteer work on the 
Montrose campus until 1999. All subsequent visits were for outpatient 
urology and optometry, the last one being in September 2001. 
[Redacted], there is no record of [Redacted] appearing in the Montrose 
emergency room and requesting inpatient treatment on the date 
mentioned. Furthermore, [Redacted], who was the victim and a nurse aid 
at the Montrose facility, filed an order of protection in December 1999 
against [Redacted], indicating premeditated thoughts of violence, not 
violence due to an acute psychotic episode.
    Question 12. Your prepared testimony notes that VA is providing a 
wide variety of medical treatment and other social services to mentally 
ill veterans in need of care. You go into great detail on the amount of 
money spent providing mental health care and purchasing prescription 
drugs. In short, you paint quite a positive picture of VA's mental 
health capabilities. Are there any shortcomings in VA's provision of 
mental health services to veterans in need of such care?
    Answer. Although the VA health care system is effective in the 
provision of mental health services, no system is perfect. The 
following are areas in which we could make improvements.
    Access to Substance Abuse Services. In response to the requirement 
of section 116 of the Veterans Millennium Health Care and Benefits Act, 
Public Law 106-117, VHA received 101 requests for new or enhanced 
substance abuse programs. Thirty-one of these requests were funded. The 
remaining 70 projects indicate additional need for specialized 
substance abuse care. Twelve U.S. cities with documented serious heroin 
problems have no methadone maintenance clinic at the local VA medical 
facility, indicating a need for VA to develop such services.
    Mental Health Intensive Care Management (MHICM) Programs. In 
October 2000, we identified 9,538 MHICM ``eligible'' veterans. This 
figure is based on the number of veterans discharged from a psychiatric 
inpatient program with a serious mental illness diagnosis and either 
three admissions or 30 hospital days in FY 2000. As of March 31, 2002, 
we have 3,298 MHICM patients in our programs. Those figures suggest a 
need for 6,240 additional slots.
    Psychosocial Rehabilitative Services. A 77 percent sampling of 
patients with serious mental illness in FY 2000 revealed that 54 
percent scored below 50 on the Global Assessment of Functioning (GAF), 
indicating significant functional impairment. This suggests that 
approximately 105,000 veterans might benefit from recovery-oriented 
psychosocial rehabilitative services. However, in FY 2002, only 14,000 
received such services in our psychosocial programs. Only 30,000 of the 
678,000 veterans served in VA mental health programs in FY 2000 
received any form of work-based rehabilitation, in spite of the clear 
and substantial evidence of the effectiveness of integrating work into 
most forms of treatment. Unemployment among people with mental illness, 
and particularly psychosis, is very high. Access to compensated work 
therapy programs, which can improve a patient's chances to become more 
functional in their community, is limited. Residential rehabilitation 
programs, designed as alternatives to hospitalization, have also not 
been fully developed nationally. To ensure equal access to VA 
residential services, it is estimated that an additional 22 
Psychosocial Residential Rehabilitation Treatment Programs (PRRTPs) are 
needed.
    Access in Community-based Outpatient Clinics (CBOCs). We recognize 
the need to improve access to mental health services in CBOCs, 
particularly in those located in remote communities that may lack non-
VA mental health services. Data suggest that between 10-20 percent of 
patients seeking general medical care in VA have mental disorders that 
would benefit from treatment.
    Specialized PTSD Treatment. In July 2000, in response to the 
requirement of section 116 Public Law 106-117, 21 Networks, 
encompassing 69 facilities, submitted proposals to develop additional 
specialized treatment for PTSD. Eighteen proposals were funded. This 
may represent an underestimate of the overall additional need. For a 
number of reasons, not all program needs within each network were 
submitted for review. Many networks conducted an internal 
prioritization exercise and only submitted their highest priority 
needs.
    In summary we have identified a number of areas in which we could 
expand or enhance our mental health services. It is important to 
recognize that we are actively working to fill these gaps in services, 
for example, with Network-based plans for MHICM, provisions of mental 
health services in CBOCs, and substance abuse care expansion. WE face 
these challenges because VA provides high-quality mental health 
services that address the needs of veterans that in many cases cannot 
be met in their communities.
    Question 13a. Your prepared testimony states that VA's Central 
Office has received and approved plans from all Network Directors to 
comply with the requirements of the Homeless Veterans Comprehensive 
Assistance Act of 2001, Public Law 107-95, that each VA outpatient 
clinic provide mental health services to all veterans needing such 
services. How will you monitor implementation of this mandate?
    Answer. Implementation is monitored quarterly during each Network 
Director's Performance Reviews with the Deputy Under Secretary for 
Health for Operations and Management.
    Question 13b. When will this mandate be met?
    Answer. We anticipate that we will fully meet the mandate by the 
end of FY 2002.

    Chairman Rockefeller. Dr. Losonczy?

 STATEMENT OF MIKLOS LOSONCZY, M.D., CO-CHAIRMAN, COMMITTEE ON 
 CARE OF VETERANS WITH SERIOUS MENTAL ILLNESS, ASSISTANT CHIEF 
OF STAFF FOR MENTAL HEALTH AND BEHAVIORAL SCIENCES, NEW JERSEY 
  HEALTH CARE SYSTEM, AND ASSOCIATE PROFESSOR, DEPARTMENT OF 
       PSYCHIATRY, ROBERT WOOD JOHNSON SCHOOL OF MEDICINE

    Dr. Losonczy. Thank you, Mr. Chairman and members of the 
committee. As the Co-Chair of the Committee on Care of Veterans 
with Serious Mental Illness, we are very appreciative of the 
opportunity to share our views about possible directions for 
mental health care in the VA.
    As you have heard from Dr. Roswell, the VA does serve over 
700,000 veterans annually in specialized mental health programs 
with a wide array of services. In the view of the SCMI 
committee, the VA has the potential for being clearly the 
benchmark in quality for mental health care in the United 
States. Despite these significant strengths, in the view of the 
committee, there are still areas for substantial gains.
    The special focus of the SCMI committee is on the veteran 
who is disabled due to serious mental illness, a population 
which needs and relies on the Department for treatment and 
rehabilitation, and is a group central to the VA mission. The 
committee has monitored, from a variety of sources, access to 
specialized mental health services throughout the department, 
and has been struck by the degree of variability in these 
services across the various networks.
    Over time, these variations have widened, leaving the 
committee to conclude that there is a need for national 
standards which are evidence- and population-based for the 
provision of mental health services. By performing a national 
mental health needs assessment, it would be possible to 
identify gaps in service and develop a national strategic plan 
to provide such services. Fully implemented, this should 
materially diminish the high variability of mental health 
services across the country and lead to better outcomes for 
this critical population of veterans, many carrying the 
emotional wounds of war for their lifetimes.
    This recommendation, made in both the Fifth and Sixth 
Annual Reports of the SCMI Committee, is a natural outcome of 
concern by the committee that the VA has not systematically 
planned for large-scale deinstitutionalization of veterans with 
serious mental illness over the past 6 years. The SCMI 
committee from its inception has strongly supported the 
development of an array of community support programs to enable 
discharged veterans to function well in the community. We 
thought living in the hospital was the wrong place for these 
veterans and they needed to be in the community, but with the 
right supports.
    Logically, these programs should be in place before large 
numbers of veterans are discharged. Such programs should 
include intensive case management, supported housing, a 
spectrum of work restoration efforts, easy access to mental 
health services in the community, family support, and help with 
socialization. Together with appropriate medication management, 
these programs are key to foster recovery for veterans with 
serious mental illness.
    The VA in 1995 was funded by mechanisms that reinforced the 
development of inpatient and not outpatient programs. The shift 
to the capitation funding mechanism in 1996 guaranteed pressure 
on managers to decrease inpatient costs without clear 
incentives to shift these savings to community support 
development efforts. From the analysis detailed in our written 
testimony, it appears that less than 20 percent of the savings 
from closing inpatient mental health beds were reinvested in 
new outpatient services, less than the increase in outpatient 
mental health demand alone.
    The lack of even development of community support programs 
was noted in the committee's review of the department's 
capacity report. The committee and the department agreed in 
1997 to define capacity for the SMI population as both the 
number of veterans served and dollars expended in their care as 
a measure of intensity of services, but avoiding beds or FTE as 
counterproductive measures. The committee discussed that 
appropriate inflationary adjustments would be needed over time 
to make this definition meaningful, but the department has 
inconsistently included inflation in its own reports.
    Without an inflationary adjustment, the department has only 
found a capacity problem in maintaining its substance abuse 
services. Using inflation-adjusted dollars, the SMI committee 
in its 2000 report saw a total shortfall for care of the SMI 
population of $476 million on a recurring basis, a loss of 23 
percent. This same decline has been noted in the overall 
staffing of specialized mental health services.
    To reverse this decline in capacity and to address the 
needed community support program development, the SCMI 
committee recommended immediate development of several specific 
evidence-based interventions. First, the VA should implement 
intensive case management programs sufficient to meet the 
needs. Second, it should provide access to specialized mental 
health services wherever possible at the community-based 
outpatient clinics. And third, it should reverse the decline in 
substance abuse services, in part by providing opioid 
substitution programs in large metropolitan areas currently 
without them.
    The committee is fully aware of the resource challenge 
faced by the VA, especially in light of the unanticipated rapid 
and enormous increases in lower-priority Category 7 veterans. 
By our calculations, this population has required a subsidy 
from medical appropriations of $747 million in fiscal year 
2001.
    I see that the light is red. I would like to summarize the 
rest of my comments by acknowledging that the Office of the 
Under Secretary has consistently been very supportive of the 
Special Committee for the SMI and we very strongly believe that 
that support will continue. It has, however, been difficult to 
translate some of that support into concrete gains in terms of 
helping the SMI population in the long run.
    We see that there are unmet needs. We need to have a 
mechanism of identifying what they are, having a plan in place 
to meet those unmet needs, and we look forward to working with 
the VA to accomplish that task.
    Mr. Chairman, I appreciate this opportunity to share our 
views and I will be available for any questions you may have.
    Chairman Rockefeller. Thank you, Dr. Losonczy.
    [The prepared statement of Dr. Losonczy follows:]
Prepared Statement of Miklos Losonczy, M.D., Ph.D., Co-Chair, Committee 
            on Care of Veterans with Serious Mental Illness
    The SCMI Committee appreciates the opportunity to help inform the 
Senate Veterans' Affairs Committee about the issues raised in your 
letter of July 3, 2002 in requesting our testimony for today.
    I'd like to begin by offering some background on the role of the 
committee, its legislative mandate, and its composition.
  i. legislative mandates for the committee on care of veterans with 
                serious mental illness (scmi committee)
    Public Law 104-262, section 335, The Veterans Eligibility Reform 
Act of 1996, established the Committee. This law required that the 
Secretary of Veterans Affairs, acting through the Under Secretary for 
Health, ``establish in the Veterans Health Administration a Committee 
on Care of Severely Chronically Mentally Ill [SCMI] Veterans.''
    The function of the Committee as defined by Public Law 104-262 is 
to assess the capability of the Veterans Health Administration to 
``meet effectively the treatment and rehabilitation needs of mentally 
ill veterans whose mental illness is severe and chronic and who are 
eligible for health care furnished by the Department, including the 
needs of such veterans who are women.'' To accomplish this function, 
Public Law 104-262 requires that the Committee:
    (1) evaluate the care provided to SCMI veterans;
    (2) identify system-wide problems in such care;
    (3) identify specific VA facilities that need program enrichment in 
order to improve treatment and rehabilitation of SCMI veterans;
    (4) identify model programs that could be more widely implemented 
within VA;
    (5) advise the Under Secretary regarding the development of 
policies for care and rehabilitation of SCMI veterans; and
    (6) make recommendations to the Under Secretary regarding the 
improvement of care, the establishment of education programs, the 
research needs and priorities, and the appropriate allocation of 
resources.
    In addition to the section mandating the establishment of the 
Committee, section 104 of Public Law 104-262 requires that the 
Department ``maintains its capacity to provide for the specialized 
treatment and rehabilitative needs of disabled veterans,'' including 
those with mental illness. To fulfill this requirement, the Secretary 
of Veterans Affairs must consult with the Committee on Care of Severely 
Chronically Mentally Ill Veterans.
    The legislation that mandated the maintenance of capacity for 
special populations was amended in 1998. The amendments mandated that 
the Under Secretary develop job performance standards for the VA 
leadership who have responsibility for the allocation and management of 
the resources needed for the maintenance of capacity. These performance 
standards are to be developed in consultation with the SCMI Committee.
    Finally, Public Law 104-262 requires that the Secretary of VA 
submit an annual report to Congress that addresses the effectiveness of 
VA's treatment and rehabilitation of veterans who are severely, 
chronically mentally ill. The SCMI Committee releases an annual report 
in February to the Under Secretary that constitutes the findings and 
recommendations to which the Secretary must respond in the mandated 
report to Congress. Public Law 106-419 amended the original law and 
extended VA's reporting requirements through 2004.
                ii. reporting structure of the committee
    The SCMI Committee reports directly to the Under Secretary. The 
Committee publishes an annual report with recommendations in February 
that is sent to the Under Secretary for his response. The report and 
the Under Secretary's response are then sent through the Secretary of 
Veterans Affairs to the Congress.
    In addition to the formal mechanism of the Annual Report, the Co-
Chairs will typically meet with the Under Secretary after a meeting of 
the Committee. Or, in some cases, the Under Secretary will attend the 
actual meeting for a discussion with the entire Committee.
    The Committee is also required by Congress to comment on VA's 
annual report on the maintenance of capacity for the special emphasis 
populations. The point at which the Committee members receive a draft 
version of the Capacity Report varies each year. Once the draft is 
received, the Committee formulates a draft response that is sent to the 
VA Central Office official responsible for the capacity report. If 
changes are made in the Capacity Report, the Committee may re-draft its 
response to reflect these changes. The final response of the Committee 
is attached to the Capacity Report and sent to Congress.
    Finally, the SCMI Committee has a close working relationship with 
VA Central Office's Mental Health Strategic Health Care Group (MHSHG). 
The Chief Consultant of the MHSHG and members of his staff serve as 
consultants to the Committee, but the Committee is independent of them.
   iii. composition of the scmi committee: members, consultants, and 
                           consumer liaisons
    The SCMI Committee membership is field-based. The members are 
professionals from the major mental health disciplines, hold a variety 
of positions within VHA (both at the facility and Network level), and 
represent a variety of geographic areas within the VA system. The 
members of this diverse group, however, have all demonstrated 
excellence in their respective disciplines and commitment to the 
service of veterans who are seriously mentally ill. The Committee 
members are solely responsible for the formal recommendations made to 
the Under Secretary.
    In their work, the Committee members are assisted by consultants 
from the MHSHG, from the field, and from VA's Serious Mental Illness 
Treatment Research and Evaluation Center in Ann Arbor. The consultants 
contribute additional expertise to the Committee, as well as provide 
essential data on VHA's mental health services.
    The Consumer Liaisons are the third component of the SCMI 
Committee. Early in the life of the Committee, the membership realized 
that they needed the input and unique perspective of mental health 
consumers. The Committee asked representatives from the Veterans 
Service Organizations and from national mental health organizations to 
attend the Committee meetings, join in the monthly conference calls, 
and generally to advise the Committee. These representatives from the 
consumer groups have been articulate voices for those veterans who are 
seriously mentally ill. This body does not vote on Committee 
recommendations, which are the sole purview of the members of the 
Committee.
    See Attachment A for a complete listing of Committee members, 
consultants and consumer liaisons.
      iv. key findings of the committee in its 2002 annual report
    Your letter of July 3, 2002 asked the Committee to review the 
findings of the Committee. The SCMI Committee has issued six annual 
reports. It may be most useful to summarize the most recent report, 
dated February 2002.
    The SCMI Committee has noted for years that there is substantial 
inter-VISN variability of access to, and intensity of, a variety of MH 
services. Indeed, the percentage of patients served by VHA who receive 
any type of mental health service has dropped from 20.3% in FY96 to 
17.4% in FY2001. In FY2001 Networks varied widely and unexplainably in 
the proportion of veterans receiving mental health care, by a factor of 
2, from 12.9% to 24.8%. Whether one examines mental health intensive 
case management (MHICM) programs, MH services in Community Based 
Outpatient Clinics (CBOCs), opioid substitution programs, or any of a 
whole host of mental health programs, the inter-VISN variability is 
marked. Long-term care beds for veterans with serious mental illness 
are also distributed quite unevenly, with 11 of the 22 VISNs with 
little or no such beds available. Furthermore, there is no defined 
mental health benefits package nationally. These considerations led the 
Committee to make, as one of its key recommendations this year, the 
following:
``VHA needs to develop comprehensive national standards for the 
        required continuum of care for the veteran with serious mental 
        illness and a strategic plan to achieve these standards.''
Recommendation
    ``A concerted, integrated effort to detail the optimal, population-
based continuum of care for the various mental disorders should be 
completed, under the direction of Patient Care Services Mental Health 
Strategic Health Care Group (MHSHG), in 2002. The first step should be 
to delineate VHA's mental health benefits package. The continuum of 
care recommendations should include the types and intensity of services 
that are to be available in areas with various population densities. It 
should also include recommended measures of productivity for programs 
and staff in these programs or services. These standards should then be 
applied nationally no later than FY 2003. Any variance from these 
standards should be explicitly justified by the Networks and should be 
subject to approval by the Under Secretary.''
    Under Secretary's Comments to this recommendation in the Annual 
Report: ``Concur in part. The establishment of a population-based 
continuum of care is an appropriate goal for all VA health care 
services including our mental health services. VHA policy on the 
breadth of the mental health continuum of care and the overall benefits 
package are already in place. Initial needs assessments of mental 
health services have taken place, and an approach to assessing current 
services and the range and scope of future needed services is part of 
the CARES process in which mental health services are a part. MHSHG and 
other program offices and field representatives of these services will 
have input into CARES. The Mental Health Strategic Health Care Group 
will put together a task group to look at research-based evidence 
regarding productivity standards in mental health programs and to make 
recommendations to the Under Secretary for Health by December 30, 
2002.''
    Status of this recommendation: The Committee made a similar 
recommendation to the Under Secretary in its 2001 Annual Report. The 
Under Secretary responded to this 2001 recommendation by also noting 
that the Capital Asset Realignment for Enhanced Services (CARES) 
initiative would be the appropriate vehicle for identification of a 
continuum of care for mental health services
    The Committee remains unconvinced that the CARES initiative is the 
proper mechanism to delineate a continuum of care for mental health. 
CARES conducted its initial project in Network 12. The published 
implementation process for CARES required adequate input from local 
providers and stakeholders. However, after the publication of the 
report on Network 12, the Committee determined that there was actually 
little input into the project from the Network mental health leadership 
and other stakeholders. In addition, it appears that the model relies 
on private sector data, which are not particularly applicable to the 
population of veterans with serious mental illness. Most private sector 
health plans attempt to exclude more than minimal contact with such 
individuals. Furthermore, the actuarial model used in CARES to predict 
future demand has been notoriously inaccurate in recent experience, 
since these models predicted declining demand, while actual experience 
has been increasing demand. The Committee would like to see that the 
second phase of the CARES project incorporates a more VA-based model, 
and a real understanding of unmet mental health needs of veterans.
    The second major concern of the SCMI Committee has been the lack of 
systematic development of evidence-based community support programs 
following the massive deinstitutionalization of the population of 
veterans with serious mental illness since FY96. The Committee, since 
its inception, has strongly supported the need for VHA to move away 
from the heavy emphasis on hospital-based mental health programming. 
There is a special need to develop programs that successfully 
transition veterans who have spent long periods of time as inpatients. 
However, the Committee has always maintained that this can only be 
properly done by development of a comprehensive array of community 
support programs, which are not inexpensive, and require time, money 
and effort to put into place. In 1999, in response to a request from 
the Under Secretary, the Committee outlined its view of mental health 
services, with full implementation of a continuum of integrated medical 
and psychosocial services for veterans with mental illness (see 
Attachment B).
    The need to do such reinvestment of the resources saved by closing 
inpatient beds into outpatient programs has been recognized by many 
public programs. In New York state, the 1993 Community Reinvestment Act 
required 100% of the savings from bed closures to be reinvested in 
outpatient programs to serve the mentally ill. Similarly, under 
Governor Whitman, the state of New Jersey has committed to a 
reinvestment of 100% of the savings into community support development 
(personal communication, Alan Kaufman, Director, NJ Division of Mental 
Health). These states began with substantial outpatient programs before 
the deinstitutionalization programs of the 1990's, unlike the VA, yet 
still invested in their continued development. VHA had historically 
only minimal interest in outpatient programs, until the major 
reorganization in 1996 fashioned through the Network structure and 
VERA. Yet, the reinvestment of inpatient into outpatient resources has 
been substantially less in VHA than in other parts of the public 
sector.
    According to information published by the Northeast Program 
Evaluation Center (NEPEC), the National Mental Health Program 
Performance Monitoring System: FY2001 (and FY1996) report (Table 6-8), 
the reinvestment for the VA can be computed as follows (all dollars in 
millions):

----------------------------------------------------------------------------------------------------------------
                                                                            Inpatient             Outpatient
----------------------------------------------------------------------------------------------------------------
$ spent on services 1996...........................................           1,481.7                 484.8
$ spent on services 2001 unadjusted................................           1,133.6                 796.3
$ spent on 2001 adj to 96..........................................             850.2                 597.2
Change from 96.....................................................            -631.5                +112.4
----------------------------------------------------------------------------------------------------------------

    Medical inflation was assumed to be a very modest 25% during this 
time period (approximately the compounded annual salary increase, and 
much less than the medical care inflation index for this time period). 
Thus, the $631.5 million dollar savings (in 1996 dollars) from closing 
inpatient beds was accompanied by a $112.4 million dollar increase in 
outpatient services, reflecting a reinvestment percentage of 17.8%, 
which is a very modest reinvestment percentage. In fact, when one 
considers that the outpatient MH workload increased during this time 
period by 25% (NEPEC table 5-6), the reinvestment in outpatient care 
was not sufficient to keep up with the increased demand. There was very 
little capacity to provide the increase in community support services 
needed by the outflux of deinstitutionalized veterans. These figures do 
not include increases in the cost of psychiatric medications, which 
totaled $192 million in FY2001 (or $144 million in FY96 dollars). Since 
cost data are not available for psychiatric medications in FY96, the 
increased expenditure can only be estimated. In any case, increases in 
cost due to medication will not reflect increased community support 
programs. The major advantage of the newer, more costly medications is 
the decreased likelihood of tardive dyskinesia, and a change in side 
effect profile that may be more tolerable for some patients.
    It is understandable that VHA had enormous challenges finding 
adequate funding to meet all of the various needs of the rapidly 
expanding population of veterans seeking services. Lower priority 
veterans, who often use VHA for a marginal portion of their health 
care, for services not covered by their other health insurance options, 
have been drawn increasingly to VHA services. The number of Category C 
veterans treated in VHA increased by 964% (almost ten-fold) from FY96 
to May 2002. During the first eight months of FY2002 the rate of growth 
in Category C veterans has continued to accelerate. The number of 
Category C veterans increased by 46%, compared to the same period in 
FY2001. In FY2001, only 23% of the costs of treatment for Category C 
veterans was reimbursed by insurance. The net cost to VHA in FY2001 for 
the treatment of Category C veterans was $747 million. During a 
comparable time period, FY1996 to FY2000, there was a decrease of $478 
million (inflation adjusted dollars) in expenditures for specialized 
mental health care for veterans with serious mental illnesses. These 
data suggest that the dollars saved in mental health expenditures were 
absorbed by the treatment costs of lower priority, Category C veterans. 
It is not surprising that little was available for reinvestment of 
saved inpatient dollars into new community support programs to address 
unmet needs of this high priority group.
    This low level of reinvestment is reflected in the ongoing concern 
by the Committee that the Department has consistently not met the 
provisions of the capacity legislations laid out by Congress. Since the 
Capacity Report for FY2001 is still in draft form, the Committee is 
unable to comment on it, so we will review the Committee assessment for 
FY2000.
    It is important to restate the precise language of the capacity 
provisions of Public Law 104-262 for reference. That law stated: ``. . 
 the Secretary shall ensure that the Department maintains its capacity 
to provide for the specialized treatment and rehabilitative needs of 
disabled veterans (including veterans with spinal cord dysfunction, 
blindness, amputations, and mental illness) within distinct programs or 
facilities of the Department that are dedicated to the specialized 
needs of those veteran in a manner that (A) affords those veterans 
reasonable access to care and services for those specialized needs, and 
(B) ensures that the overall capacity of the Department to provide such 
services is not reduced. . . .'' The baseline year for determining 
capacity is FY96. Public Law 104-262 itself originally did not define 
capacity. (We note, however, that this law was recently amended to 
include, among other changes, a definition of capacity.)
    The Department, after consulting with the Committee, originally 
determined that both the number of veterans treated and the dollars 
expended for their care in specialized programs would be the most 
appropriate measures for capacity. Capacity could only be maintained if 
both components were met. It was recognized that mere measurement of 
the number of individuals served was insufficient, since these patients 
have broad needs for a full continuum of care, and the mere measurement 
of the number served could result in providing inadequate service to 
the same or larger number of patients.
    The quality and adequacy of the care required by these special 
patients also must be measured. The Committee concurred that beds would 
not be an appropriate measure of quality, since there was the desire to 
move the care of these patients to the community whenever feasible. It 
was recognized, however, that comprehensive community care for these 
very complex patients was also expensive, and that VA had a great need 
to expand and improve its array of community-based services prior to 
the deinstitutionalization of the seriously mentally ill. Dollars 
expended was seen as a pragmatic means to measure the intensity of 
service provided this special population. The Committee's advice was 
sought and we concurred that this was a reasonable way to monitor 
whether the necessary reinvestment of resources from institutional to 
community-based care was occurring. This measure would be used until 
valid and comprehensive measures of the outcomes of care for these 
patients were implemented nationally. As a measure of intensity of 
service, the Committee believes this is meaningful only if a reasonable 
adjustment for inflation is included. Over the several years of the 
capacity report, such an adjustment has become more important. Indeed, 
the FY99 Capacity Report included in Table 1 inflation adjusted dollars 
expended on specialized services, in response to comments from the 
Committee on the need to do so. Subsequently, the FY00 report omits 
this key information.
    Reviewing the summary information for the report, as presented in 
Table A.1 of the FY00 report, one should only compare the two elements 
of the definition of capacity above, after appropriate adjustment for 
inflation. Even without such an inflation adjustment, however, it is 
clear that the two elements of the capacity definition were not both 
met for PTSD, the overall SMI group, and most strikingly, for the 
Substance Abuse population of veterans. They were met for the SMI 
homeless population. The interpretations provided in this table use the 
term capacity solely for the numbers of individuals served. These 
interpretations are at variance with the capacity definition. Based on 
the data supplied in the FY2000 Capacity Report, the Committee 
concluded that the Department was still not in compliance with the 
Capacity provisions of P.L. 104-262. The Capacity report indicates that 
in FY00 VHA was spending, in unadjusted dollars, only 92% of the FY96 
expenditures for the seriously mentally ill. The erosion of financial 
commitment to these patients, when expressed in terms of constant 1996 
dollars, is actually greater, with the Department spending only 77% of 
the 1996 levels on their specialized care, a further decrease in buying 
power over last year's report. This reflects an effective decline of $ 
478 million annually. To meet the intent of the capacity law, this 
amount should be immediately and on a recurrent basis invested in 
community support development.
    To most meaningfully reverse this decline, and meet the intent of 
the capacity law, the Committee specifically recommended expansion of 
intensive case management programs, providing MH specialty access in 
the CBOCs and expansion of opioid substitution programs where need 
exists. The Under Secretary supported these measures with Directives 
and performance measures. There has been some expansion of MHICM teams 
throughout the VHA since then, although these teams appear to have come 
from redirecting already existing MH resources, and a number of key 
components of the MHICM directive have not been consistently followed 
by many programs. Plans have been created to bring MH access into CBOCs 
and expand opioid substitution programs in the past year, but it is 
unclear if these will lead to new services in the near future.
    On a related note, the Committee noted in its 2002 Annual Report 
that VERA must be assessed and revised as necessary to assure that the 
overall funding of mental health cohorts in VERA is in alignment with, 
and not less than, the overall costs of these cohorts. Funding 
generated revenue for mental health cohorts that was less than costs by 
10% in FY00. This difference is even greater for the subpopulation of 
the SMI veteran, which was underfunded by 20%. With the difficulties 
already cited above in establishing a continuum of care for the SMI 
veteran, removal of fiscal disincentives is a logical and necessary 
step. The Under Secretary, in his testimony to Congress during the 
Capacity hearings in June, 2001, committed to eliminating these fiscal 
disincentives and to ensuring that the funding model is cost-neutral 
for the mentally ill. A number of changes have been made in the model, 
but data are not yet available to determine if the fiscal disincentive 
through VERA has been removed. Concerns continue that changing the VERA 
model to another, diagnosis-based model, will need careful scrutiny to 
ensure that it is at least cost-neutral for mental health cohorts.
    Through the years, the Under Secretary has been generally 
supportive of the recommendations of the SCMI Committee. We have seen 
major recommendations implemented to
     bring new antipsychotic medications into the VA national 
formulary
     to develop Mental Illness Research, Education and Clinical 
Center grants for 8 sites, with the possibility of an additional two 
sites
     prevent decreases in mental health programs without 
headquarters approval (Directive 99-030)
     to develop Mental Health Intensive Case Management 
Programs sufficient to meet the need
     to require VISN plans to bring MH specialty programs to 
CBOCs except by approved exceptions
     to require VISN plans to implement opioid substitution 
programs where needs exist
     to develop professional training programs in psychiatric 
research fellowships, and psychosocial rehabilitation fellowships
     to produce a national satellite broadcast series on 
recovery for the veteran with serious mental illness
    Given the challenge of meeting the needs of the entire, rapidly 
expanding veteran population, the Committee understands the difficulty 
of finding resources for the expansion of the needed community support 
structure for veterans with serious mental illness. Indeed, it may not 
be fiscally possible without abruptly discontinuing other services, 
unless there is a major expansion in appropriations. The Committee 
hopes that VA will find a way to fund all needed medical and 
psychiatric services for the veterans who have served our country 
selflessly throughout the years, and who now need service in return.
    In summary, the committee is recommending to the Under Secretary 
that he direct VHA to
     Conduct a national assessment of unmet needs for veterans 
with SMI, leading to
     National population-based standards for a MH continuum of 
care
     A strategic plan, with appropriate incentives, to 
eventually achieve these standards
     Take immediate steps to fully implement MHICM, access to 
specialized MH services in CBOCs, and ensure access to opioid 
substitution programs
     Ensure that the funding model has no disincentives to care 
for veterans with SMI
     Reinvest savings from MH inpatient closures to address 
these unmet needs in community support programs
    The SCMI committee wishes to thank the members of the Senate 
Veterans Affairs Committee for their time and support for these 
disabled American veterans.
   Attachment A.--Committee on Care of Veterans with Serious Mental 
                                Illness
                        members of the committee
    John Barilich, MSW, Vice President of Operations, VA Medical 
Center--Delafield Road, Pittsburg, PA
    Stephen Berman, MSW, Chief, Social Work Service, West Los Angeles 
VA Medical Center
    Matthew Blusewicz, Ph.D., Associate Chief of Staff for Mental 
Health, Davis, CA
    Stephen Cavicchia, Psy.D Committee Co-Chair, Associate Chief of 
Staff, Mental Health, Coatesville VAMC, Coatesville, PA
    Paul Errera, M.D., Professor Emeritus Psychiatry, VA Medical 
Center, West Haven, CT
    Thomas Horvath, M.D., Chief of Staff, VA Medical Center, Houston, 
Texas
    Miklos Losonczy, M.D. Ph.D. Committee Co-Chair, ACOS Mental Health 
& Behavioral Sciences, DVA New Jersey Healthcare System
    Stephen R. Marder, M.D., Director, VISN 22 MIRECC, West Los Angeles 
VA Health Care Center
    Alan Mellow, M.D., Ph.D., Director, Mental Health Service Line, 
VISN 11, Ann Arbor, MI
    Susan Pendergrass, Ph.D., Clinical Services Manager, VISN 16, 
Jackson, Mississippi
    James Robinson, Ph.D., Chief, MH&BS Service Line, VA Medical 
Center, Salisbury, NC
    Robert Rosenheck, M.D., National Director- Northeast Program 
Evaluation Center, VA Medical Center, West Haven, CT
    Mark E. Shelhorse, M.D., Chief Medical Officer, VISN 6, Durham, NC
                      consultants to the committee
    Fred Blow, Ph.D., Director--Serious Mental Illness Treatment 
Research and Evaluation Center, Ann Arbor, Michigan
    James Breckenridge, Ph.D., Chief of Psychology Service, VA Medical 
Center, Palo Alto, CA
    Tony Campinell, Associate Chief for Psycho-Social Rehabilitation, 
Mental Health Strategic Healthcare Group, VA Central Office
    Thomas Craig, M.D., Program Director, Office of Quality & 
Performance, VA Central Office
    Robert Gresen, Ph.D., Chief of Treatment Services, Mental Health 
Strategic Healthcare Group, VA Central Office
    Terry Harbert, MSW, Associate Director, Primary Care, VA Medical 
Center, Topeka, Kansas
    Mary A. Jansen, Ph.D., Deputy Chief Consultant, Mental Health 
Strategic Healthcare Group, VA Central Office
    Gay Koerber, Associate Director Policy/Operations, Mental Health 
Strategic Healthcare Group, VA Central Office
    Laurent Lehmann, M.D., Chief Consultant, Mental Health Strategic 
Healthcare Group, VA Central Office
    Richard Suchinsky, M.D., Associate Chief for Addictive Disorders, 
Mental Health Strategic Healthcare Group, VA Central Office
    William Van Stone, M.D., Associate Chief for Psychiatry, Mental 
Health Strategic Healthcare Group, VA Central Office
    Christine Woods, Program Specialist, Office of the Director, VA 
Medical Center, Hampton, VA
                           consumer liaisons
    Frances Andrew, Assistant Director of Legislative Affairs, National 
Mental Health Association
    Moe Armstrong, National Association for the Mentally Ill
    Fred Cowell, Staff Director, Health Policy Department, Paralyzed 
Veterans of America
    Dr. Frederick J. Frese (alternate representative), National 
Association for the Mentally Ill
    Lisa Goodale, ACSW, LSW, Constituency Relations Director, National 
Depressive Manic Depressive Association
    Donald Mooney, M.S.W., National Appeal Representative, National 
Veterans Affairs and Rehabilitation Commission, The American Legion
    Linda Schwartz, RN, MSW, Ph.D., Yale University School of Nursing, 
Vietnam Veterans of America
    Paulo del Vecchio, Senior Policy Analyst, Substance Abuse & Mental 
Health Service Administration, Center for Mental Health Services
    Joy Ilem, Assistant National Legislative Director, Disabled 
American Veterans
    Rick Weidman, Director of Government Relations, Vietnam Veterans of 
America
   Attachment B.--Integrating Biomedical Technology and Psychosocial 
       Recovery in the Treatment of Mental Illness in the New VA

  Committee on Care of Veterans with Serious Mental Illness (9-24-99)

     i. integrating biomedical technology and psychosocial recovery
    In the last decade, major advances in the treatment of mental 
illness have been achieved in both new biomedical technologies and 
through the development of progressive models for psychosocial 
recovery. New medications for the treatment of both major mental 
illness and substance abuse have been thoroughly evaluated and are 
being widely adopted. In addition, the Recovery model of psychosocial 
rehabilitation has demonstrated that all people with mental illness, no 
matter how impaired initially, can benefit from programs in which their 
human capabilities are expanded through exposure to appropriate work 
opportunities and constructive community activity. The VA of the future 
must sponsor a mental health system which integrates Biomedical 
advances and the psychosocial Recovery model to maximize the health and 
well being of veterans with mental illness across the nation.
                             ii. the new va
    During the past four years VA has reoriented its priorities away 
from being a health care system based on institutions and towards one 
that provides equitable service to entire populations. During the next 
five years VA must further commit itself to the goal of providing 
appropriate mental health services to all veterans: (1) regardless of 
where they live (whether they happen to live nearby or far from a VA 
hospital); (2) to people with mental illness at the same level as to 
those with physical illnesses; (3) to female as well as male veterans; 
(4) to minorities requiring culturally sensitive services as well as to 
whites; (5) to elderly veterans as well as to young veterans in 
transition from military to civilian life; (6) to veterans with 
illnesses requiring specialized treatment such as PTSD, substance 
abuse, psychotic disorders and to the dually diagnosed with co-morbid 
psychiatric and substance abuse disorders; (7) and to homeless veterans 
and others with major needs for social support and material assistance 
as well as for medical treatment. VA's vision for mental health care in 
the future must therefore be to integrate Biomedical technology and 
Recovery equitably and systematically for all eligible veterans.
                           iii. core services
    The Under Secretary's Committee on Care of Severely Chronically 
Mentally Ill Veterans identified nine services in three broad 
categories that should be the target of developmental efforts in the 
coming years (Table 1).
    Biomedical Technology. Four of these services are in the area of 
biomedical technology and involve: (1) assuring ready access to crisis 
intervention and acute hospital care in the event of psychiatric 
emergency; (2) timely adoption of new pharmacologic agents once their 
cost-effectiveness has been demonstrated; (3) ready access to basic 
mental health care in both specialty mental health clinics and primary 
care clinics, to assure continuity for those with general as well as 
specialized treatment needs; and (4) comprehensive primary physical 
health care to address the poor health and high risk of mortality among 
many people with serious mental illness.
    Psychosocial Recovery. Three additional services fall under the 
category of psychosocial recovery enhancement. (5) Every veteran 
deserves humane housing with supports adequate, not only to maintain 
them in the least restrictive environment, but to encourage improved 
functioning and community adaptation. (6) Rehabilitation and employment 
programs must also be readily available not only to maximize 
functioning, but also to enhance self-respect and dignity. Finally, (7) 
the active involvement of families and consumers as partners in the 
pursuit of recovery is fast becoming a standard of practice in 
progressive mental health systems. VA must seize the opportunity to 
participate in this development, giving those with the most to gain 
from the VA a voice in its evolution, and making Recovery a goal for 
every veteran with mental illness.
    Service Integration. Finally, two kinds of special integrative 
services are needed. (8) Case management is necessary to assure 
integration and ready access to needed services for the most disabled 
veterans. (9) Outreach efforts must be mounted to assure access to VA 
services among veterans who are especially alienated and distrustful, 
such as homeless veterans, the elderly, and veterans with PTSD who are 
contacted through the peer-oriented Vet Center program.
                          iv. a plan of action
    Delivery of premier mental health services in VA can be advanced 
through a three-stage process.
    (1) First, the availability of each of the nine services listed 
above must be assessed for each geographic area of the country (i.e. 
for each VISN), as well as for minority groups, female veterans, and 
veterans in high risk diagnostic groups. Data are readily available on 
some of the nine service categories (e.g. on Mental Health Intensive 
Case Management and acute hospital care). However, data will be more 
difficult to get about others (e.g. housing, residential care). VA 
should set itself on a course to review its performance, nation-wide, 
in each of these areas of core service delivery.
    (2) Second, in areas of the country, or for sub-populations for 
whom services are not available at all, or are available at suboptimal 
levels, action must be taken to fill service gaps, whether in the area 
of biomedical technology, psychosocial recovery, service integration, 
or all three. New staff and programs will need to be brought on line to 
fill these deficiencies, whether they are internal VA programs or non-
VA programs whose availability to VA patients is guaranteed by either 
informal community partnerships or formal contracts.
    (3) Finally, the overall performance and maintenance of each of 
these nine service domains should be monitored to assure adherence to 
best clinical practice models and to facilitate flexible transfer of 
innovations from one part of the system to the others.
                             v. conclusion
    To deliver mental health care second to none, VA must commit itself 
to a comprehensive program that fosters the development of services 
that integrate both biomedical technology and psychosocial recovery, 
and that provide accessible, customer-focused service of the highest 
quality across the entire nation.
table 1. integrating biomedical technology and psychosocial recovery in 
                     the new va: nine core services
I. Biomedical Technology
    1. Crisis intervention/Acute hospital care
    2. Advanced pharmacotherapies as they are developed and as their 
value is demonstrated.
    3. Primary mental health care.
    4. Primary medical care.
II. Psychosocial Recovery
    5. Appropriate Living Environments (Housing, Supported Housing, 
Residential care)
    6. Rehabilitation/Work
    7 Family involvement/Consumer Support
III. Integration of Services
    8. Case management
    9. Outreach
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
                    to Miklos Losonczy, M.D., Ph.D.
    Question 1. According to your testimony, the VA is not meeting the 
Capacity requirements. If a Congressional mandate and your own 
Committee's findings are not enough to ensure that VA treats mental 
health at the same level as primary care, what does the SMI Committee 
think it will take to ensure parity?
    Answer. VA management is highly attuned to the details of the 
Performance Monitoring system and to the funding allocation model. It 
is with these tools, used in a more focused manner, that VHA management 
could positively affect meeting mental health unmet needs on par with 
primary care.
                  the performance measurement program
    VHA supports its strategic planning process with a Performance 
Measurement Program, administered by the Office of Quality and 
Performance Services. Performance Measure compliance is monitored 
closely and regularly throughout VA, and results are of great interest 
to Network and Facility Directors. Although certain Performance 
Measures, such as those for MHICM and for opioid maintenance, have 
direct Capacity implications, many mental health-related measures do 
not. In addition, superficial compliance has undermined the intent of 
certain measures. Thus, recent NEPEC data suggests that many VISNs have 
implemented MHICM teams in apparent compliance with the Performance 
Measures, but have inadequately staffed these programs. Plans for 
insuring access to mental health in CBOCs have similarly suffered from 
wide variation in meeting the intent of this performance measure. The 
adequacy of opioid substitution program enhancement plans, in response 
to that performance measure, has yet to be assessed by the Committee.
    Improvements with respect to VA mental health parity would result 
from (1) increased priority assigned to the mental health-related 
components of the VA Performance Measure Program; (2) greater 
involvement of SMI Committee members and VACO Mental Health Strategic 
Health Group staff in the Performance Measure development process; and 
(3) VA adoption of Performance Measures that specifically target 
Capacity issues (i.e., changes in numbers of patients treated, 
available staffing, etc.). As an example of (3), consider that data 
from the VA National Patient Care Database has consistently shown that 
in recent years a substantial number of VA users carry a psychiatric 
diagnosis but receive no VA mental health care; nevertheless, it is 
unlikely that all such patients are in remission or otherwise require 
no psychiatric evaluation or treatment. A Capacity- related Performance 
Measure could be developed to monitor facility and VISN rates of 
untreated veterans with mental health disorders, benchmarked against 
national annual averages.
                           funding allocation
    VA manages health care delivery in the context of the funding 
allocation system, the Veterans Equitable Resource Allocation System 
(VERA). The SMI Committee believes that progress towards mental health 
parity would be greatly facilitated by appropriate revisions to VERA. 
Presently, VERA prices only a relatively small group of seriously 
mentally ill patients in the highest of three reimbursement levels, 
which has the net effect of under funding mental health patients 
overall. External reviews of VERA, including the most recent General 
Accounting Office review, have called for major revisions, particularly 
with respect to VERA's limited number of reimbursement classes. The two 
proposed VERA revisions under present consideration result in very 
large but greatly inconsistent redistributions of VISN funding. 
Furthermore, neither of the two proposed revisions appears to 
adequately address VA mental health costs. The Diagnostic Cost Group 
(DCG) proposed revision is based on a system developed for very 
different non-veteran patient samples. The DCG-based proposed 
alternative was thus forced to employ the current VERA patient registry 
for mental health and other special populations. Consequently, it 
offers little real improvement with respect to these patient groups
    VERA was from the outset designed to utilize the resource 
allocation system to support major changes in national policy. The VERA 
Patient Classification Workgroup should reconsider the current proposed 
revisions while giving special attention to allocating funding required 
for maintaining capacity for treating special populations in VA. 
Specifically, revisions to VERA should consider the large proportion of 
VA patients with mental health diagnoses (>25%) and the substantial 
heterogeneity in costs associated with this population. The SMI 
Committee thus supports the position of several independent reviews 
suggesting that two or three reimbursement categories do not adequately 
address the variations in VA health care utilization or costs. 
Moreover, health services research evaluating diagnosis-based risk-
adjustment methods for VA mental health care has recently yielded 
promising results, which may further support future mental health-
related revisions of VERA. If changes in the performance monitoring and 
resource allocation systems do not promote sufficient Capacity 
improvements, it may be necessary to consider increased centrally 
administered specific purpose funding for this purpose.
    Question 2. VA is embarking on an expanded effort to ``restructure 
and realign'' how VA delivers services--the CARES effort. How will the 
CARES process take into account the needs of the seriously mentally 
ill, now and in the future?
    Answer. CARES represents a bold strategic planning effort to align 
VA's resources in a manner so as to optimize provision of veterans 
health care in the next twenty years. Considerable effort has gone into 
developing quantitative models to project system demand over this time 
period. The Committee remains concerned, however, that despite the 
wealth of modeling data and projection assumptions already established 
for this project, there remains no, explicit, quantitative plan to 
account for the VA mandate to care for special populations, in 
particular those with serious mental illness.
    In the most recent description of the CARES planning model (CARES 
Guidebook, Phase II, June, 2002, p. 43), it is acknowledged that the 
actuarial consultant ``did not model special disability programs''. 
While there is a mention that ``mandated levels (of utilization) will 
be substituted as needed'' to ensure capacity maintenance, the 
Committee feels that, given the expedited nature of the CARES project, 
this lack of detail this late in the process is inadequate; it is 
critical that the appropriate modeling for this be developed 
immediately, so as to ensure adequate input/feedback from VA Mental 
Health leadership and other stakeholders before development of final 
plans for each VISN. Such modeling must explicitly take into account 
not only capacity requirements, but an accounting for the patterns of 
veterans mental health care utilization (for which there are not good 
correlates in the private sector models used by VA's actuarial 
consultant), e.g., need for a robust continuum of care and need for 
access which is more in line with that expected for primary care rather 
than specialty care, given the vulnerability of this population. The 
reliance on extrapolating recent trends in utilization also has 
potential pitfalls. There is wide variation in mental health program 
development and elaboration throughout the country. On top of that, the 
variation in utilization trends is also substantial. Using these 
trends, rather than a population based needs assessment, risks 
projecting future needs on highly variable historical commitments and 
declines.
    Given the Committee's concerns, we have undertaken to engage the VA 
CARES leadership in a collaborative effort to correct what we believe 
to be a substantial problem in the CARES planning process. To ensure 
this problem is remedied consistent with the timeline for the CARES 
process, we strongly feel that a focused task force, made up of both VA 
Mental Health and CARES personnel should be immediately charged by the 
Under Secretary with explicitly defining the modifications to the CARES 
models required for an adequate accounting of special populations. We 
have already expressed our grave concern at the ongoing erosion of VA's 
resource commitment to the care of the seriously mentally ill. We are 
concerned that without a vigorous addressing of the CARES issue, the 
erosion could escalate further under the auspices of a strategic plan, 
which inadequately accounts for a major priority of VHA.
    Question 3. Your network (VISN 3) has been particularly challenged 
by the influx of higher-income veterans. As this has occurred, are 
services for veterans with mental illness unequally targeted for cuts?
    Answer. To address this issue, I'd like to share my personal view 
of some of the defects in the VERA model, which is used to determine 
resource allocation at the VISN level, but without any significant 
guidance as to how that allocation is further distributed within the 
VISN.
    First, the VERA model intentionally causes massive under funding of 
long-term care. There are three large categories of long-term care used 
in the VA nationally: (1) nursing home beds (2) long stay patients in 
mental health and (3) intermediate medical beds. If a patient stays an 
entire year, VERA causes the facility to lose about $70,000 per 
veteran, even after factoring in the higher reimbursement of the 
complex care category. This is an enormous disincentive to provide this 
level of care. Indeed, there have been very substantial reductions in 
this level of care. Nursing home advocates succeeded in convincing 
Congress to require VHA to maintain at a VISN level the number of 
nursing home beds existing in 1998, when it passed the Millennium Bill. 
The dual impact of the VERA model and the Millennium bill posed special 
challenges for VISN 3.
    Historically, there was very wide variation in the development of 
long-term care beds throughout the country. In 1996, VISN 3 had the 
highest number of patients in such beds, accounting for 50% of its 
total costs. These long-term beds reflected the historical investment 
in developing both nursing home beds and mental health beds, including 
the largest number of long stay mental health beds in the country. The 
immediate impact under VERA was to put VISN 3 under the largest funding 
deficit in the country. In my view, there should have been a thoughtful 
estimate of surplus beds and/or unmet needs for both nursing home and 
mental health beds in all VISNs throughout the country. This would 
allow the resource model driving a set of clinical standards based on 
need, not history. Furthermore, when there is a large variation of 
current costs and VERA guided reimbursement, there should be a planned 
transition period that adequately takes into account the time it takes 
even highly efficient planning to radically alter existing distribution 
of programs. Instead of this more measured approach, VHA simply placed 
a cap on the amount of loss any one VISN would need to sustain, but the 
overt view was that the need to place a cap was the result of poor 
management performance, not due to an inevitable time lag for massive 
program change (or even undesirable program change).
    Second, whether through oversight, design, or another inertia of 
history, VERA does not adequately adjust for geographic cost variation, 
in my opinion. The VERA adjustment for labor and contracts 
significantly under-reimburses VISN 3 for medical care. Included in the 
costs of medical care in NY are not only salary costs but also items 
like fuel and utilities and contracts. The relative lack of geographic 
adjustment in VERA is underscored by examining how this issue is 
handled in other federal health care reimbursement structures. For 
example, the HCFA reimbursement for DRG 430 (Psychosis) is 50% higher 
in the NY metro area than the national average. VERA makes no such 
adjustment. It is hard to understand why the federal government would 
be willing to have such a large geographic adjustment to reimburse 
public and private facilities through its far larger HCFA budget, but 
VA would use a very different standard. As you know, VERA does not 
reimburse for Category 7 veterans, the assumption being that these 
veterans are not poor. Whereas this may hold true in some rural parts 
of the country where an annual income of $24,000 a year is considered a 
reasonable means test cut off for Category 7, in NYC an individual 
making $24,000 is considered impoverished. Indeed, the HUD definition 
of very low income identifies $29,050 a year for a single person in the 
VISN 3 area, while the same definition in the south can be more than 
$10,000 less. As a result, many category 7 patients in NY are more 
similar in medical and social needs to Medicaid patients living in 
poverty than to middle class patients, yet VISN 3 receives no 
reimbursement for these patients because of the lack of adjustment for 
the means test. In addition, these impoverished veterans are penalized 
by having to pay a co-payment for care. The rationale for a meaningful 
regional adjustment is particularly clear, in my mind, when one 
considers the income levels used to establish the critical boundary 
between category 7 veterans and higher priority categories.
    As the SCMI Committee testimony makes clear, category 7 veterans 
cost VISNs (and the VHA) substantial sums, so the definition of the 
income boundary for this category is crucial. The basic notion of this 
group is that they are not service connected and are not poor. One 
would think that any rational definition would take into account the 
fairly large variation in cost of living from one part of the country 
to another. A veteran earning even $10,000 dollars above the current 
category 7 boundary in VISN 3, a very high cost area, would face far 
higher housing costs, and many other living costs, than the veteran in 
the part of the country with average living costs, or even below 
average costs. Yet there is no geographic adjustment in definition of 
category 7 vets that takes this key factor into account. This means 
that instead of being reimbursed by VERA for the veterans in this 
marginal income group, VISN 3 is obligated to lose substantial sums on 
the care of these veterans.
    There are other, less obvious, impacts on clinical practice of 
serving in this area. Low-end housing costs (on which the vast majority 
of psychiatric patients are forced to rely) are much, much higher in 
VISN 3 than most other parts of the country. This makes it more 
challenging to have a range of alternatives available to assist 
veterans when they are homeless or have lost their housing during an 
inpatient admission. Rent alone, even at the low end, can be higher 
than income available to some veterans. This has a tendency to increase 
lengths of stay and hospital costs, relative to an area with a much 
lower low-end rental market.
    Finally, when Congress passes legislation requiring a specific 
distribution of services within the VA, but does not require the 
adjustment of VERA or the overall total VHA budget to reflect the 
impact of such legislation, it can pose special challenges for affected 
networks. Indeed, such was the case with the Millennium legislation. 
Since VISN 3 started with one of the most significant commitments to 
providing nursing home beds, passage of that legislation had a greater 
effect for VISN 3 in requiring it to provide a higher level of service 
than the national population-based average for a very costly service. 
From my point of view, VERA needs to be properly adjusted when 
legislation removes fiscal control from VISN managers. Naturally, the 
issues raised above affect not only VISN 3, but also many other VISNs 
as well to lesser degrees.
    Given the above considerations on issues outside the control of 
VISN 3 managers, the massive projected shortfall for VISN 3 year after 
year after year, forced VISN 3 to cut or redesign services wherever it 
could safely do so. Historically, VISN 3 had enjoyed one of the 
greatest investments in providing mental health services of any 
network. However, the network mental health services were too heavily 
invested in inpatient-based care, and had incompletely developed 
community support programs. Nevertheless, compared to other VISNs, even 
in 1996, VISN 3 had MHICM programs (then called Intensive Psychiatric 
Community Care) at 4 of its 6 sites and relatively intensive day 
treatment programs at most sites. The continuing budget contraction 
made it very difficult to reinvest any significant fraction of savings 
from inpatient services, but both Lyons and Northport were able to 
create new MHICM teams from a partial reinvestment. The commitment of 
the VISN to maintaining high quality mental health services as feasible 
under its budgetary constraints was visible from its inception. The 
VISN CEO, Mr. Jim Farsetta, has a long history of involvement and 
support for mental health (he is on the Board of Trustees for Rockland 
Psychiatric Center, a New York State facility, for example). One of his 
first VISN-wide initiatives was to charge a VISN level mental health 
leadership group with improving and coordinating care. Homeless 
services, critical in the expensive New York metropolitan environment, 
have significantly expanded under his leadership, and that of Ms. 
Henrietta Fishman, the first VISN service line coordinator. It is also 
the first VISN to monitor the outcome of the significant numbers of 
veterans deinstitutionalized during this period, and can accurately 
assert that they are doing well and are successful in the community. 
Given the very small flexibility in VISN 3 to act in this environment, 
it is my impression that the cuts were fairly equally distributed among 
the various clinical services. If VERA had been more fairly designed, 
the budgetary pressure to reduce staff would have been substantially 
less, and there would have been more flexibility in developing new 
community support programs to address unmet needs.

    Senator Jeffords. Mr. Chairman, I have to leave. I just 
wanted to thank the----
    Chairman Rockefeller. Did you want to ask questions, 
Senator Jeffords?
    Senator Jeffords. I have got to start another hearing. I 
appreciate the opportunity to be here and certainly want to do 
anything I can to help you, Mr. Chairman, take care of their 
problems. Thank you.
    Chairman Rockefeller. Spoken like the good veteran you are.
    [The prepared statement of Senator Jeffords follows:]

Prepared Statement of Hon. James M. Jeffords, U.S. Senator From Vermont

    Mr. Chairman, I would like to thank you for holding this 
important hearing. Some would argue that mental health services 
have a relatively low profile in the VA. In my mind, however, 
they are among the most important services the VA can provide 
to this nation's veterans. Veterans will tell you that they 
travel great distances to go to a facility that appreciates 
their unique status as a veteran and treats them with 
corresponding respect. This special feeling of being valued and 
being understood is of paramount importance when it comes to 
treatment of mental illness. The VA is the right place to 
deliver this care. It has some of the nation's top mental 
health expertise, years of clinical experience, and most 
importantly, the VA has the trust of veterans. It is high time 
that the program was provided the funding it needs and the 
attention that it deserves.
    While we will not have time to focus specifically on PTSD 
treatment and research today, I would like to bring to my 
colleagues attention the important contributions of the VA's 
National Center for Post-Traumatic Stress Disorder. This 
center, headquartered in White River Junction, Vermont, is 
dedicated to improving the quality of VA treatment provided to 
veterans with PTSD. The Center's research, educational, and 
consultation activities have unquestionably promoted better 
clinical treatment for veterans with PTSD. The center has made 
significant contributions to our scientific understanding about 
the causes, diagnosis, and treatment of this potentially 
incapacitating disorder that affects thousands of service-
connected veterans. The Center has been innovative in its 
efforts to get information about PTSD treatment into the hands 
of practitioners, who can put the information to use with 
patients. For example, the Center has developed some unique 
resources for mental health professional, such as an award-
winning website and the largest and most comprehensive 
bibliographic database in the world, called PILOTS, the 
Published International Literature on Traumatic Stress.
    As a central authority on PTSD, the National Center has 
frequently served as a consultant to VA policy makers as well 
as other governmental and international officials on matters 
concerning treatment programs and practices. The Center has 
played an important role in developing practice guidelines for 
individual treatment and for early intervention following major 
disasters. Detailed information on the Center is included in 
its latest Annual Report, which has already been distributed to 
members of this Committee.
    I wanted to take this time today to acknowledge the 
important work of the VA's National Center for PTSD. Strong 
support for this Center is an important part of any effort to 
improve VA mental health care and improve treatment for 
veterans with PTSD.
    Mr. Chairman, once again, I appreciate your holding this 
hearing today. I hope that these efforts will highlight the 
areas where improvements must be made, and underline the 
critical importance of doing so immediately. I apologize for 
not being able to stay for all of the testimony, but I am 
chairing a hearing of the Environment and Public Works 
Committee in just a few moments, but I will be interested to 
hear what comes of your discussion.

    Chairman Rockefeller. I am glad to hear that veterans with 
mental illness have the full support of the Under Secretary, 
but I would like to see more concrete results. That is the 
essence of oversight, it seems to me. In other words, there is 
no question that Dr. Roswell is supportive. What the veterans 
care about is results. And between the Washington words 
``supportive of'' and the services provided--the concrete 
results, is the difference.
    You used the words ``aggressive case management,'' or 
``intensive case management,'' did you not, in your testimony?
    Dr. Losonczy. Yes, we both did.
    Chairman Rockefeller. I would like to understand what is 
meant by that. What needs to happen in intensive case 
management of an individual veteran with a mental health 
problem? Dr. Roswell, then I would like you to say what you 
think this means, and what it is that you can and cannot do to 
make it happen.
    Dr. Losonczy. Intensive case management in the sense that 
the committee has used the word is also called assertive 
community treatment and is a well studied, evidence-based 
process that clearly is effective in many ways for the 
seriously mentally ill. But let me just underscore that this is 
not a treatment that is designed for everybody, not even 
everybody that is seriously mentally ill. It is a treatment 
that is designed for those people that have particular trouble 
accessing services on their own, who spend a lot of time on the 
inpatient side, in part because they have trouble accessing 
outpatient services, who require rehabilitation efforts in 
order to be able to achieve their best potential.
    The way that the MHICM, or intensive case management model 
has been adopted in the VA is a modification of the evidence-
based ACT programs in the community. They are multi-
disciplinary by definition. An intensive case management team 
can have no fewer than four members. It should have a 
psychiatrist, a psychologist, a social worker, a nurse, ideally 
a rehab specialist. For the intensive case management to work 
effectively, it should focus on what the veteran is able to do, 
what the reasonable goals they can agree with the veteran on 
achieving, and to develop an effort to achieve them.
    Chairman Rockefeller. Can I stop you there and then turn to 
Dr. Roswell. Just tell me, and obviously there are variations 
across the country, but what is it that VA could do to meet 
that standard and what is it that VA cannot do to meet that 
standard.
    Dr. Roswell. I agree with everything Dr. Miklos Losonczy 
said, but Mr. Chairman, the key of assertive community 
treatment is the interdisciplinary team that Miklos spoke of, a 
psychologist, a psychiatrist, a psychiatric social worker. 
There are basically two main therapeutic approaches----
    Chairman Rockefeller. No, no, I asked a question. I 
understand what he said and I understand what you are saying. 
What I am asking is how well and how consistently do you meet 
that standard?
    Dr. Roswell. We meet it inconsistently.
    Chairman Rockefeller. This is the difference between 
support and concrete results.
    Dr. Roswell. We meet the standard inconsistently. We do 
have over 65 of these programs in place and others are being 
developed.
    Chairman Rockefeller. Sixty-five covering how many?
    Dr. Roswell. We have over 1,200 locations of care.
    Chairman Rockefeller. So what kind of statement is that?
    Dr. Roswell. Where I was trying to go is that mental health 
care for the more serious mental illness is resource-intensive. 
It requires an interdisciplinary team, but one of the 
modalities is psychotherapy. Psycho-social readjustment 
involves a lot of close interpersonal interaction between 
patient and clinician, and an interdisciplinary team, such as 
the community case management model that we are speaking of, to 
be efficient, has to have a critical mass of at least 30 to 40, 
possibly 50, patients to be able to utilize the talents and 
capabilities of the professions involved in the 
interdisciplinary team.
    So the difficulty is placing that kind of expertise at so 
many distributed locations of care. Our typical community 
outpatient clinic has a physician, two or three nurses, and a 
couple of support staff. So to try to put in a team of four 
mental health professionals in that location would be extremely 
resource-intensive, and then if we were to do that, we would 
find that they would not have the patient population that 
supported----
    Chairman Rockefeller. And I understand that. Excuse me for 
interrupting. So, in effect, in these 1,200 locations--and, of 
course, some of those are outpatient, as you have indicated, 
what is the degree of your effectiveness? It sounds like a 
shortfall, and if it is, I do not want to criticize you for it.
    Dr. Roswell. It is a shortfall, Mr. Chairman. It is hard 
for me to characterize the magnitude of the shortfall, and 
again, I think that is where we have to do a better job of 
needs assessment, as was mentioned. I think the mental health 
improvement plan allows us to begin to more accurately assess 
what the actual needs are.
    Chairman Rockefeller. Can you do your assessment? But then 
is the money, this thing that Senator Wellstone said about what 
to put back into the budget. Is the money going to be 
available, regardless of what your assessment comes out to be? 
Are you going to be able to do it, or is it one of these 
constantly elusive Washington goals?
    Dr. Roswell. Obviously, we are struggling with a tremendous 
demand for resources and the reinvestment that Senator 
Wellstone spoke of is low, partly because we believe that the 
way we can provide mental health today, including the type of 
model we are speaking about, is less costly and, therefore, 
should generate savings that can be used to provide a more 
comprehensive spectrum of mental health services for veterans.
    Chairman Rockefeller. That is interesting. Your statement 
it is very honest. But what you are, in essence, saying is that 
you want to be able to do more, but cannot.
    Plus, you do not really decide your budget, nor do we in 
this committee. That decision is made by the Appropriations 
Committee, the White House, and OMB. You cannot come here and 
say things that you may want to because of OMB. We understand 
that.
    Dr. Roswell. Yes, I know.
    Chairman Rockefeller. So when you say that we have to cover 
the full spectrum of health care needs, that is a statement 
about mental health priorities. I am just putting that out for 
you to ponder. What kinds of things might happen if you focused 
more on mental health?
    Dr. Roswell. Well, today, there are over 300,000 veterans 
across this country who will have to wait 6 months or more to 
receive care that they were told they would be eligible to 
receive. That causes me a tremendous concern. Many of those 
veterans who have come into our system just within the last 
couple of years after the system was opened to all veterans, 
beginning in October 1998.
    There are higher-income veterans, the Priority 7 veterans, 
who do not have service-connected disabilities and do not have 
special needs, such as serious mental illness. Many of them are 
coming to the VA for the first time ever to seek prescription 
benefits to augment their current Medicare coverage. It is 
difficult to manage that kind of demand for care and the 
political pressure it generates.
    I can tell you, though, that as we are aggressively 
studying this population and attempting to manage the problem, 
I can provide some preliminary reassurance that the large 
numbers of new veterans who are seeking care through the VA do 
not have a high prevalence of serious mental illness. Rather, 
the prevalence of serious mental illness seems to be greatest 
in our core population, as one would expect it to be.
    So on the one hand, we are challenged by the demand for 
prescription medications and less complex care that is created 
by the new demand of an open enrollment system, and by still 
assuring that we meet the needs of the seriously mentally ill 
veteran population, whom we have historically served and will 
continue to serve, albeit now on an outpatient basis.
    Chairman Rockefeller. OK. On April 3, 2002, there was a 
letter written to Secretary Principi by many veterans' service 
organizations and by mental health advocates. They would want 
to see complete coverage of mental health care. That letter 
will be made part of the record.
    [The information referred to follows:]

                                                     April 3, 2002.
Hon. Anthony J. Principi,
Department of Veterans Affairs,
Washington, DC.
    Dear Secretary Principi: As organizations concerned that this 
nation meet its commitment to veterans with mental illness or substance 
abuse disorders, we are writing to express our grave concern that the 
Department of Veterans Affairs (VA) health care system is failing to 
comply with its statutory obligation to provide needed services to 
these veterans.
    That obligation, expressly codified in law (at 38 U.S. Code section 
1706(b)), directs the Secretary of Veterans Affairs to provide for the 
specialized treatment and rehabilitative needs of veterans with mental 
illness and substance use disorders through distinct programs and 
facilities dedicated to their specialized needs. The law requires the 
Secretary to ensure that the overall capacity of the Department to 
provide those specialized services is not reduced below the capacity in 
place in October 1996, and further directs the Secretary to afford 
veterans who have a mental illness reasonable access to care for those 
specialized needs.
    A review of the legislative history underlying this law shows that 
Congress imposed the requirement that VA maintain the capacity to 
provide specialized services through dedicated programs because of a 
concern that fiscal pressures associated with a then-proposed 
reorganization of the Veterans Health Administration might lead 
administrators to close or shrink these often-costly programs. Those 
concerns have regrettably been bome out. A special committee, chartered 
in law and charged both with overseeing the quality of care afforded 
veterans with severe mental illness and with monitoring adherence to 
the requirements of the ``capacity law'', has advised the Under 
Secretary for Health on its findings. For the last four years that 
expert committee has reported that ``the Department has not maintained 
capacity for veterans with serious mental illness'' (including those 
with substance use disorders).
    Disturbed by the Department's failure to comply with this statutory 
mandate, Congress has twice amended the ``capacity'' law, most recently 
in Public Law 107-135. In those recent amendments, Congress was clear 
in delineating VA's statutory responsibilities under the law. First, it 
amended the capacity law to make explicit that the requirement to 
maintain capacity is not simply a VHA-wide obligation but one that 
applies to each of the 21 Veterans Integrated Service Networks (VISNs), 
rejecting some VISN officials' view that this law is ``someone else's 
responsibility''. Second, it made explicit that the Department could 
not employ outcome data to meet the requirement to maintain program 
capacity, rejecting the notion that satisfactory patient outcomes would 
satisfy the law. Third, it delineated what the term ``capacity'' means 
for various specialized mental health programs. Congress employed very 
specific, objective measures, requiring VA to maintain funding levels, 
program levels, staffing levels and patient workload. Finally, the law 
calls on the VA's Inspector General to ensure through its independent 
audit function that these requirements are carried out.
    With VA's failure--both nationally and in many networks--to 
maintain its precious specialized program capacity to serve veterans 
with mental illness and substance use disorders, Congress has directed 
VA to eliminate the gap between the mental illness and substance abuse 
program capacity that existed in 1996 and the much-diminished capacity 
in place today. This law requires nothing less than that VA expand 
substantially the number and scope of specialized mental health and 
substance abuse programs so as to afford veterans real access to needed 
specialized care and services.
    We see no evidence, however, that the Department has absorbed the 
import of section 1706(b) of title 38, U.S. Code, as amended. We note 
with dismay that the budget is silent regarding both the capacity law 
and the steps VA proposes to take to meet its requirements. Since 1996, 
VA's record of compliance with this law has been limited to the 
mechanical act of compiling and submitting reports. The capacity law is 
not principally about reporting to Congress, and the submission of 
further reports--without accompanying program expansion--will not 
satisfy its mandate. It is about allocating appropriate resources to 
meet an explicit statutory requirement.
    The Department's failure to allocate the necessary resources, or 
even budget for them, is inexplicable and indefensible. This failure is 
all the more disturbing when one considers the high percentage of 
veterans with severe mental illness who are service-connected for that 
illness.
    We ask, accordingly, that you advise us, and the appropriate 
committees of the Congress, of your plans for carrying out these 
responsibilities.
            Sincerely,
                           American Psychiatric Association
                                                     AMVETS
                                 Disabled American Veterans
                                          Freedom from Fear
                    Military Order of the Purple Heart Inc.
                     National Alliance for the Mentally III
       National Depressive and Manic-Depressive Association
                         National Mental Health Association
                              Paralyzed Veterans of America
                                        The American Legion
                                   Veterans of Foreign Wars
                                Vietnam Veterans of America

    Chairman Rockefeller. These groups say that the VA health 
care system is failing to comply with its statutory obligation. 
So what I would like to get each of you to do is to help me 
understand the discrepancy.
    Dr. Roswell. Well, I believe the statutory obligation 
refers to a statutory requirement to maintain our serious 
mental illness capacity at 1996 levels. In fact, we have just 
completed our capacity evaluation and examined the number of 
veterans who are currently receiving care and I am pleased to 
report that the most recent capacity report data show that, in 
fact, we have increased capacity slightly since our 1996 
levels. So in the strict sense of the law, we are meeting our 
statutory requirement.
    Now, having said that, does that fully address the mental 
health needs of our population? I think not, and I think that 
our challenge is to make mental health services available at 
all locations of care, including our community-based clinics, 
recognizing that management of serious mental illness in those 
locations is not optimal. Therefore, we have to address the 
kind of models that Dr. Losonczy spoke about and try to have 
those distributed as best we can, recognizing that they will 
not be available in all locations because of the intensity in 
resources.
    We are working to use distance technology, telemedicine, if 
you will, to enhance telepsychiatry in outlying locations. We 
are using clinical practice guidelines. We will be focusing on 
primary care provider education and support mechanisms to 
enhance their ability to provide care to less seriously 
mentally ill veterans in outlying or community locations, and 
we will continue to focus our efforts on building the MHICM's, 
the Mental Health Intensive Case Management programs, in areas 
where the numbers of veterans who would benefit from that type 
of care are sufficient to justify their creation.
    Chairman Rockefeller. I want to ask you also, Dr. Losonczy, 
to respond to that, but I also want you to respond to something 
Dr. Roswell just said about telepsychiatry. I do not know, as a 
lay person, whether--psychiatry is usually in person. 
Historically it is very much a one-on-on, physically present 
type of service. Does telepsychiatry interrupt that intimacy, 
or does telepsychiatry take away a little bit the discomfort 
that one has in discussing inner problems.
    Now, just as Dr. Roswell said, that is a very interesting 
thought, and I want you to, first, answer the question which I 
asked him, and then second, respond to what I just said.
    Dr. Losonczy. Can I do the second one first?
    Chairman Rockefeller. Yes.
    Dr. Losonczy. OK. Telepsychiatry is a relatively new 
intervention, and when I first heard about it, I had some 
trepidation along the line of the need for human contact in 
order for it to be effective, and I think there are definitely 
individuals for whom it does not work as well due to the lack 
of human contact.
    But we have had some experience directly with it ourselves 
and we did patient satisfaction surveys on both staff and on 
the patients in some small pilot efforts and found that, in 
fact, we had no problem from the patients' perspective of being 
able to see a therapist on the other end of the TV screen. We 
did have some staff who had been trained in various models that 
found it unsettling and said they would miss some subtle cues 
that they would be able to tell in person.
    I think the jury is out. There really have not been large-
scale comparison trials, to my knowledge, about the 
effectiveness or deficits of telepsychiatry. My guess is that 
it is going to turn out to be fine for a large number of 
people, and then we will probably understand better for whom it 
will not be fine. Does that answer your telepsychiatry 
question?
    Chairman Rockefeller. It does.
    Dr. Losonczy. On the issue of how is it that the department 
and the special committee can look at the same set of data and 
have exactly opposite conclusions, historically--my 
understanding is this year's capacity report is still in draft 
form, so we are only talking about previous years' reports.
    In previous years, the interpretation of the department 
about the twofold definition of capacity was different from the 
committee's. The twofold components are that the number of 
veterans served in a specific diagnostic group, and there are 
four of them for SMI, and the dollars expended for their care 
would be at 1996 levels.
    Now, when the committee was consulted in this definition 
and agreed upon--in fact, I strongly urged the committee to 
agree on this because we did not want to limit the ability of 
the VA to be creative in the way they configured mental health 
services. We knew that the current configuration was wrong in 
1996. However, when we had our discussions with VA 
representatives, we also saw that in a year, 2 years, 3 years, 
4 years, with inflation being present, that the only logical 
definition of resources expended would include an inflationary 
adjustment.
    So the committee has always included an inflationary 
adjustment in its evaluation. The VA 1 year did and other years 
has not. So that is essentially the source of how could it be 
that two well-meaning groups looking at the same exact data 
come to diametrically opposed conclusions.
    Chairman Rockefeller. I will accept that without comment 
for the moment, but I need to think about it.
    Dr. Roswell, Dr. Losonczy highlights that there has not 
been adequate reinvestment in outpatient care after the massive 
closure of beds. Adjusting for inflation, VA only reinvested 18 
percent of the savings from the closures into additional mental 
health outpatient treatment. Where did all this money go? 
Senator Paul Wellstone brought this up, and I want you to tell 
me where the money went, because it obviously did not go to 
mental health.
    Dr. Roswell. In 1996, VA was treating about 2.9 million 
veterans each year. This year, the VA will treat 4.6 million 
veterans.
    Chairman Rockefeller. You mean in general?
    Dr. Roswell. In general. I am talking about all veterans.
    Chairman Rockefeller. Yes.
    Dr. Roswell. Within the 4.6 million veterans who will 
receive care from VA this year, the percentage of veterans with 
serious mental illness--is, we believe, less, even though the 
actual number has increased. So the growth has been disparate 
across our system between the growth in demand for mental 
health services and the overall growth in demand for all types 
of care and services.
    During this same time period, VA shifted from a delivery 
system that was primarily 172 hospitals to an outpatient 
delivery system that now includes over 600 community-based 
outpatient clinics in addition to our hospitals.
    Chairman Rockefeller. I am going to interrupt again, and I 
apologize. What do you mean by ``less''?
    Dr. Roswell. I said percentage, and I am sorry if I 
disconnected that. What I am saying is that the number of 
veterans who today require and receive mental health care 
services from the VA is greater, but the growth in veterans in 
need of mental health services is not as great as the overall 
growth in veterans seeking some type of care from VA. Most of 
the growth comprises Priority 7 veterans for prescription 
benefits, and that has put tremendous pressure on us to utilize 
any available resources to meet that growing and burgeoning 
demand for care, as opposed to reinvesting in historical 
programs.
    As I said earlier, intuitively, I believe that shifting a 
delivery model from an inpatient basis to an outpatient basis 
should generate cost savings per individual treated. I believe 
there is substantial data that support that. The question that 
I have tasked some of my staff with, including the special 
committee, is how do we assess the veteran population and truly 
determine what the needs are and how effectively we are meeting 
those needs, because I do not believe our mental health 
capacity should be measured in dollars. I do not believe it 
should be measured in inpatient beds. I do not believe it 
should even be measured necessarily in the number of veterans 
treated.
    Rather, it should be measured based on the population of 
veterans we serve with data systems and with whatever 
mechanisms we have at our disposal to determine the absolute 
total need within that population and then measure how close we 
are coming to meeting that entire need.
    And sir, we are not there yet. But as a system, we are 
using the talents, the resources, the technology and our 
capability to move us closer to that goal.
    Chairman Rockefeller. What percentage of veterans with 
mental health problems, self-identify as such?
    Dr. Roswell. As a non-mental health physician, I would 
answer that serious mental illness is usually evident. Our 
outreach programs, particularly with the homeless population, 
where we have an underserved population of veterans with 
serious mental illness, is very important because they may not 
seek care. But if they do seek care, serious mental illness is 
usually evident.
    Where we are focusing on reaching out to identify mental 
health needs is in the less-serious mental illness, including 
depression screening, which is now a performance measurement 
monitoring system at all of our community-based outpatient 
clinics. We believe that all primary care providers should be 
screening patients for depression unless there is mental 
illness, but I will certainly defer to Dr. Losonczy for his 
comments.
    Dr. Losonczy. The Chairman asks a very interesting question 
and it really goes to the core of the insight that people with 
serious mental illness have about the fact that they have such 
an illness. There is work by Javier Amador, who is a 
psychologist recently moved to the evaluation staff of NAMI, 
who has examined the degree to which people with schizophrenia 
understand that they have symptoms and there is about 40 
percent of the population with serious mental illness that do 
not have insight into the fact that they have that, and they 
are particularly challenging to treat, as you can imagine 
because they do not usually come knocking on the door and 
saying, ``I would like your help, please.''
    Dr. Roswell is also pointing out that if a clinician were 
to see them, it would be evident that they have serious mental 
illness.
    Chairman Rockefeller. To the clinician?
    Dr. Losonczy. Yes.
    Chairman Rockefeller. I have used this example before, but 
I can remember going to a couple of outpatient clinics in West 
Virginia. There were receptions going on, and there were people 
in this case, relatively young men in coats and ties. I thought 
that they were local elect officials that I had not yet met. It 
turned out that they were there for post-traumatic stress 
disorder treatment.
    It was very interesting to me, and ever since then, I've 
wondered, when was it that they discovered their illnesses? Was 
it they who discovered it, or was it a family member who 
discovered it. There is such denial on mental illness and also 
a lack of understanding. Therefore, there is pressure on VA to 
be more proactive.
    Dr. Losonczy. Would you like me to respond to that?
    Chairman Rockefeller. Please.
    Dr. Losonczy. PTSD is a very separate illness, of course, 
from schizophrenia and it has a long history of different names 
throughout civilization. It is only very recent that it 
developed the PTSD name.
    Chairman Rockefeller. What was it called previously?
    Dr. Losonczy. War stress, people have felt that there was 
battle fatigue, there was a whole host of names for it----
    Chairman Rockefeller. OK. I understand.
    Dr. Losonczy. But the full syndrome was really only 
described, I think, in the 1970's, Larry, is that right?
    Dr. Lehmann. 1998.
    Dr. Losonczy. 1998, even later than that. I think that it 
is fair to say that education of the public has been critical 
for the ability of family members and patients themselves to be 
able to self-identify PTSD. It is much more challenging to 
identify PTSD by a clinician who does not have a patient 
automatically reporting these symptoms to them than to identify 
serious mental illness, a psychotic individual.
    In fact, in the older population, World War II and the 
Korean veteran population, there is much less awareness and 
knowledge about the symptoms of PTSD, although it is now 
beginning to come out, and we are seeing a growth in the older 
individual that has been diagnosed with PTSD but probably had 
it since the war.
    Chairman Rockefeller. Yes, sir?
    Dr. Lehmann. Just a few additional comments on that. One is 
that the way you saw those gentlemen at that meeting, their 
deportment, their clothes, and their demeanor, is an evidence 
of the fact that the positive impact of treatment on 
individuals who do come for treatment for PTSD and it is 
treatable and people can improve.
    I think that one of the things that we are finding--the 
information that Dr. Roswell passed on, we have increasing 
numbers of veterans who are coming to us for care for PTSD. Of 
those 57,000 who are seen in our specialized PTSD programs, 
about 20,000 of those folks were people who had not been seen 
in those programs before. So they are coming in increasing 
numbers, and about 11 percent pretty regularly tend to be 
individuals from World War II, Korea, and those populations, 
and about half of the people who we see in our general mental 
health programs for PTSD are people who are World War II/Korea, 
largely because the specialized PTSD programs were initially 
set up for veterans from the Vietnam era.
    But we are not only doing screening for major depressive 
order in primary care. We are doing that, but we are also doing 
screening for PTSD and other stress disorders. We have 
developed an educational program as part of the Veterans' 
Health Initiative for the recognition and understanding of PTSD 
in primary care settings and looking at the things one can do 
either in primary care or enhancing the referral capabilities 
for individuals who have PTSD and need referral, to specialty 
mental health treatment.
    And in addition, we have mentioned a couple of times the 
clinical practice guidelines. VA actually developed the first 
PTSD clinical practice guideline as part of our original 
depression practice guidelines, one of those modules, and 
primary care clinicians, as well as those from Readjustment 
Counseling Service, were part of that project team. I actually 
headed that project team.
    Right now, as a matter of fact, 2 weeks ago, over in 
Virginia, we started work on a new stand-alone PTSD practice 
guideline that included staff from the National Center for 
PTSD, members of the Under Secretary's Committee on PTSD, 
clinicians from Readjustment Counseling Service, and colleagues 
from all the branches of the Department of Defense.
    Chairman Rockefeller. I thank you.
    On the legislative side, our job is to make sure that all 
kinds of health care needs are covered. This then has to become 
consistent with our willingness and your willingness to fight 
for a budget to get it all done. This is obviously quite 
difficult when you start out with an enormous budget deficit 
for the next 10 years. But our job is to take care of veterans.
    So with that as a framework, Dr. Roswell, I would be very 
appreciative if you would give to this committee what it would 
cost for quality mental health care. Not to do the 65 multi-
disciplinary teams and stretch them too thin, but what it would 
cost to do mental health care properly, as you previously 
described.
    One of the reasons I am going to ask that is because I do 
not know for sure if you can give me that figure. If you will 
be allowed to give me that figure. Either way, I want that to 
become part of the public record. Do you understand? That is in 
your interest as well as my interest. If OMB says, ``no,'' you 
cannot do that, then you can tell me. Would you be willing to 
do that?
    Dr. Roswell. Mr. Chairman, I would be willing to attempt to 
develop a plan that identifies the full needs and attempt to 
convey that to this committee.
    Chairman Rockefeller. Under CARES, in a sense, you are 
looking at the whole spectrum of care so you are going to have 
to do it internally.
    Dr. Roswell. I would be happy to do that. I would point out 
that, without deviating too much, one of the most problematic 
aspects of the CARES process is being able to, with any kind of 
reasonable accuracy, project what the veteran population will 
be at a future year, what the veteran demand for care will be, 
what the disease burden will be, what health care will be like, 
and what facilities would be needed to treat that health care 
burden. It is extremely complex.
    Chairman Rockefeller. Do not worry about the future. Your 
budget may change for some reason. Do not talk to me about the 
future. Just stop time today and tell me what you would need in 
order to take today's population and give them the kind of 
treatment that they fully need.
    Dr. Roswell. Mr. Chairman, thank you for your continued 
strong leadership and your advocacy for veterans. We appreciate 
the guidance you have given us and I will do everything I can 
to give you that information as quickly as possible.
    Chairman Rockefeller. OK, and I thank all of you very, very 
much for your patience.
    Dr. Losonczy. Thank you.
    Chairman Rockefeller. I will be sending along a few more 
questions, too.
    The second panel consists of Ralph Ibson from the National 
Mental Health Association; Dr. Renato Alarcon representing the 
American Psychiatric Association; Colleen Evans, a psychiatric 
nurse from Pittsburgh's VAMC, representing the American 
Federation of Government Employees, and two representatives 
from the National Alliance for the Mentally Ill, Dr. Frederick 
Frese and Moe Armstrong.
    I thank you all for coming. Dr. Ibson, we will begin with 
you.

    STATEMENT OF RALPH IBSON, VICE PRESIDENT FOR GOVERNMENT 
          AFFAIRS, NATIONAL MENTAL HEALTH ASSOCIATION

    Mr. Ibson. Thank you, Mr. Chairman. I am honored to appear 
before you today on behalf of the National Mental Health 
Association and our 340 State and local affiliates. Mr. 
Chairman, we applaud your commitment, your steadfast efforts on 
behalf of veterans with mental illness and substance abuse 
disorders. We are delighted that you have called this hearing.
    As has already been said this morning, the VA has a special 
obligation to veterans with mental illness and substance abuse 
disorders, an obligation that has been expressly set forth in 
statute, reaffirmed twice since then. We agree with the 
findings of the Committee on Care of Veterans with Serious 
Mental Illness, the so-called ``SMI committee.'' The VA has 
failed, tragically failed these veterans, breaching both a 
statutory obligation and what we see as a moral obligation.
    People occasionally ask and have asked over the years, why 
does our government operate a health care system for veterans? 
They go on to ask, why not meet that obligation through a 
voucher system or some similar arrangement? For the almost 30 
years that I have worked in veteran' affairs, an answer to that 
question has almost consistently addressed itself to the 
specialized treatment programs for which VA has long been noted 
and those programs for veterans with mental illness high among 
them.
    Those explaining the need for the VA health care system 
have also underscored VA's important role as a safety net. That 
safety net mission is particularly important and highlighted, I 
think, for the many members of this committee who have worked 
so hard and are working so hard for the enactment of mental 
health parity legislation.
    As you know, Mr. Chairman, and others know so well, we have 
serious problems in the Medicare program and in health 
insurance with arbitrary limits which discriminate against 
people with mental illness. Those barriers, in our view, 
contribute substantially to the reliance that veterans with 
mental illness place on the VA.
    As has been alluded to this morning, some 6 years ago, the 
VA began a dramatic transformation of its health care system. 
This committee and its House counterpart foresaw within VA's 
vision of a decentralized, deinstitutionalized system the 
potential dangers that came with that move, the potential for 
unleashing cost-cutting zeal. And you predicted that without 
safeguards, VA's plans could ultimately threaten the viability 
of the very costly specialized programs which we have talked 
about this morning. In essence, you foresaw that without proper 
checks, the VA health care system could well become a mirror of 
national HMO plans in the private sector.
    The concerns led Congress to the enactment of the special 
capacity law, which has been discussed this morning. Despite 
the clear direction in that law, and again, echoing the 
findings of the ``SMI committee,'' the VA has failed to comply, 
in our view, with the mandate to maintain program capacity to 
treat veterans with mental illness and substance abuse 
disorders.
    As the SMI committee has also noted and has been discussed 
this morning, VA officials beginning in 1998 allowed a policy 
goal, namely to bring more veterans into the system, to thwart 
the ``maintain capacity'' mandate. Department officials queried 
about this have spoken of the maintain capacity requirement as 
a, quote-unquote, ``unfunded mandate.''
    In P.L. 104-262, in which the special capacity law was 
established, Congress, as you know, also established an 
enrollment system, a system of priorities, with highest 
priorities to service-connected veterans and the lowest 
priority for enrollment to veterans who have no special 
eligibility and whose income exceeds VA's means test threshold. 
The law makes it clear that those higher-income veterans, as 
dearly as we hold our commitment to veterans, are only eligible 
for care ``to the extent resources and facilities are 
available.''
    The law could not be clearer in instructing VA. Yet in 
1998, it did, in fact, open its doors wide, indeed, marketing 
its health care system to all veterans. The result, as the 
special committee and others have noted, is more than evident. 
We have gone from a system dedicated to serving principally 
service-connected and low-income veterans, which in 1996 had 3 
percent of its users as those Priority 7 veterans to a system 
which next year, according to VA's budget, will enroll one-
third of its veterans in that lowest-priority category.
    At the same time, as VA mental health and substance abuse 
programs have contracted and shrunk across the system, having 
fallen prey to other priorities, the savings from those 
contractions have been channeled into non-mental health care. 
In our view, Mr. Chairman, we have to judge the VA system not 
only by the general quality of care indices which this 
committee has emphasized, importantly so, but by the quality of 
its commitment to veterans with mental illness and substance 
abuse disorders. As a society, we have seen the tragedies of 
de-institutionalization of our public mental health system as 
it failed to reinvest dollars into community mental health 
care, and I am afraid we are seeing the same in the VA today.
    Chairman Rockefeller. You will need to finish up.
    Mr. Ibson. I shall.
    I think it is important for the committee to turn to 
stronger measures than the capacity law which was an important 
step, but one which has not borne the fruit we hoped. I would 
urge the committee to continue its vigorous oversight efforts 
which have made an important difference, and to look to steps 
like ``fencing'' funding, which VA has done successfully in the 
past, as a way to ensure that its mental health commitment is 
made and made effectively.
    Chairman Rockefeller. I will have a question about that 
later.
    Mr. Ibson. Surely.
    Chairman Rockefeller. Thank you very much.
    [The prepared statement of Mr. Ibson follows:]
   Prepared Statement of Ralph Ibson, Vice President for Government 
              Affairs, National Mental Health Association
    Mr. Chairman and Members of the Committee:
    I am honored to appear before you today on behalf of the National 
Mental Health Association (NMHA). My testimony will draw in part on my 
work as a member of the staff of the House Veterans Affairs Committee 
from 1990 to 2000.
                 the national mental health association
    NMHA is the country's oldest and largest nonprofit organization 
addressing all aspects of mental health and mental illness. In 
partnership with our network of 340 state and local Mental Health 
Association affiliates nationwide, NMHA works to improve policies, 
understanding, and services for individuals with mental illness and 
substance use disorders. NMHA sits on the Consumer Liaison Council of 
the Committee on Care of Veterans with Serious Mental Illness. Mr. 
Chairman, we applaud your commitment and continued interest in assuring 
that VA meets its obligations to veterans with mental illness and 
substance use disorders.
  critical decline in va specialized mental health treatment capacity
    The VA health care system has a special obligation to veterans with 
mental illness and substance use disorders. That obligation was 
expressly set forth in statute in 1996 and reaffirmed with even greater 
specificity last year in Public Law 107-135. VA also has a profound 
moral obligation to veterans with mental disorders. Yet it has failed, 
and continues to fail these veterans, by breaching both its statutory 
and moral obligations. Those failures are both tragic and inexcusable. 
But they are all the more shocking when one considers that as VA has 
diminished its support to veterans who are most vulnerable and most in 
need of VA assistance, it has virtually altered its mission to serving 
an ever-growing number of those with the lowest claim to VA care.
        the significance of va's specialized treatment programs
    During my years working in the House I was asked from time to time, 
why does our Government continue to operate a health care system for 
veterans? Why, some questioned, couldn't the obligation owed veterans 
be as effectively discharged through a voucher system or some similar 
arrangement? The response I gave--and VA officials continue to give to 
such questions--consistently cited VA's specialized treatment programs 
for veterans with mental illness as a critical core that sets VA health 
care apart as a vital resource that should be preserved.
     va: a unique ``safety net'' for veterans with mental illnesses
    Those explaining the importance of maintaining the VA health care 
system also cite its unique role as a ``safety net'' for veterans. That 
safety net mission is particularly important to veterans with mental 
illness or substance use disorders because--unlike many other 
veterans--these individuals often lack other health care options. As 
the many members of this committee who have fought for mental health 
parity well know, both the Medicare program and most private health 
insurance imposes arbitrary, discriminatory barriers to mental health 
care. Under the Medicare program, individuals face a 50% copayment for 
outpatient mental health services and a lifetime cap on coverage of 
psychiatric hospitalization. Most employer-provided health plans have 
evaded the spirit of the Mental Health Parity Law of 1996 by 
substituting other discriminatory mechanisms (such as limits on numbers 
of outpatient visits or days of hospital coverage, or greater cost-
sharing burdens) to limit coverage of mental health services. These 
barriers contribute substantially to the reliance veterans with mental 
illness place on VA for care. For example, more than 50 percent of 
veterans service-connected for a psychosis, and more than 60 percent of 
veterans service-connected for PTSD, used VA health care services in FY 
2000.
      statutory directive to maintain specialized program capacity
    As you know, Mr. Chairman, some six years ago VA embarked on what 
became a major transformation of its health care system. But this 
committee and its House counterpart recognized the potential dangers in 
VA's plans. You foresaw the unleashing of cost-cutting zeal within VA's 
vision of a more decentralized, deinstitutionalized system. And you 
predicted that, without adequate safeguards, VA plans could ultimately 
threaten the viability of often costly specialized treatment programs, 
including those that served veterans with mental health and substance-
use problems. In essence, you foresaw the risk that, without proper 
checks, VA could unwittingly transform itself into a national HMO with 
little to distinguish itself from other then existing private-sector 
systems.
    Those concerns led Congress in 1996 to enact statutory language 
(within an eligibility-reform law) to protect the unique specialized 
programs that distinguished VA and served those veterans most in need 
of the system. That law imposed a requirement that VA maintain its then 
existing specialized treatment capacity to serve veterans with mental 
illness and other specified conditions. Section 1706(b) of title 38, 
U.S. Code (amended in P. L. 107-135) expressly directs the Secretary of 
Veterans Affairs to provide for the specialized treatment and 
rehabilitative needs of veterans with mental illness and substance use 
disorders by operating and maintaining distinct programs and facilities 
dedicated to their specialized needs. The law requires the Secretary to 
ensure that the overall capacity of the Department to provide those 
specialized services is not reduced below the capacity VA had in place 
in October 1996. The law further directs the Secretary to afford 
veterans who have a mental illness or substance use disorder reasonable 
access to care for those specialized needs. Despite that direction in 
law, the VA has failed to comply substantially with the mandate to 
maintain required capacity to treat veterans with mental illness or 
substance disorders, as documented by the annual reports of the VA's 
Committee on Care of Veterans with Serious Mental Illness (hereinafter 
``the SMI committee''). For example, during a period in which medical 
care appropriations increased 30 percent, the SMI committee reports 
that 18 networks showed a decline in inflation-adjusted dollars for the 
care of veterans with serious mental illness. In substance-use, 20 
networks showed a decline, with a 15 percent decline in number of 
patients overall. Decentralization has aggravated the problem. VA data 
has consistently showed wide variability from network to network in the 
services available to veterans with mental health needs.
              va policy and statutory directives conflict
    Largely ignoring the ``maintain capacity'' mandate, VA officials 
over the years allowed their own policy goal--to bring more veterans 
into the system--to thwart this statutory directive. The Department has 
since sought to explain away its obligations to veterans with mental 
illness as ``an unfunded mandate.''
    In Public Law 104-262, which required VA to safeguard its 
specialized treatment programs, Congress also directed VA to institute 
an enrollment system to govern access to VA health care. Enrollment is 
to be managed to ensure that VA care is timely and acceptable in 
quality. Under this system, eligibility to enroll for VA care is to be 
based on statutory priorities. Service-connected veterans have highest 
priority, veterans who are deemed financially needy have a lower 
standing, and those who have no special eligibility but have income 
exceeding VA's means-test threshold have the lowest priority for care. 
The law makes clear that those with the lowest-priority-for-enrollment 
(often referred to as ``priority 7'' or ``category C'' veterans) are 
eligible for care only ``to the extent resources and facilities are 
available.'' (38 U.S.C. section 1710(a)(3)). The law could not be 
clearer in instructing VA that it may not open its doors to these 
higher-income veterans unless it has the resources to do so. In 
implementing the 1996 law, however, VA officials ignored the statutory 
directive to assure that the needs of those with the highest priorities 
could be met, and opened VA's doors wide. In fact, in many areas VA 
marketed its health care services to all veterans.
    The results are not surprising. In 1996, when Public Law 104-262 
was enacted, ``priority 7'' (high-income) veterans made up 
approximately three percent of those who used the VA health care 
system. VA's budget submission this year discloses for the first time 
that ``priority 7 veterans'' will make up one-third of VA enrollees in 
2003. The SMI committee puts the issue in stark perspective in its most 
recent report. The committee highlights the skyrocketing growth in VA 
dollars (nearly $1 billion in FY 2001) devoted to those--like myself--
who have the lowest priority for services and often have other health 
coverage. At the same time, VA mental health and substance abuse 
programs, which overwhelmingly serve service-connected and low-income 
veterans, have fallen prey to sweeping contraction and cost-cutting in 
many parts of the country. Rather than channeling those savings into 
new programs for veterans with mental health and substance use needs, 
VA has allowed a redirection of those funds to non-mental health care--
in clear violation of the capacity law. Using those funds, VA has 
successfully attracted new ``priority 7 veterans'' each year into a 
growing base of system-users. These higher-income veterans frequently 
also have coverage through Medicare or employer-provided health 
insurance. While more veterans use VA care than did in 1996, the 
percentage who receive any type of VA mental health service--in a 
system demonstrably less able to serve them than it was in 1996--has 
declined.
    What is being lost in this extraordinary transformation is both 
VA's ability to deliver needed services to those most in need of 
assistance, AND something of the very legitimacy of this health care 
system.
    Since it enacted the requirement to ``maintain capacity'', Congress 
has twice amended that law. To date, however, it is not apparent that 
VA has moved substantially toward compliance. In fact, following the 
enactment of Public Law 107-135, which clearly requires VA to expand 
mental health and substance use programs to restore lost capacity, VA's 
budget submission for Fiscal Year 2003 fails even to mention this law.
                            future direction
    Mr. Chairman, this is an important hearing that I believe can help 
the Committee reach some important decisions on the future direction of 
VA mental health care.
    We must judge the VA health care system not only by general 
quality-of-care indices, but by the quality of its commitment to those 
grappling with mental illness. As a society we have seen the tragedies 
that have come about because dollars freed up from 
deinstitutionalization in our mental health system were not reinvested 
into community mental health care. Will we repeat that mistake in the 
VA health care system? To date, we have. Through leadership in the U.S. 
Senate, we are moving toward mental health parity in the private 
sector. Should we require less of the VA? If not, we should examine the 
manner in which VA allocates funds. Contrast the high-tech services in 
its medical and surgical suites with the relatively limited funding 
dedicated to mental health care and substance use needs at many VA 
facilities. We are very far from anything approaching parity. Indeed VA 
has yet to attain the more modest goal of maintaining the level of 
service provided six years ago.
    Permit me to offer just two more examples that raise questions 
about the Department's commitment to veterans with mental illness:
     The VA has for years operated rehabilitation programs that 
emphasize work-therapy to assist people to normalize their lives as 
part of a recovery process. VA's Compensated Work Therapy (CWT) 
Program, in particular, aims to foster rehabilitation and re-entry into 
the community by providing opportunity for learning social and work 
skills, earning money and gaining the self-respect that comes from 
employment. In Fiscal Year 2000, of those discharged from CWT, 46 
percent were placed in competitive employment and another 8 percent 
were placed in training programs. Despite successes this program has 
demonstrated, a comprehensive program evaluation conducted last year by 
VA's Serious Mental Illness Treatment Research and Evaluation Center 
(SMITREC) highlights that VA has failed to insure that veterans with 
serious mental illness participate in CWT. SMITREC found substantial 
underutilization of the program by such veterans who are in their prime 
working years and shown to be employable with appropriate supports. 
While current research shows that most people with severe, chronic 
mental illness want to work, less than 1 percent of the 82,000 veterans 
with psychosis age 50 or less participate in VA CWT.
     The General Accounting Office (GAO) completed a study this 
spring examining VA's prescribing guideline for atypical antipsychotic 
use to determine whether it has restricted access to medications and 
adversely affected the quality of mental health services provided to 
veterans. GAO found that nearly one in ten VA psychiatrists responding 
to its survey reported they did not feel free to prescribe the 
antipsychotic drug of their choice, and numerous VA facilities have 
implemented procedures that ``have limited or could restrict access to 
certain atypical antipsychotic drugs on the VA's national formulary 
because of cost considerations.'' Given that some 50 percent of 
veterans treated by VA for schizophrenia are service-connected for that 
illness, with more than 130 thousand veterans service-connected for 
psychoses, we question whether VA would permit cost to be a 
consideration, let alone a determining factor, in treatment decisions 
regarding any other group of service-connected veterans.
                            recommendations
    NMHA would be pleased to offer recommendations on the two issues 
cited above. But the record of the last six years certainly suggest 
that strong measures are needed to realize the goals of the ``maintain 
capacity'' law and the special obligation owed veterans with mental 
illness and substance use disorders. In our view, an appropriate 
response must take account of both the highly variable commitment among 
VA's 21 networks to mental health and substance use services and the 
erosion that has occurred systemwide. This Committee has been more than 
patient. Additional legislative efforts which result, at best, in 
directives from a Central Office that fails to enforce its policies do 
not appear to offer promise. NMHA would urge the Committee instead to 
consider more ``invasive surgery'' to include requiring VA and its 
networks to ``fence'' (that is, segregate and track) funding for mental 
health and substance use services, with meaningful penalties for 
diverting those funds to other uses. Prior to 1996, ``fenced funding'' 
did offer protection to vulnerable mental health programs while three 
rounds of legislation clearly have not. Ultimately, however, such 
efforts must be combined with the kind of aggressive oversight this 
Committee has long exercised, and for which we thank you, Mr. Chairman.
    This concludes my statement. I will be happy to answer any 
questions the Committee may have.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
                             to Ralph Ibson
    Question 1. Your testimony stated that Congress should require VA 
to ``fence'' monies allocated for mental health so as to be absolutely 
sure that it is spent on mental health. Why is the Congressional 
mandate to maintain capacity not enough? Why is it necessary to make 
such a change?
    Answer. The testimony presented at this hearing (and the record of 
earlier hearings) underscores that the ``capacity law'' has not 
adequately protected the fragile VA infrastructure that served veterans 
with mental illness and substance use disorders, and, did not provide 
an effective check or constraint on administrators operating in a 
decentralized health care system who were more responsive to fiscal and 
other pressures than to a statutory policy. While the capacity law sets 
an important ``line in the sand'' its intended beneficiaries--veterans 
with mental illness and substance use disorder--have lost ground and 
suffered because of the difficulties inherent in enforcing its mandate, 
particularly in a decentralized system. The continued fiscal pressures 
facing the VA health care system will further test the ``capacity 
law''. But short of providing Congress with data to document continued 
shortcomings, the law itself provides no assurance that Department 
officials--making allocation decisions in 21 different networks and 
among hundreds of VA facilities--will jointly and individually dedicate 
the funds needed to realize the requirements of the law. Employing a 
mechanism such as ``fenced funding'', provides a tested, credible 
``audit-able'' means of ensuring that funds appropriated and allocated 
for mental health and substance use disorder care are in fact channeled 
to those purposes and are not siphoned off to other purposes.
    Question 2. Some inpatient mental health beds will always be 
necessary. In VA, however, there is a tremendous propensity to cut 
these kinds of beds. How can VA find the right balance?
    Answer. Experience has shown us that with proper treatment and 
support services, people with the most severe mental illnesses can live 
successfully in the community, and at lower cost than keeping them in 
inpatient care. There are model programs, such as The Village 
Integrated Services Agency in Los Angeles, that VA could look to for 
guidance. If appropriate community services were in place, it is likely 
that only a very small percentage of veterans with mental illness would 
require long-term hospital care, Until VA puts adequate community 
services in place, we unfortunately won't really know how many veterans 
truly need tong-term inpatient care.
    The problem with ``cutting beds,'' however, is that these funds 
have not followed the veteran into the community. (The fact that many 
VA outpatient clinics don't even have mental health personnel, let 
alone provide more extensive treatment or support services is very 
disturbing.) Funding for even one patient bed should never simply be 
``cut''--if bed closures are warranted, funding should be always be 
``transferred'' to the array of services needed to support the 
individual in the community, and that individual must have a detailed 
treatment plan with guaranteed access to those services prior to 
discharge.
    Certainly we should avoid a situation where the only choices 
available to a veteran with severe and persistent mental illness is 
institutionalization or discharge to a community without adequate 
service systems. With that stark choice, no ``balanced'' solution 
exists. VA must develop community mental health services that will 
minimize the number of inpatient beds needed.

    Chairman Rockefeller. Dr. Alarcon?

STATEMENT OF RENATO D. ALARCON, M.D., PROFESSOR OF PSYCHIATRY, 
    EMORY UNIVERSITY, REPRESENTING THE AMERICAN PSYCHIATRIC 
                          ASSOCIATION

    Dr. Alarcon. Mr. Chairman, I am a psychiatrist and 
currently a Professor of Psychiatry at Emory University School 
of Medicine in Atlanta, and until March 20, 2002, Chief of the 
Mental Health Service Line of the Atlanta VA Medical Center, 
where I work for a total of 9 years.
    As a member of the American Psychiatric Association since 
1970, I am honored to represent in this hearing, dealing with 
very crucial aspects of the delivery of mental health care in 
such a large and unique system as the VHA.
    I thank you for the opportunity and request that my full 
written testimony be included in the record.
    Chairman Rockefeller. Doctor, all testimony is fully 
included, so you need to sort of get to the basics.
    Dr. Alarcon. The shortest answer to the central question of 
this hearing, Mental Health Care: Can the VA System Still 
Deliver? Is, yes, it can, but it does not do it now.
    My testimony will address five areas to substantiate this 
assertion: financial, clinical, logistic, research, and what I 
call dynamic or environmental interactions between different 
components or members of the system.
    On the financial front it has been said many times it will 
never be enough. The budget allocation for mental health care 
within the VA is still short of what is really needed. A number 
of figures have been presented. I am now going to insist on 
that. The APA recommends the allocation of more financial 
resources for mental health in the VHA compatible with the 
growing, clinical, academic, administrative and research needs 
of the system and its specialized programs. Furthermore, budget 
resources should restore depleted services in some programs and 
reflect a fair revenue distribution based on workload served 
and complexity of cases cared for.
    Chairman Rockefeller. Doctor, can I interrupt and ask how 
the American Psychiatric Association has pushed on the subject 
of more resources? Are you simply saying that in testimony 
today, or has there been an effort by the Association to affect 
budget levels in this committee or with the administration?
    Dr. Alarcon. It is a consistent policy and actions on the 
side of the American Psychiatric Association to request, 
support and push for these type of requests.
    Chairman Rockefeller. Obviously, there is a constant desire 
to see it happen, but it sort--when did you last call up OMB or 
last call up Dr. Roswell, or last had all of your folks write? 
In other words, how do you put on pressure?
    Dr. Alarcon. The VA caucus in the APA is very active. Less 
than 2 months ago the APA was one of the signataries of a 
letter to Mr. Principi, and has continuously requested this 
type of action. In April, APA testified before the House VA 
Appropriations Committee and in March met with Senate staff. 
The context between the leaders of the American Psychiatric 
Association, Congress Committees and the VA are frequent 
members, M.D. members of the VA are members of the American 
Psychiatric Association, and they channel their views through 
the existing caucuses and committees.
    Chairman Rockefeller. I'm going to push that more. You may 
remember that the American Psychiatric Association, for year 
and years fought psychologists from them getting reimbursed 
under Medicare. In the end, psychologists receive reimbursement 
under Medicare. Now, that is just the historical benchmark for 
asking. Do you work alone as psychiatrists or do you work with 
others who care about mental health care, and specifically, do 
you team up with psychologists and others in your lobbying 
effort to get the resources for what you want ?
    Dr. Alarcon. I think you are touching on one aspect of what 
I was going to talk about which is the dynamic aspects of the 
works of the VA system and professionals within the VA system 
and psychiatrists and psychologists specifically. I think that 
regardless of discrepancies between professions, leaders and 
the work force in those professions understand that the cause 
of the veterans is extremely important. I have been aware of 
how the multi-disciplinary effort, which by the way, has been 
best represented in medicine by psychiatry, goes beyond the 
boundaries of the medical profession, and requires us, it has 
been said many times, the multi-disciplinary effort. It is in 
that context that the actions in favor of veterans have been, I 
would say, united. It has been a united front and the American 
Psychiatric Association, regardless of interprofessional 
politics I think has the highest cause of the veterans in 
sight.
    Chairman Rockefeller. Thank you, and I apologize for 
interrupting you.
    Dr. Alarcon. Can I continue?
    Chairman Rockefeller. Oh, yes.
    Dr. Alarcon. Thank you very much.
    It has been also said that from the clinical perspective, 
mental health parity in practice does not exist in the VA. The 
example of substance abuse programs is more than eloquent, and 
it has been discussed here. I want just to say that together 
with implementation of a mandate for the prompt establishment 
of opioid substitution programs or methadone clinics, the APA 
supports and requests the immediate inclusion of mental health 
services in more than half of the existing community based 
outpatient clinics, the CBOC's, that still do not have them, 
and the strengthening of mental health intensive case 
management, homelessness, post traumatic stress disorder and 
compensated work therapy programs. Furthermore, resources for 
psychotropic medications should be protected and this has been 
discussed already.
    Logistically, I want to emphasize again the need for a full 
compliance with a capacity low, and the continuous close 
supervision of its implementation by individuals and groups 
working in the field. To give budget and more significant 
administrative responsibilities to clinicians, rather than 
limiting them to the hands of known clinicians would be wise. 
Furthermore, the shortage of psychiatrists and other mental 
health professionals that compromises the quality of services 
provided must be squarely addressed.
    In the research arena less than 9 percent of the VA health 
research is dedicated to mental illness and substance abuse 
issues, even though 35 to 40 percent of the VA patients need 
mental health care. We respectfully request and support that 
three additional MIRECC's be funded in fiscal year 2003. The 
need to develop a strategic vision for the further development 
of mental health research in the VHA is pressing. More 
collaboration with funding agencies such as the NIMH and with 
those of affiliated economic centers must be pursued.
    Finally, let me examine two clusters of dynamic issues 
within the system. The first is the relationship between 
administrators and clinicians. It is no secret that there is a 
sort of warfare between these two groups. Many administrators 
give preference to those considered more powerful clinical 
players. And I must say with all due respect to my colleagues 
in medicine, primary care, surgery, et cetera that mental 
health deserves better in the system. Some administrators may 
be passive instruments of an overall stigmatizing environment. 
Prejudice against the mentally ill is still a powerful factor 
in some segments of the VHA staff. The same ambivalence is 
reflected in the way administrators deal with the relatives of 
mentally ill patients. This mentality may be more or less 
subtly rationalized by the enthusiastic embracing of business 
like practices imported from the managed care sector. APA 
strongly recommends multi-disciplinary and interprofessional 
activities for administrators and clinicians, aimed at a 
continuous awareness of the social, cultural and human 
uniqueness of the veterans with mental illness.
    The second dynamic issue has to do with the relationship--
--
    Chairman Rockefeller. You will need to finish up.
    Dr. Alarcon. I appreciate that--between VA medical centers 
and their academic affiliates.
    I just want to say that the healthy tension between the VA 
and the academic affiliated institutions' agendas can only be 
healthy if it is a balanced interaction between and a truly 
integrated work among the components.
    In summary, Mr. Chairman, there is no mental health parity 
in the delivery of care to VHA system. A great variety of 
indicators establish clearly the increasing numbers of 
patients, the systematic decrease in resources and a pervasive 
sense of a stigmatization of veterans with mental illness. 
Mental health is still treated as a Cinderella, a younger 
sibling, a relegated component of a historically important 
system. While a lot of progress has been made, much remains to 
be done before a profound respect for the human dignity of 
psychiatric patients and their families must help to open a 
path of hope for them, a path always worth walking.
    Thank you very much.
    [The prepared statement of Dr. Alarcon follows:]
Prepared Statement of Renato D. Alarcon, M.D., M.P.H. and the American 
                        Psychiatric Association
    Mr. Chairman and Members of the Committee:
    My name is Renato Alarcon. I am a psychiatrist, currently a 
Professor of Psychiatry at Emory University School of Medicine in 
Atlanta, and until March 20, 2002, Chief of the Mental Health Service 
Line, at the Atlanta VA Medical Center where I worked for a total of 
nine years. I am honored to participate in this hearing on behalf of 
the American Psychiatric Association. I was born in Peru, I am an 
American citizen, graduated as M.D. in my native country, did my 
residency training in the United States, and have been mostly a 
clinician, medical educator, and academician throughout the almost 30 
years of my professional career. The last nine years have clearly 
enriched my experience also as an administrator, and it is in all of 
these capacities that I attend this hearing whose central topic touches 
on very crucial aspects of the mental health care delivery in such a 
large and unique system as the VHA.
    My opinions are those of one who has learned to appreciate the 
extraordinary role that the VHA plays in the care of individuals who 
served their country loyally and devotedly, and who of course deserve 
the best care they can be provided. At the same time, my opinions also 
are as objective as I can be in trying to emphasize both the positive 
and negative elements in the structure and operations of such a complex 
system. I am guided by the American Psychiatric Association's 
commitment and my own desire to contribute to the national debate on 
health and mental health issues, critical for the present and the 
future of our nation.
    From the more that 15 million veterans in this country, 
conservative estimates indicate that more than 25% have some kind of 
mental problem. Out of more than 4 million individuals who received 
health care in the VHA system in 2001, 712,045 (almost 20%) required 
mental health care, an increase of 44%, from the 494,386 seen in 1990. 
There is, however, significant consensus in that we are seeing only a 
small number of those in need, another example of the proverbial ``tip 
of the iceberg.'' Furthermore, veterans with mental illness have 
significant medical comorbidities, that is coexisting medical 
conditions, that make their care even more complicated. Even worse, the 
majority of mentally ill veterans experience problems in their social, 
family, and community interactions--between 45 and 65 % of the homeless 
population in this country are veterans with mental conditions. Their 
lives have been further devastated by the concomitant use or abuse of 
alcohol and drugs, consumed in many cases as desperate attempts at 
self-treatment of their underlying emotional condition. These social 
circumstances make them also a rather mobile population, unsettled both 
emotionally and geographically, mistrustful of a system that they 
perceive with significant ambivalence, and voiceless in the face of 
their own handicaps when dealing with sources of funding, legislation, 
and society's support.
    The testimony will examine five areas of mental health care in the 
VA system, trying to utilize existing hard data as well as, whenever 
possible, my personal experiences throughout the last 9 years. The 
areas are: Financial (budget issues), Clinical (programs), Logistic 
(personnel, structural, and administrative), Research, and last but not 
least, a series of what I would call ``Dynamic'' or environmental 
interactions between different components of the system that provide a 
somewhat hidden but enormously impacting background for the everyday 
operations of mental health care in the VHA.
                           financial aspects
    Budget allocations. It has been said many times but it will never 
be enough: The budget that the VA provides for mental health care is 
still short of what is really needed. The total per capita expenditures 
for veteran mental health patients has declined by 20.6% since 1995. 
Between 1995 and 2001, the number of veterans in need of mental health 
services has increased 26%, yet the total mental health expenditures 
have increased only 9%.
    While I personally am of the opinion that money does not solve 
every problem, it is clear that in some areas of mental health care in 
the VHA, more financial resources are needed. As is well known, the 
Veterans Equitable Resource Allocation (VERA) program was established 
as a way to connect volume of services and workload with income for 
Networks and, through them, to local facilities. While the VERA model 
has evolved on the basis of recognizing previous limitations and 
difficulties, and recommendations have been recently made by the VERA 
Patient Classification Workgroup on Mental Illness regarding 
development of new complex care classes, qualifications for assistance, 
and the number of days needed for long term psychiatric care, VHA must 
do more to ensure that there are no financial disincentives, and to 
correct VERA's skewed dimensions that hurt the care of special 
populations. The SCMI suggested that VERA be assessed and revised to 
assure that the overall cost of mental health cohorts is in alignment 
with and not greater than the overall VERA revenue distribution to 
those cohorts. In fact, GAO has recommended, as recently as the past 
February that VA better align VERA measures of workload with actual 
workload served regardless of the veteran priority group, incorporate 
more categories into VERA's case mix adjustment, update VERA's case mix 
weights using the best available clinical data on clinical 
appropriateness and efficiency, determine what has caused budget 
shortfalls in the Networks, and establish a mechanism using the 
national reserve fund to partially offset the cost of the highest 
complex care patients. A forthcoming Rand Corporation study will 
hopefully further these requests.
    Budget management. It is well known that some Network directors and 
other administrators such as Medical Center Directors claim to favor 
the inclusion of mental health services in CBOCs but question how to 
fund such services, and whether all CBOC's should provide mental health 
services. This view does not make sense. Similarly, programs such as SA 
(Substance Abuse) and PTSD (Posttraumatic Stress Disorder) should have 
depleted services restored. On the other hand, even though a recent 
memorandum recommends that contract orders be rolled into the grant-
per-diem program in order to make dollars available to new Homeless 
Veterans programs, and thus insure their survival, and that this grant-
per-diem program may be an effective vehicle for maintaining capacity 
in SA abuse programs, the sheer fact is that there has been an erosion 
of access to these specialized services in the VHA since 1996. Network 
and local facility leaderships continue to ignore management directives 
and Congressional mandates in this regard, and they need to be held 
accountable.
    The Millennium Bill mandated that in FY 2000 VHA increase funding 
for SA and PTSD by at least 15 million dollars on an annual basis. In 
June 2002, the Under Secretary agreed that requests for proposals 
(RFPs) should be issued, and that off the top funding should be 
provided for the period of time necessary to assure that the programs 
are deployed, mature, and generate sufficient VERA funds (which have a 
lag time of two years) to assure their continued financial viability. 
The RFPs and the distribution of funds were delayed. Many programs were 
either not deployed in fiscal year 2001 or were deployed late in the 
year. The SCMI has recommended that special purpose funding be supplied 
to these programs in both FYs 2002 and 2003. The Under Secretary has 
concurred that whenever possible, specialized programs should be 
maintained beyond the 2-year minimum to meet the intent of the law. 
That is certainly our position.
                            clinical aspects
    The inequities towards those with mental illness that one sees in 
other health sectors in the country, also persist in the VA system. 
Mental health parity, in practice, does not exist in the VA. Some of 
the most significant examples follow:
    Substance Abuse. Substance Abuse (SA) is a dramatic example. While 
total VA spending rose 10% between 1993 and 1999, spending for SA 
treatment declined by 41%, from almost $ 600 M to about $ 330 M in the 
same period. The number of VA SA treatment programs decreased by 37% 
between 1994 and 2000, from 386 to 243. In 1996, only 33 % of patients 
diagnosed with a substance abuse disorder received specialized care. 
From 1996 to 2001, the number of severely mentally ill (SMI) patients 
treated for SA decreased by 15,935, an impressive 15%. The proportion 
of VA SA programs that have veterans waiting for treatment is rising: 
between 1994 and 2000, 68 to 75% in inpatient settings, 58 to 80% in 
residential, 42 to 60% in intensive outpatient, and 41 to 51% in 
standard outpatient settings.
    More recently, the establishment of Opioid Substitution Programs or 
Methadone Clinics, mandated for the system in response to a real need 
among veterans, and in order to correct the ill consequences of a 
massive bed closing executed about seven years ago, has not been 
implemented in a number of Networks. (Incidentally, the number of beds 
in SA inpatient and residential treatment settings was 5,920 in 1994, 
and only 2,893 in 2000). Reasons invoked for the slowness of this 
implementation range from the fact that the money devoted to this 
program has not been ``fenced'', to the feared prospect that in three 
years, local facilities or Networks will have to assume the expenses 
related to these programs. The result is that more than half of the 
Networks have not yet established Methadone Clinics, particularly in 
metropolitan areas where patients in need concentrate sometimes in 
dramatic numbers.
    Community-Based Outpatient Clinics (CBOCs). The medical care of the 
mentally ill veteran is a truly critical area. Psychiatric patients 
(particularly among veterans) do have a significant number of medical 
complications, larger than the non-psychiatric patients. In this 
context, the connection between mental health and primary care services 
is critical for a better, more efficient and effective care. The 
primary care programs, justifiably so, receive significant support from 
the VHA, and the establishment of the Community-Based Outpatient 
Clinics (CBOCs) a little over two years ago was deservedly applauded. 
That has not built up, however, the strength of comprehensiveness in 
the case of mental health care, as reflected on the fact that only 47% 
(265 out of 561) of the Networks that have CBOCs do include some mental 
health services, and that almost 20% of them provide very few service 
options.
    The CBOC mandate, that confirms the theoretically valid and 
necessary visibility of mental health in the outreach clinics, has 
little to show at the present time. This reality is devastating because 
mental health is not going to be addressed appropriately in close 
physical connection (location wise) with medical clinics, the most 
ideal approach. Again, it's a case of foot- dragging by administrators 
who in the name of ``savings'' may not hesitate to sacrifice mental 
health, first and foremost. They make promises, they can even say that 
they are impressed by the commitment of mental health clinicians to 
develop these programs (which, by the way, are a good example of the 
correct approach to bed closing) but then do nothing to implement them. 
The problem gets worse because of the aging of the veteran population. 
The CBOCs are expression of the best intentions to outreach veterans in 
areas where hospitals cannot have an impact; they also sanction the 
value of interdisciplinary care, but the VA is letting us all down by 
providing more support to the development of these programs in other 
departments, Primary Care in particular. In this context, Congress 
should be, as it has always been, an effective ally of the mental 
health community in the VA.
    Mental Health Intensive Case Management (MHICM) program. Other VA 
programs also suffer. The Mental Health Intensive Case Management 
(MHICM) program, a well proven alternative to hospitalization based on 
a close and comprehensive approach to care, saves money but lacks in 
resources, and therefore reaches only a minimal portion of patients in 
need. In October 2000, the VA identified 9538 MHICM eligible veterans 
(based on the number of patients discharged from inpatient psychiatric 
beds), and yet as of March 2002, there were only 3298 MHICM slots 
available. Some modifications in the criteria to include patients into 
the MHICM program could enlarge the population to be served. Psychiatry 
and mental health have advanced in the conceptualization and operation 
of therapeutic programs such as MHICM, and the crucial question is 
whether we as a society are ready to dedicate the funding to sustain 
them.
    Homelessness and Posttraumatic Stress Disorder (PTSD) programs. 
These programs have been paid attention by the VHA, Congress, the 
government and other sectors. Nevertheless, the fact is that for 
specialized intensive PTSD treatment programs, the average waiting list 
time is 47.15 days, and at some facilities veterans must wait as long 
as one year for an intake diagnostic assessment. PTSD patients 
considered as severely mentally ill (SMI) increased 42% from 1996 to 
2001, while expenditures increased only 22% during the same period. 
Veterans who are service-connected for PTSD use VA mental health and 
medical services at a rate at least 50% higher than other user groups.
    Compensated Work Therapy (CWT) program. The access to newer 
treatment modalities (cognitive behavioral therapy, intensive 
psychosocial rehabilitation, etc.) requires funding. Only 30,000 of the 
678,000 veterans served in the VA mental health programs received any 
form of work-based rehabilitation in 2001 (80,000 of them are under the 
age of 50). The unemployment rate for people with mental illness is 
approximately 75%. In 2001, 67% of veterans in specialized outpatient 
PTSD programs were not employed. Less than 1% of the 82,000 veterans 
with psychoses age 50 or less participate in the VA's Compensated Work 
Therapy (CWT) program, an initiative worthy of more consistent support 
that, for instance in my Medical Center, was specifically targeted for 
``savings''.
    To summarize, the numbers of individuals assisted by these programs 
are still relatively small, the complexity of their clinical realities 
is not addressed comprehensively, the resources are not there, and 
administrators are reluctant to provide them with minimal technical 
equipment. Appropriate screening teams and programs among homeless, the 
issue of comorbidity and multiple diagnoses among PTSD patients, the 
social and employment (or lack thereof) sequale of these conditions are 
realities that the system still needs to face squarely. The VHA has 
issued a wonderful set of practice guidelines for depression, 
psychosis, substance abuse, plus one for PTSD coming soon. It is fair 
to say, however, that in spite of well written technical, clinical, and 
professional norms, the implementation of programs has to do as much 
with financial resources as it does with disposition, interest, and 
sincere commitment to the cause of the mentally ill veteran.
    Pharmacy and medication resources. The issue of pharmacy resources 
and medication availability for mental illness is also an important 
one. There have been reports (including one by the GAO) that some 
Networks have established either rigid limits for the use of some 
medications (for instance, atypical antipsychotics), or have simply 
insisted on the use of old medications or of generics, together with 
other restrictions. I am not talking about a universal phenomenon, but 
we all know that even a few cases can ``make or break'' a policy and 
the programs that it intended to inspire. While it is true that 
resources for pharmacy need to increase in general (due to a number of 
decisions made regarding treatment of some chronic medical conditions), 
the fact that money devoted to psychiatric medication agents is 
diverted to those other areas comes very close to being short-changed, 
and to think that our patients may not be considered as ``important'' 
as medical patients. Is there a difference between the suffering that 
shortness of breath brings to a patient and that of those who are 
hearing voices, are devastated by anxiety or depression, are 
contemplating suicide, or wander around in the city or under the 
bridges? The budget for psychotropic agents, and not only generics, 
should be increased and protected to keep its intended purpose.
                            logistic aspects
    Capacity. The capacity of any given health care system (in simple 
terms, the number of individuals being served and the resources with 
which the system counts) is a crucial logistic concept. The Congress 
approved the Capacity Law (38 U.S. Code, Section 1706 (b)), and 
established several years ago, the Severely Chronically Mentally Ill 
(SCMI) Committee, currently named Committee on Care of Veterans with 
Serious Mental Illness, to primarily monitor the ongoing measures of 
capacity related to the care of the mentally ill veteran. This 
Committee has been a driving force in protecting the rights of mentally 
ill veterans, and calling the attention of the Department of Veterans 
Affairs and the VHA in dealing with their plight. The sad reality is 
that in the last 6 years (between 1995 and 2001), the number of 
veterans in need of mental health care has increased 26%, the cost has 
been reduced about 4% for programs and 24% for patients, the average 
length of stay in inpatient units has been reduced almost 42%, and yet 
(as mentioned above) the mental health care expenditures have increased 
only 9%. The conclusion is clear. The VA is not providing the same 
number and perhaps even quality of service to mentally ill veterans, in 
spite of efforts and declarations in that direction. Moreover, each 
time these incongruities have been called to the attention of the 
system, the bureaucracy has rallied around the cry of ``capacity is 
being maintained''. That is simply not true.
    Managed Care ``imports'' and Quality of Care. Some time ago, there 
was a not-so-subtle pressure to reduce significantly the average 
patient stay in the inpatient units. Like many others, these parameters 
were copied or ``imported'' into the VA from the Managed Care sector. 
The specific suggestion was to reach an average inpatient Length of 
Stay (LOS) of 5 or 6 days, while before 1993 such stay was 35 or more 
days. In my Service we made a determined effort to reduce the stay but 
with two provisos: one, to be able to establish adequate continuity of 
care and follow up in the outpatient clinic or our community psychiatry 
programs, and two, not to go down to the 5 suggested LOS days; rather, 
we determined that nine or ten days was the minimum acceptable for a 
decent (not necessarily the best) care of a veteran with mental 
problems. We have to continuously remind the administrators that the 
mentally ill veteran is not the average middle class ``healthy 
neurotic'' that may be seen in the private sector, or even in some 
community mental health centers.
    The administrators' emphasis on ``productivity'' and ``efficiency'' 
run a collision course with quality. I think this only reflects an 
excessive business-oriented philosophy that can have unintended 
consequences, such as a saturation of available services caused by 
opening the door to individuals for whom the VA is not necessarily a 
``safety net''. We, clinicians, are understandably mostly interested in 
quality of care. This is part of the humanistic dimension of medical 
care in general, and mental health care in particular, where many 
emotional, subjective, and human aspects of existence are threatened. I 
am afraid this dimension is being lost in an atmosphere colored by 
managed care practices and cold, some times callous managerial 
decisions. I have observed that whenever there are financial 
difficulties in a Medical Center, mental health is one of the first 
services to be looked at, and eventually cut out of resources. On the 
other hand, whenever a fiscal bonanza occurs, mental health is the last 
one to get resources. This, no matter how loudly the Mental Health 
Service Line representatives speak about the issues. This may be a case 
of what we call ``selective inattention''. And I wonder if all these 
factors help to understand why the overall satisfaction with inpatient 
mental health care, for instance, has declined 15% since 1995.
    Workforce shortages. There is a shortage of physicians and other 
mental health professionals in the VA workforce. It is not a secret 
that whenever a vacancy occurs in a psychiatrist position, 
administrators immediately start thinking about either eliminating such 
position, or recruiting a non-psychiatrist professional to replace him/
her. This goes against technical criteria, professional rules, and even 
the interdisciplinary atmosphere that needs to operate in environments 
like mental health care. Nobody is suggesting that every leadership 
position should be occupied by psychiatrists, but it is important to 
recognize levels of expertise, training, clinical experience, and 
background to consider these possibilities. Furthermore, salary 
schedules need to be revised in order to make VA positions more 
attractive. It is true that a number of International Medical Graduates 
(IMGs), and perhaps even minority American Medical Graduates (AMG) 
physicians compose a significant segment of the VA workforce in mental 
health. That is a very relevant and not frequently acknowledged or 
fairly analyzed contribution of minorities and IMGs to the viability of 
the system. It is important to make sure that Continuing Medical 
Education (CME) and other professional opportunities for advancement 
are always available. The personnel problem in clinical areas of the 
VHA system (and mental health is not an exception) has become even 
worse when we consider that nursing staff, for instance, is currently 
at its lowest level ever. The quality of services is, thus, doubly 
compromised.
    Performance evaluation. The DVA adopted in recent years the 
mechanism of issuing a ``report card'' outlining the performance of 
individual networks, and even individual facilities. While the purpose 
is good, the data included may be misguided since it provides more 
relevance and weight to administrative views or data rather than clear 
clinical indicators. In this connection, the overall clinical and 
operational functioning of Service Lines in the system, at the local 
facility level, is the subject of a study by Dr. Robert Rosenheck and 
collaborators, to be published soon in a prestigious medical journal. 
These authors measured continuity and quality of care over a 6-year 
period before and after the 1995-1996 reorganization, in 139 VA Medical 
Centers. The assumption that the first year of the establishment of 
Service Lines (SLs) would be worse, with gradual improvement over the 
years, along the lines of six indicators utilized by the study, did not 
pan out. In fact, the results indicated that the first year after the 
establishment of SLs was better than the second year, when no 
differences were found with regards to the status prior to the 
reorganization. The third year became even worse, particularly due to 
unexpected reductions in indicators of community-based resources. Over 
time, more emphasis on so-called cost efficiencies, restricting 
expenditures and services overwhelmed the real clinical needs and 
clinical realities faced by the SLs. In short, SL implementation was 
associated with a decline in mental health expenditures relative to 
non-mental health services. This is a sobering reflection on changes 
that are made with the best of intentions but fail to meet their 
intended objectives. It is true that the development of SLs is a very 
uneven process throughout the 22 Networks in the VA system (themselves 
appropriately labeled as ``22 individual experiments''), and that a 
hard look has to be taken at its theoretical, structural and 
operational bases. My opinion is that, unfortunately, each new 
administration in the VHA attempts to change things to leave a 
``legacy'' or its stamp for posterity, with resulting confusion and 
demoralization, bordering on cynicism. I would reiterate that what is 
needed is the establishment of means and mechanisms to supervise 
structural developments and guide their advancement.
    Physical plants. The physical plant of a number of mental health 
services in VA facilities require more attention. In cases, painting 
and cleaning efforts are accelerated each time that the Joint 
Commission for the Accreditation of Hospital Organizations (JCAHO) 
survey/visit is imminent. In cases, the facilities themselves are old 
and not fully used for such reason.
    Other logistic concerns. Other suggestions concerning the logistic 
areas in the mental health sector of the VA include:
          a) The VHA should assess the long term care needs of veterans 
        with serious mental illness by providing a detailed analysis of 
        the need vs. availability of, for instance, psychiatric nursing 
        home beds.
          b) The VA must ensure that the capacity of the Department to 
        meet the needs of the veterans with serious mental illness is 
        maintained in accordance with Congressional mandates. 
        Monitoring compliance with the Capacity Law and the preparation 
        of drafts of the capacity report should be the responsibility 
        of an individual or a small group of individuals with active 
        input from groups such as the SCMI.
          c) Mental Health Consumer Advisory Boards should be totally 
        and fully implemented in all VISNs so that patients, veterans 
        organizations, and community groups as well as other mental 
        health advocacy entities can have a voice, and help direct the 
        process of mental health care in the VHA system.
                            research aspects
    Less than 9% of the VA health research budget is dedicated to 
mental illness and SA, even though 35-40% of VA patients need mental 
health care. These are the real facts, in spite of a most significant 
improvement in the area of mental health research in recent years--the 
creation of Mental Illness Research, Education and Clinical Centers 
(MIRECCs), modeled after the highly successful Geriatric Research, 
Education and Clinical Centers (GRECCs). This has mobilized an 
extensive set of potential research resources on specific areas, 
particularly in the Health Services Research (HSR) component. Mental 
Health has also a fair share in the Cooperative Studies and 
Rehabilitation research series. The Northeastern Program Evaluation 
Center (NEPEC) in West Haven, has made substantial contributions to the 
field. It is expected that two or three more MIRECC's will be funded in 
FY 2003 to get closer to the total of 15 envisioned by some VHA 
leaders. A 5-year funded follow-up study of medical problems in Vietnam 
veterans with PTSD will no doubt result in compelling findings.
    Mental health research strategy. The methodological area of 
research is an important one addressed partly by the role of QUERI, a 
program aimed at developing quality of performance measures, 
particularly outcome measures that can clearly reflect the clinical, 
psychosocial, cultural, and environmental factors of disease, beyond 
some too general or gross parameters. Issues such as discharge 
criteria, quality of life, multiple diagnoses, comorbidity, 
psychosocial treatment approaches, ethnopsychopharmacology, drug 
interactions and side effects, economics of mental health care, and 
studies on specific entities with a truly clinical and epidemiological 
component are much needed.
    The foregoing should not prevent the VA system from developing a 
truly strategic vision to strengthen mental health research. Sadly, 
such effort has not been sufficiently enhanced, and in some cases 
shallow reasons (i.e. ``There are not too many mental health 
researchers in the system'') have been provided to justify such 
inaction. After some promising developments in previous years, at this 
point the dialogue between the VA Research Office and the National 
Institute of Mental Health (NIMH) seems to be almost non-existent.
    Training of researchers. Closely related to research efforts are 
the training needs of professional staff members. The VA should provide 
sufficient funding to the Office of Academic Affiliations for 
furthering Fellowships in the field of SMI patient care and other 
areas. Fellowships should also emphasize the multidisciplinary needs of 
effective mental health care, addressing the elements of a recovery- 
and quality of life-based care system, as well as evidence-based best 
practices in psychosocial rehabilitation. The VHA and its research arm 
also should encourage the academic affiliates to provide research 
funding from their own sources into veterans populations, considering 
the uniqueness of mentally ill veteran patients and the collaborative 
philosophy of these affiliations. Currently, such investment from the 
affiliated institutions is very small.
                            dynamic aspects
    There are two clusters of dynamic issues within the system. One is 
the relationship between clinicians and administrators, and the other 
is the relationship between VA facilities and their academic 
affiliates. Both, I think, have significant impact on the overall 
development and functions of the VHA system and its provision of mental 
health care.
    Administrators and Clinicians. It is no secret that there is a sort 
of ``warfare'' between administrators and clinicians in any healthcare 
system. From the mental health perspective, it seems clear that many 
administrators give preference to those considered ``more powerful 
players''. With all due respect to my colleagues in medicine, primary 
care, surgery, etc. mental health deserves better in the system. On the 
other hand, with very few exceptions, Service Line directors or 
managers have not been given budget authority to effectively handle the 
programs they lead. Management should be truly participatory. 
Experienced clinicians need to have the administrative tools and 
capabilities in order to review or veto non-clinician's approaches that 
are not going to work. If this is not done, I am afraid that there will 
be an adverse impact on the overall provision of mental health care. As 
the economy languishes in some areas, more and more veterans may turn 
to seek care in the VHA, thus creating more pressures, more demands, 
and more needs for which we should be duly prepared. Because of the 
inherent weakness (voicelessness) of the veteran with mental illness, 
we have resorted to Congress on many occasions in order to strengthen 
our capacity, reinstate our losses, monitor our operations, etc.
    Some administrators may also be passive instruments of an overall 
stigmatizing environment. A case in point is the excessive rulings 
about controls, seclusion and restraints, elopement control measures, 
etc. whenever applied to mentally ill vs. non-mentally ill patients. I 
would dare saying that prejudice against the mentally ill is still a 
powerful factor in some segments of the VHA staff.
    Administrators and patients and their families. The same 
ambivalence is reflected in the way administrators deal with relatives 
of mentally ill veterans, whose participation is a crucial component of 
any management program. Our experience is that some VA administrators 
are not interested in developing ties with families of mentally ill 
veterans. Service organizations, organizations such as the National 
Alliance for the Mentally Ill (NAMI), the National Mental Health 
Association (NMHA), and community agencies should provide input and be 
active players in the management of our patients.
    VA and Academia. The relationship between VA Medical Centers and 
the academic affiliates (whenever this occurs) is another field where 
dynamic factors play important roles. Let me make clear at the outset 
that I think academic affiliations are one of the greatest 
accomplishments of the VHA system throughout all its existence. They 
help to provide higher quality of care, exchange of knowledge, 
participation in the training of the future generations of 
professionals, and settings for joint research and educational 
programs.
    Having said that, however, it is important to also acknowledge the 
very different, sometimes diametrically opposed agendas of the two 
components of this equation. The VA priorities are clinical first, 
educational and research second, whereas the affiliated institution's 
priorities are educational and research first and foremost, clinical 
care second. If we add the different administrative structures, then 
the stage is set for tensions that many times create the dilemma of 
divided loyalties, or force one to point out inadequate perceptions or 
procedures on the side of the academic institution. This ``healthy 
tension'' will be productive in the context of a balanced interaction 
between partners. While ultimately, this all may depend on individual 
personalities and interactive styles, this situation needs to be 
corrected. The marriage between VA and academia is essential but we 
need to do something to make it better.
    True integration is the name of the game. There should not be 
different levels of ``citizenship'' in an academic affiliation, there 
should not be two standards of care. Vice Presidents for Health 
Affairs, Deans, Chairmen of Departments of Psychiatry and others in 
medical education institutions should address this divergence and make 
a definite statement about a philosophy of ``one campus-one mission.'' 
Clinical and educational pathways should be created that adhere to this 
integrating philosophy which is basically a strategy to level the 
playing field. What is good for the patients at the Medical School 
should be good for the veterans and vice versa. Chairmen of Departments 
do not get Without Compensation (WOC) status in the affiliated VA 
Medical Center, and work alongside their counterparts in the VA 
clinical, educational, and supervisory activities. This is a barrier to 
collaboration. There should not be incongruities in how patients are 
handled, how patients are followed up, how psychiatry and mental health 
disciplines are taught in different settings. Getting credit for 
whatever work they do in either setting is crucial. The same applies to 
the teaching of medical students where performance improvement projects 
should be developed for the corresponding clerkships.
                              conclusions
    The American Psychiatric Association was one of the signatories of 
a letter dated April 3, 2002 and addressed to Mr. Principi, Secretary 
for Veterans Affairs. In that letter it was made clear the concern of 
all that the VA healthcare system was ``failing to comply with its 
statutory obligation to provide needed services to veterans.'' The 
letter made clear that the Congress had twice amended the Capacity Law 
in order to fill gaps in the original legislation, delineating 
statutory responsibilities, making explicit that the department could 
not employ outcome data to meet the requirements to maintain program 
capacity, and delineating measures to maintain funding levels, program 
levels, staffing levels and patient workload. The sad reality, once 
again, was that some administrators at the Central Office as well as 
the Networks or even in local facilities were more than willing to 
close or reduce mental health programs going explicitly ``against the 
letter and the spirit of the law which requires that the VA expands 
substantially the number and the scope of its specialized mental health 
and substance abuse programs so as to afford veterans real access to 
needed specialized care and services''. The Department's failure to 
allocate the necessary resources or even budget for them was in the 
opinion of the signatories ``inexplicable and indefensible''.
    As a former employee of the VA system, I have to concur in general 
terms with the intent of this letter. Mental Health is still treated as 
a Cinderella, a younger sibling, a relegated component of a 
historically important system. While the situation is difficult, I 
don't think it is desperate or hopeless. There are very valuable 
members of the VHA family, at the administrative, clinical, and 
academic levels that want to do well and want things to improve. A lot 
has been done in terms of growth and consolidation of some MHSLs, 
creation of true multidisciplinary teams, establishment of case 
management practices, the continuity of care philosophy, utilization of 
electronic documentations, expansion of some outpatient services and 
programs, pioneering research, and academic and scholarly 
accomplishments within the VA. One thing should never be forgotten: 
Veterans with mental illness are part of the so-called ``Special 
Populations'' in the VHA, patient groups that every DVA leader over the 
years has promised never to abandon. That does not seem to always be 
the case however, as we take an objective look at the system nowadays.
    Much remains to be done in terms of clinical, logistic, financial, 
physical space, recruitment and retention of personnel, creation and 
sustainability of special programs, interaction with primary care and 
other non-psychiatric services, budget authority, equal partnerships, 
and removal of prejudices and discrimination towards the mentally ill 
veteran in some people's minds. On the basis of my testimony, the 
opening Executive Summary includes specific recommendations about 
mental health care in the VA system made on behalf of the American 
Psychiatric Association.
    My experience at the VA has been extremely rewarding. My colleagues 
and staff have taught me lessons of honor, of courage, of dedication, 
of passion for the things they do, and the pathway they chose in life. 
We should continue fighting against biases towards the mentally ill, 
and attitudes that hurt and deny them the respect we should have for 
their suffering, their human dignity, their cultural background, their 
value as persons and human beings. We should continue working on trying 
to integrate the system, prevent budget cuts, create evidence-based 
research. It is not too late to right wrongs, and to make sure that we 
are true to principles of fairness, honesty, eagerness to learn and 
teach, love to our profession, concern for and commitment to our 
patients and their families. The journey of life is made up of 
encounters and separations, and they together create a path of hope for 
something better. A path always worth to walk in.
    Thank you very much. I appreciate the opportunity to speak with you 
today on behalf of myself and the American Psychiatric Association.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
                     to Renato D. Alarcon, MD, MPH
    Question 1. Your testimony states that the VA's ``emphasis on 
productivity and efficiency runs a collision course with quality.'' Can 
you give the Committee an example of this from your experiences at the 
Atlanta VA?
    Answer. Productivity, understood, for instance, as number of 
patients admitted to an inpatient unit, or number of visits to the 
outpatient clinic, or number of patients seen per hour; and efficiency, 
considered as a reflection of an adequate ``fit'' between existing 
professional resources and volume of patients requiring services in any 
given health facility, are both technical or administrative terms 
frequently mentioned in the VHA as performance parameters for the 
clinical staff. The problem is that the measures or criteria used to 
establish supposedly acceptable levels for these parameters are 
arbitrary at best due to the abstract, impersonal way in which they are 
generated and conveyed to the field. Network and local facility 
administrators tend to enforce these expectations without paying due 
attention to the special and unique characteristics and needs of 
veterans with mental illnesses--the clinicians' main concern. The 
pressure to meet performance expectations forces clinicians to stretch 
their schedules (and their efforts) to see more patients in the same or 
even less time; or they may have to discharge patients earlier than 
medically indicated. In general, clinicians have fewer opportunities to 
provide the kind and level of treatment that patients require. Thus, 
quality of care suffers.
    An example of this negative interaction in the Atlanta VA Medical 
Center was related to the closing of almost 50 beds in the inpatient 
unit at the beginning of the reorganization process (around 1996), and 
the simultaneous suggestion to shorten the patient's length of stay in 
the unit. Within a year from the implementation of this decision, the 
number of patients admitted to the unit in a 12-month period increased 
from less than 700 to more than 1200, which meant that work-ups, 
treatment plans, and related inpatient clinical programs had to be 
intensified for each patient. Concomitantly, the number of outpatient 
visits increased from an average of 35,000 to more than 120,000 per 
year.
    Professional staff members had not only to change work habits and 
focus but, most importantly, their numbers were not increased 
proportionately to such work increase. Our professionals worked harder, 
saw many more patients, had their schedules stretched to the limit, 
spent longer working day hours. Yes, their productivity increased, some 
administrators may even say that this represented a more ``efficient'' 
use of resources, but the fact is that we felt we were not doing 
everything that our skills would allow us to do for our patients, due 
to the pressures and demands that limited precious contact time with 
them. Quality of care suffered; there is no question about that. With 
such pressures and the reality of not doing their best for the 
patients, morale in the professional staff suffered.
    Question 2. It is clear that there is futility in keeping mental 
health patients in the hospital if they do not need to be there. 
Frequently, mental health for even the very ill can be provided in an 
outpatient setting. Describe what the VA has done to make sure that 
their outpatient mental health care is just as effective as inpatient 
care.
    Answer. This question is closely related to the previous one. It is 
true that in a number of cases and clinical conditions, good outpatient 
care is just as effective as outpatient care, and can generate savings 
overall. There is pertinent data in the literature to substantiate 
these claims. To balance out the impact of bed closing, the VA system 
fostered the growth and development of more outpatient programs 
including group therapy, psychoeducational activities, recreational 
therapy, and socialization efforts. The establishment of the Mental 
Health Intensive Case Management program may have been part of the same 
approach, even though its structure and operations, dictated by a 
strict technical protocol, can benefit only a limited number of 
patients. On the other hand, the numbers cited in my July 24, 2002 
testimony and those of others in connection with the Substance Abuse 
Treatment Programs and the Methadone Clinics, offer another clear 
example of this. Once again, the lack of professional resources to 
implement and conduct additional programs, the lack of financial 
resources to hire qualified professionals, respond to increased space 
needs, acquire equipment and materials, etc. were factors that 
militated against the better intentions of the system. Yes, in some 
cases the readmission rate has not been as high as feared after bed 
closing; the number of ER visits for mental health patients has not 
increased dramatically; and the protests of veteran organizations have 
not been deafening. However, the waiting lists are longer, the level of 
satisfaction with outpatient care has decreased, and numbers of 
admissions of the same patients in geographically distant Medical 
Centers or figures of clinical occurrences such as suicide rates or 
levels of chronicity, may offer a different picture.
    Question 3. Some inpatient mental health beds will always be 
necessary. Yet, in the VA, there is a tremendous propensity to cut 
these kinds of beds. How can the VA find the right balance?
    Answer. The propensity to reduce inpatient beds is primarily 
related to the costs of inpatient care (estimated from US $ 600 to 1200 
per patient per day), the notion that in a number of cases outpatient 
care may produce similar results at lesser costs, and the decision to 
trim down segments of the federal government's bureaucracy. 
Unfortunately, in some cases, the trend may have been carried out 
excessively, or the move was not well evaluated in advance. The glut in 
demand for outpatient services noted above is one of its most visible 
consequences. Some steps that the VHA can take to right the balance 
includes:
          a. Deployment of adequate numbers of well trained personnel 
        to outpatient areas
          b. Creation of new and intensive outpatient clinical programs
          c. Creation of additional assistance and psychoeducational 
        programs with active involvement of families, veterans' 
        organizations, and community agencies
          d. Networking with state and local mental health facilities 
        for coordinated assistance to the needs of mentally ill 
        veterans
          e. Re-evaluation of need to cut down beds on the basis of a 
        systematic assessment of patients' clinical condition, 
        severity, availability of alternatives, readmission rates, 
        waiting lists, and other parameters. If necessary, after this 
        analysis, reopen needed beds in some areas.
          f. Establishment of the continuity of care approach in 
        clinical work, i.e., the assignment of patient cohorts to the 
        same multidisciplinary teams in inpatient, outpatient and even 
        community settings
          g. Intensification of efforts to improve sensitivity and 
        awareness about mental illnesses and their management among 
        primary care providers, so that beds other than psychiatric 
        ones can be used for the care of dually diagnosed or medically 
        ill psychiatric patients. Outpatient management of some of 
        these patients by non-mental health providers should also be 
        promoted.
          h. Re-examination of decisions made to provide care to 
        veterans that have a lowest service-connection priority, and 
        that have started to crowd service demands in detriment of 
        those who are in most need and may require hospitalization or 
        treatments that are more aggressive.
    A number of these suggestions are based on the need to reinvest in 
mental health services within the VA, savings made through different 
measures in the recent past. It is well known that this has not 
happened. Maintenance of capacity mandated by law, accurate 
inflationary adjustments of capacity reports, continuous assessment of 
needs and care costs are urgent steps. Fair budget resources and 
specific allocations for mental health must reflect all of these needs 
and concerns.

    Chairman Rockefeller. Thank you, Doctor.
    Colleen Evans, you are working in an Acute Schizophrenic 
Unit at Pittsburgh, so I am interested to hear what you have to 
say.

 STATEMENT OF COLLEEN EVANS, STAFF NURSE, ACUTE SCHIZOPHRENIA 
    UNIT, VA PITTSBURGH HEALTH CARE SYSTEM, HIGHLAND DRIVE 
DIVISION, AND CHIEF STEWARD, AMERICAN FEDERATION OF GOVERNMENT 
                           EMPLOYEES

    Ms. Evans. I would like to thank the members of this 
committee for providing me this opportunity.
    I have worked at the Highland Drive site of the VA 
Pittsburgh Health Care System for 18 years as a registered 
nurse. I have worked in a variety of roles in both management 
and staff positions, in the care and treatment of mentally ill 
veterans. And, frankly, I am both angry and deeply saddened by 
the changes in the level of care that I have witnessed for this 
segment of the veteran patient population.
    The loss of beds, programs and staff under the pretense of 
shifting to outpatient care mirrors the national image. The 
decrease in number of beds, psychologists, social workers and 
nurses have had a deleterious effect on both patients and 
staff. The decrease in psychologists has severely hampered our 
ability to provide intense one-to-one counseling. The loss of 
social work professionals has reduced our capacity to follow 
patients once they leave the facility. In addition to the 
actual social workers lost in real numbers, many of those that 
remain function in administrative rather than patient care 
roles. Patients are transferred to nursing homes, between 
nursing homes or discharged to the community and fall between 
the cracks, resulting in missed appointments, patients being 
without medication or worse.
    Some end up in jail or living under bridges. A few commit 
suicide or are found dead due to an inability to manage their 
own care. Many self treat or self medicate, if you will, with 
alcohol or illegal drugs and show up months or years later with 
full-blown psychosis, cancers of the head and neck, and/or 
liver failure. We are concerned that the savings in resources 
resulting from the shift to outpatient care have not been 
committed to mental health. Outpatient intensive mental health 
care management has not become a reality for most of our 
patients.
    And what staff find most frustrating and infuriating is 
that the management keeps pointing to performance measures, 
which they have established and do not measure the impact on 
patient care. The message that we are repeatedly given is that 
our concept of reality is severely distorted. It is like the 
shady bookkeeping that apparently became popular in the 
corporate world. We are saying the sky is blue and they keep 
saying, no, it is black. Just look at these charts and graphs. 
In an effort to prevent----
    Chairman Rockefeller. Can you explain that? This will not 
reduce your time, but can you explain that a little bit more 
clearly so I understand it better?
    Ms. Evans. They have set up these performance measures 
and--should I just give you an example?
    Chairman Rockefeller. Yes.
    Ms. Evans. An example, recently, the facility stopped 
transportation for veterans. They used to provide 
transportation, and now they have--they have worked with the 
DAV to try to help them to do it. And it has created a major 
problem and difficulty for our patients to get to the facility 
now to receive their care. So in the past month our waits and 
delays have improved because approximately 355 patients could 
not get to their appointment because they had no way to get 
there.
    In an effort to prevent duplication of services two units 
were merged at Highland Drive, resulting in the loss of any 
medical capability whatsoever. The sad result is that we are no 
longer able to care for our patient population that had medical 
diagnoses in addition to mental health concerns. Patients being 
bounced back and forth between sites to address their medical 
concerns remains a problem despite our efforts to address this 
issue. But the saddest scenario involves those patients we send 
over but cannot accept back due to a lack of medical 
capability.
    It is not my intention to indict the concept of outpatient 
care. We wholeheartedly endorse and support the management of 
care as outpatients for those who are capable of keeping 
followup appointments, maintaining their medication regime and 
are not a danger to themselves or others, but with the 
resources to effectively follow and evaluate that ability, must 
accompany the philosophy. It is my intention to advocate as 
vigorously as I can for that part of the veteran population 
that is unable to say, ``My symptoms are exacerbating. I think 
I should call my care provider.'' These are the most vulnerable 
of our patient population. These are the people that the VA 
must be there for, that do not show up on the performance 
measures because they do not come in.
    The shift from inpatient to outpatient, as we see it, 
exists in theory only. It could be described as a shift from 
inpatient to nonpatient. We currently have no inpatient beds 
for substance abuse, detoxification and rehabilitation 
treatment. The VISN is hoping the community will absorb our 
population, despite its admission that community resources are 
inadequate. The shifting between facilities, the lack of mental 
health services at CBOC's, the loss of programs and 
unavailability of staff has sent a clear message to mental 
health and substance abuse patients. We do not care about you.
    To magnify that communication our patients recently lost 
all privileges. That means during the entire time they are 
inpatients in our units, they cannot smoke a cigarette, go out 
for a bit of fresh air or go to the canteen to purchase 
personal items unless they are accompanied by an escort. The 
loss of freedom has led to a loss of dignity and self respect. 
This injury to self image has negatively affected treatment and 
recovery. The confinement has led many patients to resist 
admission even though they are aware of an exacerbation of 
their symptoms. Many have made comments likening the units to 
being incarcerated. We believe it has also led to patients 
being discharged at their insistence before they are ready to 
go home. The loss of privileges has led to increased congestion 
on psychiatric units where patients, many with paranoid 
delusions, need space. Tension on the units has increased, and 
unit treatment programs has suffered as a result. One 
administrator made the comment that he had no doubt that we 
will see a serious decline in the number of patients seeking 
admission now that we have eliminated patient privileges. 
Whether by design or just as the unintended consequences of 
this decision, it is the firm belief of the staff that 
conditions are worse for our patients. It is in our best 
interest as a society to provide adequate care and treatment 
for this population. They have served their country when asked. 
We, at the very least, owe then the dignity of access to 
adequate and humane care.
    I again would like to thank the members for this 
opportunity and ask for your continued support to help the most 
vulnerable segment of our patient population, the seriously 
mentally ill and the chemically dependent.
    Thank you.
    [The prepared statement of Ms. Evans follows:]
 Prepared Statement of Colleen Evans, Staff Nurse, Acute Schizophrenia 
 Unit, VA Pittsburgh Health Care System, Highland Drive Division, and 
       Chief Steward, American Federation of Government Employees
    Chairman Rockefeller and Ranking Member Specter, my name is Colleen 
Evans.
    For the past eighteen years, I have been a Psychiatric Registered 
Nurse at the VA health care system in Pittsburgh, Pennsylvania. I am 
also the Chief Steward of the Professional Staff unit of Local 3344 of 
the American Federation of Government Employees, AFL-CIO. Thank you for 
the opportunity to share with you what it is like on the front lines of 
mental health care at the VA.
    I work on a secured acute psychiatric unit. The veterans I see in 
my nursing practice primarily carry the diagnoses of schizophrenia and 
schizo-affective disorder. Veterans admitted to my unit are at various 
levels of distress. Seventy percent of our patients voluntarily admit 
themselves for psychiatric care. My facility also treats patients with 
post-traumatic stress disorder (often referred to as PTSD) and severe 
mood-disorders, such as depression or bi-polar disorder. My facility 
also treats geropsychiatric patients, who are acute psychiatric 
patients who are over 65 years of age. My facility has no inpatient 
beds for long-term psychiatric care.
    The veterans at my facility are among the roughly 455,000 veterans 
who suffer from a mental illness, which the VA has determined to be 
service-connected, that is, the illness was incurred or aggravated in 
military service. For these veterans the psychological wounds of war 
are very real, raw and ever present. Every day I see the courage of 
veterans with serious mental illness trying to stay connected to 
reality and to have a clear mind. Care of these vulnerable patients is 
at the heart of VA's mission.
    Mental illness still carries a stigma in society. This stigma 
systemically undercuts mental health parity in the VA health care 
system as evidenced by:
     VA's termination of inpatient substance abuse treatment 
programs;
     VA's elimination of nearly all inpatient psychiatric beds 
under the pretense of shifting to comprehensive outpatient care, and:
     VA's failure to maintain an adequate complement of 
psychologists, social workers and nursing staff to handle the demand 
for intensive care from low-income veterans and veterans who are 
service-connected with mental illness.
    As advocates for our patients, staff is angered, frustrated and 
deeply saddened by the changes in the level of care and access to care 
that we have witnessed for this vulnerable segment of the veteran 
population.
    The elimination of inpatient medical beds has had a deleterious 
effect on the care of my patients.
    The Pittsburgh VA health care system has three locations: the 
Highland Drive facility, where I work, which houses psychiatric and 
substance abuse treatment; the Heinz facility, which provides geriatric 
and extended care; and, the University Drive facility, which is an 
acute medical care facility.
    Most of our psychiatric and substance abuse treatment patients also 
have multiple medical diagnoses, which also require medical care. Many 
have infectious diseases, such as Hepatitis C, Hepatitis B and HIV. 
Because our patient population has multiple physical and mental 
conditions, the Highland Drive psychiatric facility at one point had a 
separate medical unit. The failure to provide prompt medical treatment 
to seriously mentally ill patients can thwart their psychiatric 
recovery and rehabilitation. For example, an untreated urinary tract 
can worsen psychotic hallucinations and lessen a patient's 
responsiveness to medications to treat their mental illness.
    Staff on the medical unit at our psychiatric facility had expertise 
in dealing with the unique and complicated issues, which arise when 
treating the medical conditions of a psychiatric patient. Our medical 
unit was a secure ward.
    In an effort to consolidate resources and save money, the VA 
decided to shutdown all the acute medical beds at our psychiatric 
facility. This has resulted in the loss of any capability to provide 
medical care within the psychiatric facility. Now we must transport our 
psychiatric patients to the VA University Drive acute medical care 
facility for treatment on units that do not have the staff, training, 
or resources to care for seriously mentally ill patients.
    At times, we have sent a patient for medical care at VA University 
Drive and the patient has been refused admission. At times, patients 
are sent back to our facility without receiving the full complement of 
medical treatment they were supposed to receive. Why? These patients 
may be confused, acting out, having active hallucinations, combative 
and extremely difficult. The VA University Drive medical care center 
lacks the staff, and seclusion or observations rooms, that would allow 
these patients to be separated out from the general patient population 
and to be treated without risk to themselves or others.
    The saddest scenario involves those patients we send over for acute 
medical care but can not accept back into our facility, due to our lack 
of medical care capability.
    The purported reason the VA took away our medical beds was to 
prevent the costly ``duplication of services.'' A secured medical unit 
specializing in the medical care of psychiatric patients is not 
duplicative of a medical care unit for the general population. While 
the VA may have reduced its bottom line, the closing of the medical 
unit at my facility has cost our patients dearly.
    The abandonment of our inpatient substance abuse treatment program 
has hurt the recovery and rehabilitation of many veterans.
    Approximately 68% of our patients with a mental health diagnoses 
also abuse drugs or alcohol. Many veterans self-treat or self-medicate 
their mental illness with alcohol or drugs. One veteran explained to me 
that he drank to drown out the voices in his head. The Highland Drive 
facility no longer has any inpatient beds for detoxification, substance 
abuse treatment, or rehabilitation.
    Many veterans, especially homeless veterans, need the safe and 
supportive environment of an inpatient treatment program. VA management 
abolished the inpatient substance abuse treatment at the VA Pittsburgh 
health care system in 1998.
    Our opiate treatment program, which helps veterans who are addicted 
to heroin, currently has a 3 month waiting list. Veterans often give up 
waiting and fall through the cracks. VA management wanted to contract 
with community programs for additional treatment slots but they are 
full. VA needs to increase its staff for this program in order to 
provide access to this effective program.
    Until recently, patients on the acute psychiatric unit were able to 
participate in the outpatient substance abuse programs, including AA 
and NA meetings. Without advance notice or planning, our director 
instituted a policy that forbids us to allow our patients to walk 
themselves to the substance abuse treatment groups, even when assessed, 
evaluated and approved to do so by the clinical care team.
    At first, staff would escort acute psychiatric care patients to the 
outpatient substance abuse program in order for our patients to have 
access to this treatment program. Because we lack adequate staff to 
provide constant escort by staff of our inpatients during the short 
breaks in between treatment groups they are in fact barred from 
participating in the programs at our Center and Treatment for Addictive 
Disorders. We simply do not have enough staff to make treatment 
accessible under this policy.
    With no inpatient substance abuse treatment and with a policy that 
effectively bars our patients from accessing the out-patient substance 
abuse treatment, our acute psychiatric patients are being denied 
treatment that is necessary for their full recovery and rehabilitation.
    In the short-run, management has arranged for a social worker to 
come to a unit 3 days a week for half an hour to lead a group of 
patients to help them get motivated for treatment. Once motivated, if 
they remain an inpatient, they cannot receive treatment.
    The across-the-board elimination of the privilege of a patient to 
go off the unit has adverse ramifications for staffing levels, access 
to care and quality of patient care which are not being adequately 
addressed.
    The policy to bar all psychiatric patients, who are admitted to the 
acute unit, from the ``privilege'' of going off the unit has 
implications beyond the denial of access for substance abuse treatment. 
All patients on these units are forbidden from escorting themselves to 
any therapy off the unit, regardless of whether they are no longer in 
an acute status. Because staffing on the unit is already extremely 
tight, it is difficult for us to escort patients to occupational 
therapy, recreational therapy, or kinesiotherapy. Therefore, patients 
miss appointments and we are effectively denying veterans access to the 
comprehensive care they deserve. When we divert nursing staff to escort 
patients off the unit, it further cuts our staff for therapeutic 
interventions and to respond to psychiatric emergencies, leaving 
patients and staff at risk.
    The barring of the privilege to go off the unit unaccompanied, also 
effectively means those patients can no longer go smoke a cigarette. 
While that seems like a minor inconvenience, at worst, and at best the 
promotion of a healthier lifestyle, it is devastating to our patients. 
Research has shown that the addictive force of nicotine is stronger 
and, therefore, harder to break for schizophrenics. Smoking helps 
reduce the agitation of psychiatric patients and calm them. Before or 
after the immediate imposition of the new policy on privileges, 
management did not arrange to increase escort staff or to provide a 
secure day room with proper ventilation for smoking.
    The increased confinement on the units has heightened tensions and 
unit treatment programs have suffered. Recently staff had to break up 
four different altercations between patients on my unit. Before the no-
privileges policy, we had fewer altercations.
    Many patients have expressed to me that they feel they are being 
punished and penalized. Out of the frustration at the stigma attached 
to not being able to earn the privilege or trust to go for treatment, 
one patient told another nurse ``It's like jail, but I'm supposed to be 
in a hospital. At least in jail, trustees get out of the cells.'' The 
confinement has increased depression for patients and reduced overall 
functioning levels.
    Because of the lack of privileges, patients are seeking discharge 
sooner then medically warranted. One administrator made the comment, 
``I have no doubt that we will see a serious decline in the number of 
patients seeking admissions now that we have eliminated patient 
privileges.''
    When the psychiatric care team evaluated a patient to be eligible 
for privileges, we did so as part of the therapeutic process. The 
psychiatrist made the case-by-case decision to grant or refuse a 
patient's privilege of leaving the unit unescorted. When clinicians 
granted privileges, it was to patients who were following protocols, 
compliant and responsive to medications and actively engaged in unit 
therapies. The psychiatric team also used privileges to evaluate how an 
individual patient functioned, for short exposures, with outside 
stimuli. The granting of privileges allowed patients to take a small 
step back towards normalcy, increase their self-esteem and self-
accountability.
    Nursing staff would take away a patient's privileges when there 
were indicators that the patient was not behaving appropriately on or 
off the ward or not acting responsibly.
    VA management is not applying its policy uniformly. It applies only 
to patients at my facility at Highland Drive. When we send many of our 
psychiatric patients for medical care at the VA's University Drive 
facility they have full privileges. This disparity in treatment further 
confirms to patients that the VA is punishing them for their mental 
illness.
    I appreciate that the policy to bar psychiatric patients from 
leaving the unit on their own was established with patient safety as 
the objective. As a psychiatric nurse for two decades, I am fully aware 
of the potential danger some of our patients can be to themselves, 
staff, or other patients. As a psychiatric nurse, I appreciate that 
among patients admitted to an acute care unit there is a broad range of 
functioning levels. I am also keenly aware of the common prejudice to 
label all patients with psychiatric disorders as dangerous individuals 
who we should lock up in the back wards of asylums.
    But in the 21st century, we should know better. Seriously mentally 
ill veterans deserve to be treated with dignity.
    Staff are frustrated that the current policy on privileges was not 
thought out fully to ensure that our patients receive the comprehensive 
care they need. We are exasperated that VA management did not increase 
our staffing levels to deal with the ramifications of an indiscriminate 
no-privileges policy. We are troubled that the policy was developed and 
implemented before allowing input from psychiatric care staff. We are 
alarmed that the policy was put into effective immediately without any 
planning to address the adverse consequences to patients and staff.
    In February 2002, more than 200 staff signed a petition urging our 
Director to adopt a Patient Privileges/Responsibilities Policy 
developed by a team of mental health professionals at our VA facility. 
Staff firmly believes that the principle of the least restrictive care 
environment, as cited in our health care systems Patient Bill of Rights 
will lead to improve patient outcomes.
    We ask for your assistance in encouraging our Director to adopt the 
policy developed by psychiatric care staff.
    Deinstitutionalization, rehabilitation, outpatient care, and 
extended care
    The VA has rapidly ``deinstitutionalized'' our most impaired 
mentally ill patients. According to the Committee on Care of Veterans 
with Serious Mental Illness, the number of patients with psychoses 
treated as inpatients dropped from FY 1994 to FY 2000 by 34%. In 
addition, the length of the stay of these veterans has been shortened 
significantly. VA has also shifted to outpatient and community settings 
as its primary care delivery model.
    These trends may seem to be a promising shift from institutional 
care to treatment and care in the community but in reality VA has 
failed to maintain sufficient staff to ensure these vulnerable veterans 
receive the comprehensive continuum of care and support to function in 
the community.
    At my facility, we had an extended care unit with 27 beds to care 
for veterans who were chronically mentally ill and were treatment 
resistant. Veterans on this unit had psychoses, dementia and 
Huntington's Chorea. This unit rarely had unoccupied beds. In March 
2001, staff worked aggressively to discharge nearly half these patients 
to nursing homes and personal care homes in order to drop the census of 
the unit down to 17.
    The reason VA pressed to discharge these patients was to make room 
on the unit for new patients who would benefit from the state-of-the-
art care in the unit as it became the Psychiatric Recovery Enhancement 
Program or PREP. The PREP is an intensive patient-centered 
rehabilitation program designed to achieve the highest function levels 
for patients in the least restrictive environment. Unfortunately, the 
chronic mentally ill patients who we discharged to make room for the 
PREP program did not benefit from that program.
    Many of the facilities that received these patients have sent them 
back to the VA because the patients were too disruptive or combative. 
The VA is often the only place willing to provide care for these 
patients. But now we are often turning our backs on veterans who need 
extended psychiatric care. Unless a veteran is 70 percent service-
connected, the VA extended care facility in Pittsburgh will force the 
patient and his family to plead every 60 days for the veterans' 
continued care.
    One veteran's wife told me she felt like she was sitting in front 
of a Gestapo committee of administrators telling her that her husband 
had to get out. Her agony was due to the fact that her husband was 
beaten and abused when he would strike out at a caregiver in a private 
nursing home. The private nursing home staff put him in a straight 
jacket. The care he received at the VA was far superior.
    Instead of closing mental health beds the VA should convert, these 
beds into extended care and long-term care beds. The final days of a 
veteran's life should not be filled with uncertainty and fear over 
whether they can stay at the VA. AFGE is concerned that the Capital 
Assets Realignment for Enhanced Services, or CARES process, will worsen 
this situation by closing down more beds.
    The reduction in staff has limited and hurt our capacity to provide 
this intensive treatment to help patients move back into the community 
when feasible. We are under new universal staffing levels, which will 
increase the number of patients per nursing staff. This reduction in 
staff per patient will make the goals of rehabilitation and recovery 
even more difficult to achieve.
    The loss of social work professionals has reduced our capacity to 
follow patients once they leave the facility. In addition to the actual 
social workers lost in real numbers, many of those that remain function 
in administrative rather than direct patient care roles. Without 
adequate staff to help manage the cases of patients who are discharged 
into nursing homes or the community, we risk many veterans falling 
through the cracks. These patients end up in jail or living under 
bridges. A few commit suicide, others self-medicate with illegal drugs 
or alcohol, others will show up later at a VA facility with full blown 
psychosis, cancer and/or liver failure.
    The community based outpatient clinics (or CBOCs) have consistently 
failed to provide adequate access to mental health services. My service 
network, VISN 4, has ranked 20th out of 22 networks in deployment of 
mental health services at CBOCs.
    It is clear that VA saved dollars by the elimination of staff and 
beds for mental health but did not retain those dollars to support 
specialized mental health care capacity. VA instead funneled funds to 
support medical care.
    The shift to outpatient care or discharging patients into the 
community is a pretense and renders veterans non-patients if the VA 
does not provide adequate staff and resources to engage in active and 
intense case management.
                               conclusion
    Veterans served our country when asked. We, at the very least, owe 
them the dignity of access to adequate and humane care. We cannot let 
the most vulnerable segment of our patient populations, the seriously 
mentally ill and the chemically dependent, fall through the cracks 
because we lack the commitment to staff the VA and re-open beds.

    Chairman Rockefeller. Thank you. But please continue your 
good work with the VA.
    Ms. Evans. I am trying.
    Chairman Rockefeller. OK, thank you.
    Dr. Frese.

STATEMENT OF FREDERICK FRESE, VICE PRESIDENT EMERITUS, NATIONAL 
   ALLIANCE FOR THE MENTALLY ILL, AND ASSISTANT PROFESSOR OF 
     PSYCHOLOGY IN CLINICAL PSYCHIATRY, NORTHEASTERN OHIO 
                UNIVERSITIES COLLEGE OF MEDICINE

    Mr. Frese. I am real honored to be here. I am with NAMI, 
Senator Rockefeller, and the last 10 years we have been very 
active in the Senate. We have looked at Senators Pete Domenici 
and Paul Wellstone as being our champions. We call them St. 
Peter and Paul. But from my observation of you this morning, 
sir, you are definitely moving closer to those pearly gates, so 
thank you very much. [Laughter.]
    You are doing outstanding work here. In addition to being 
the recent Vice President of the NAMI board of directors and a 
veteran, I am a retired captain from the U.S. Marine Corps. I 
retired during the Vietnam war when I was a guard officer 
guarding intelligence facilities and atomic weapons, because I 
received a medical discharge because I was diagnosed with 
schizophrenia. I am wearing a suit, but it is not PTSD this 
time, Senator.
    In this condition in the past I have been involuntarily 
hospitalized numerous times in military state, county, private 
and veterans hospitals during the past three decades while 
working as a psychologist in state hospitals and community 
mental health centers. I have been receiving outpatient 
treatment from the Veterans Administration for my 
schizophrenia.
    Over the years I have served on numerous advisory panels 
for the VA including the Committee on Care for the Seriously 
Mentally Ill, the SCMI Committee, and the National Psychosis 
Algorithm Project. Today I would like to focus my testimony on 
continuum of care needed for veterans with severe mental 
illnesses and the VA's capacity. Of great concern to NAMI is 
about 30 percent of veterans who are service connected, or for 
psychosis, about 25 percent of the total are for those with 
schizophrenia, often considered the most devastating of the 
brain disorders, but in my case I am not as disabled as many of 
my fellow schizophrenic veterans.
    In NAMI's view, an acceptable continuum of care should 
include availability and accessibility of professionals in care 
and we would like to highlight the following things. One is 
adequate medications, which have been addressed already. 
Family, education and psycho-education, which has not been 
mentioned which is a major focus. Some of the VISN's have it 
and some do not, but families should be much more knowledgeable 
about our understanding of schizophrenia and serious mental 
illness than they have been, particularly with the late 
breaking news out of Decade of the Brain.
    Chairman Rockefeller. Can I interrupt you, no expense to 
your time, just to explain how that works in the best possible 
way, family involvement?
    Mr. Frese. Yes, sir. Until 20 years ago, families, 
including my own, would not talk about mental illness at all. 
It was totally taboo. Families would not acknowledge they had 
insanity in the family. That has changed somewhat in the last 
20 years. Now families are willing to take more--acknowledge 
that they have this condition and take more interest in their 
persons with mental illness in the family and particularly with 
the VA, but the VA is following customs that was set after the 
war and this has not been incorporated. So in one of the 
VISN's, Vincennes, they are moving well on this, but the rest 
are not, and that is to bring the families into the treatment 
process and make sure the families understand the nature of the 
disorder. Understanding what a broken leg or blindness is, is 
kind of intuitive to most persons. Understanding what 
schizophrenia is, is much more difficult. I often say 
handicapped parking spaces do not have an image of a Haldol 
pill, because that would not signal. It is very difficult for 
folks to understand. Families need to know more about this.
    Am I responding to your question?
    Chairman Rockefeller. So in other words, the point is, that 
to have families come for the treatment sessions, is as much or 
more for them and their evolution and support capacity as it 
would be for you as a patient.
    Mr. Frese. Yes, sir. Very good.
    In addition to focusing on family education and 
involvement, there are the CBOC's, the outpatient care. By the 
way, we are still concerned that only 46 percent of those 
community based centers offer outpatient treatment for 
psychiatric disorders. A year ago that was 40 percent so it is 
moving up a bit, but that is a concern. We are concerned about 
residential treatment and supporting housing.
    In the advocacy movement we generally say three things we 
want are housing, jobs, and by stigma, and housing for the VA 
is a problem.
    The ACT's or MHICM's that you have heard about are 
exceedingly important. You have heard there are 65 of them, but 
of the 21 VISN's, some of those do not have any at all. You 
have also been told that professionals are involved in that, 
psychiatrists, psychologists. I am very concerned personally 
that only a handful of psychologists, very few, are involved in 
those at all, and we need much more support from psychology on 
getting psychological services in the VA as elsewhere.
    Psychosocial rehabilitation, particularly focused on the 
recovery movement, it is totally a news flash to most providers 
that those of us with schizophrenia do not have what is 
characterized traditionally as a degenerative disorder. We can 
recover, and I was so please that Dr. Lehman and others allowed 
Moe Armstrong and I to give a national teleconference, and he 
signaled to the VA we are going to change from focus on care 
and maintenance to a focus on trying to get folks to recover. 
We can recover, and with their help, we can do that.
    Ms. Evans pointed out about the prejudice and stigma within 
the VA, and others have as well. That is a problem. I think the 
President's Commission, Mr. Bush says the main three things 
that need to be focused on are stigma, capacity and parity, 
that stigma is something that needs to be addressed throughout, 
particularly in the VA. Those attitudes need to be changed. I 
do not like going and getting services and being referred to as 
a schizo to my face. If you want to call me a person with 
schizo, that is something else, but those terms need to be 
toned down.
    Employment services, we need to work. Seriously mentally 
persons throughout the----
    Chairman Rockefeller. The medical staff would not refer to 
you that way, would they? Who would use those words?
    Mr. Frese. Most recently?
    Chairman Rockefeller. Yes.
    Mr. Frese. Most recently I was in this town 2 weeks ago, 
testifying before a Presidential commission and a member told 
me he was real happy that he had just gotten a job for 2 
schizos and would that not make me happy? And I told him, well, 
I am happy you got jobs for a couple of us, but I would really 
prefer you characterize us with a term other than schizo. I am 
sorry, but I am sensitive about these terms. But thank you for 
your interest. I do not want to be angry here because I 
appreciate all your work.
    Integrated treatment. This is new. It is designated by the 
American Psychiatric Association as one of the evidence-based 
practices. There has been separation of treatment for those 
with substance abuse and serious mental illness. Those of us 
with these illnesses are exceedingly vulnerable to the effect 
of those substances, alcohol and treatment drugs, but we need 
to be treated with those together. 60 to 70 percent of us with 
serious mental illness also have substance abuse problems, and 
those need to be better integrated.
    Now, those are our major issues. I have them all in the 
written statement. The MIRECC's, the research, we are very 
pleased there 8 MIRECC's and there is efforts to increase that 
research. We in NAMI particularly look forward to all the 
research findings. We are benefiting tremendously from the 
quintupling of the budget for NIMH in the last 10 years, and we 
are learning about what is going on in the brain. But the VA 
has been a substantive part of that research effort and that 
has got to keep coming.
    I have a concluding paragraph. I am over time. Would you 
like to hear it, sir?
    Chairman Rockefeller. Are they just polite or are they 
substantive.
    Mr. Frese. Our Nation's veterans deserve the best treatment 
including access to the highest quality care for goods and 
services. Thank you very much, sir.
    [The prepared statement of Mr. Frese follows:]
    Prepared Statement of Frederick Frese, Vice President Emeritus, 
  National Alliance for the Mentally Ill, and Assistant Professor of 
   Psychology in Clinical Psychiatry, Northeastern Ohio Universities 
                          College of Medicine
    Chairman Rockefeller, Senator Specter and members of the Committee, 
I am Fred Frese of Akron, Ohio. I am pleased today to offer the views 
of the National Alliance for the Mentally Ill (NAMI) on the Department 
of Veterans Affairs ability to deliver quality mental health care to 
veterans with severe mental illnesses.
    In addition to having served on the NAMI Board and the VA's 
Consumer Liaison Committee on Care of Veterans with Serious Mental 
Illness. I am a veteran myself. In 1966, I had been selected for 
promotion to the rank of Captain in the U.S. Marine Corps. That is when 
I was first diagnosed as having the brain disorder schizophrenia--
perhaps the most severe and disabling mental illness diagnosis. Since 
my original diagnosis, I have been treated within the VA medical 
system, both as an inpatient at the VA hospital in Chillicothe, Ohio, 
and as an outpatient. Over the years, I have served on numerous 
advisory panels to the VA on care for the seriously mentally ill, 
including the VA's National Psychosis Algorithm.
                              who is nami?
    NAMI is the nation's largest national organization, 210,000 members 
representing persons with serious brain disorders and their families. 
Through our 1,200 chapters and affiliates in all 50 states, we support 
education, outreach, advocacy and research on behalf of persons with 
serious brain disorders such as schizophrenia, manic depressive 
illness, major depression, severe anxiety disorders and major mental 
illnesses affecting children.
    NAMI has established a NAMI Veterans Committee to assure close 
attention to veterans mental health issues not only at the national 
level, but also within each Veterans Integrated Service Network (VISN). 
The NAMI Veterans Committee includes members in each of the 21 VISNs 
who advocate for an improved continuum of care for veterans, active 
military, and dependents with severe mental illness. The membership of 
the NAMI Veterans Committee consists of persons with mental illness, or 
family and friends of a person living with a severe mental illness who 
have an active involvement and interest in issues impacting veterans 
and our military. NAMI is therefore pleased to offer our views on the 
programs that serve veterans with severe mental illness.
    Mr. Chairman, today I would like to focus my testimony on the 
continuum of care needed for veterans with severe mental illnesses and 
the VA's capacity to provide quality mental health services. For too 
long, severe mental illness has been shrouded in stigma and 
discrimination. These illnesses have been misunderstood, feared, 
hidden, and often ignored by science. Only in the last decade have we 
seen the first real hope for people with these brain disorders through 
pioneering research that has uncovered both biological underpinnings 
for these brain disorders and treatments that work. NAMI applauds the 
contributions of VA schizophrenia research to the understanding and 
treatment of these illnesses and supports the development of the VA 
mental illness research infrastructure through the Mental Illness 
Research, Education and Clinical Centers (MIRECC). NAMI is also 
grateful to the efforts of Congress (under your leadership, Senator 
Specter) to double the funding at the National Institute of Mental 
Health on mental illness research.
       continuum of care for veterans with severe mental illness
    In NAMI's view, an acceptable continuum of care should include the 
availability and accessibility of physician services, state of the art 
medications, family education and involvement, inpatient and outpatient 
care, residential treatment, supported housing, assertive community 
treatment, psychosocial rehabilitation, peer support, vocational and 
employment services, and integrated treatment for co-occurring mental 
illness and substance abuse. The services a veteran requires from this 
continuum of care at any given time are determined by the fluctuating 
needs of his or her current clinical condition and should be 
established in conjunction with his or her treatment team. All services 
should be available without waiting lists or other barriers to 
accessing needed treatment and services. To be a comprehensive system 
of care--the VHA must have the capacity to provide such services.
    Mr. Chairman, as you know the VHA's 21 VISNs were instituted to 
administer the health services (including mental illness treatment) for 
VA hospitals and clinics. The idea of these VISNs was to decentralize 
services, increase efficiency and shift treatment from inpatient care 
to less costly outpatient settings. There is great variation within and 
between each VISN in the services it offers to veterans and a VA mental 
health benefits package can vary from network to network. Further, the 
VHA is in charge of allocating annual appropriations for each of these 
21 VISNs, but does not specifically direct funds to be spent for mental 
illness treatment and services. Once funding is received, each VISN has 
authority to allocate resources to hospitals and clinics within their 
jurisdiction with broad autonomy. NAMI's concern is that with the flat 
or declining budgets in each VISN veterans with severe mental illness 
will not receive the treatment that is needed.
    In NAMI's opinion, the lack of access to treatment and community 
supports for veterans with severe mental illness is the greatest unmet 
need of the VA. The FY 2003 Independent Budget for the VA estimates 
that 454,598 veterans have a service connected disability due to a 
mental illness. Of great concern to NAMI are the 130,211 veterans who 
are service connected for psychosis, 104,593 of whom were treated in 
the VHA in FY99 for schizophrenia, one of the most disabling brain 
disorders.
                 va must expand evidence based services
    As part of P.L. 107-135, Congress directed the VA to provide data 
on how VHA is maintaining capacity for this high priority category of 
veterans through specialized services. This law mandates, among other 
provisions, that VA provide data on the number of Mental Health 
Intensive Case Management (MHICM) teams, the number and type of staff 
that provide specialized mental health treatment in each facility and 
Community Based Outpatient Clinic (CBOCs), and the number of CBOC's 
that provide mental health treatment and services. NAMI remains hopeful 
that this data will help define how capacity is being maintained for 
veterans with severe mental illness. At the same time, we have to 
recognize that without the VA's expanding services and programs and 
providing further resources and funding, the VA's capacity to serve 
these high priority veterans will never be met.
                mental health intensive case management
    As members of this Committee know the VHA issued a directive for 
Mental Health Intensive Case Management (MHICM) back in 2000. MHICM is 
based on the Substance Abuse and Mental Health Services 
Administration's (SAMHSA) standards for assertive community treatment 
(ACT), which are proven, evidence-based approaches in treating the most 
severe and persistent mental illnesses. VHA data shows that assertive 
community treatment is cost-effective as well as effective in treating 
severe mental illness. However, the SCMI Committee reports that only 1% 
of all veterans with severe mental illnesses are being treated by a 
MHICM team. Over 12,000 veterans meet the criteria for MHICM and yet 
only 2,905 veterans are enrolled. Several networks do not have any 
teams in place at all.
    It is also recognized that very few of the MHICM treatment teams 
meet the SAMHSA standards outlined in the VA directive and that many of 
these teams are operating at minimal staffing and are now facing 
further staff reductions. NAMI strongly recommends that Congress direct 
VA to dedicate new resources to provide the essential number of new 
intensive case management teams and to fully staff existing teams so 
that our nation's most vulnerable veterans receive appropriate and 
coordinated care.
                   community based outpatient clinics
    Many of the VA's Community Based Outpatient Clinics (CBOCs) are 
instituted in areas where VA health services are not easily accessible. 
However, the SCMI Committee reports that out of the 560 CBOCs in 
operation only 46% offer minimal treatment services for veterans with 
severe mental illness. NAMI is truly concerned that meaningful 
community-based capacity is not being developed to treat chronically 
mentally ill veterans in their communities. NAMI agrees with the SCMI 
Committee recommendation that VHA should assure that adequate funds are 
available in each network to implement plans to provide mental health 
services for high priority veterans. The SCMI Committee has recommended 
that this be done even if it means requiring mandates for VISNs to 
reprioritize current funding for services of lower priority veterans 
and slow further growth of spending on lower priority veterans.
                   access to appropriate medications
    Critical to a continuum of care for veterans with severe mental 
illness is access to the most appropriate medication. NAMI has closely 
followed the implementation of the VA's prescribing guideline for 
atypical antipsychotic drugs and the subsequent GAO report (GAO-02-579) 
requested by House Veterans' Affairs Committee Chairman Chris Smith. 
The GAO investigated if this guideline has resulted in restricted 
access to more costly antipsychotic medications and the possible 
adverse effects this may have on veterans with severe mental illness.
    Mr. Chairman, NAMI is pleased that the GAO validated three of our 
primary concerns surrounding the guideline since it was first issued in 
July, 2001: (1) that selecting which antipsychotic agent to prescribe 
is difficult and patient specific, (2) that the most desirable outcomes 
are very much determined by a clinician's ability and freedom to 
properly match the right patient with the right medication, and (3) 
that while the intent of the overall guideline may be to ensure 
physician judgment is the driving factor in decisions, there exists a 
great potential for abuse of the guideline from VISN to VISN and 
facility to facility.
    The GAO report found that ``VA's guideline for prescribing atypical 
antipsychotic drugs is sound and consistent with published clinical 
practice guidelines commonly used by public and private health care 
systems.'' NAMI is troubled by this assertion and believes that is 
inconsistent with the current research base. Medical evidence supports 
the use of an atypical antipsychotic as the medication of first choice, 
but current guidelines based on this evidence specifically provide for 
clinician choice among the atypicals (other than clozapine). In NAMI's 
view, the VA guidelines go beyond the medical evidence in that they 
select preferred atypical medications based solely on cost.
    NAMI continues to be concerned regarding this policy and questions 
whether VA would make cost a consideration in the treatment of any 
other group of service connected veterans. While NAMI supports the VA's 
overarching goal to allow physicians to use their best clinical 
judgement when prescribing atypical antipsychotic for their patients, 
and while we certainly recognize the VA's need to husband resources, we 
believe that it should not come at the cost of veterans with acute 
needs.
    There are numerous studies (including the schizophrenia PORT study) 
demonstrating that these pharmacy costs are only a small part of the 
cost of schizophrenia care that can include hospitalization, 
residential care, supportive services, etc. Pharmacy savings that are 
achieved through restrictive formularies are often offset by increased 
clinical care costs elsewhere. Such studies do suggest the importance 
of looking at the costs of the entire care system for an illness, 
rather than trying to control costs in just one area.
    Unfortunately NAMI was not surprised by the GAO's finding that 
numerous VISNs have implemented procedures that ``have limited or could 
restrict access to certain atypical antipsychotic drugs on the VA's 
national formulary because of cost considerations.'' NAMI continues to 
receive reports from families, consumers receiving services, as well as 
physicians providing services within the Veterans Health Administration 
that speak of further restrictions on accessing medications and 
clinical decisions that are overridden by pharmacy managers.
    Mr. Chairman, we recommend that this Committee urge the VA to 
develop and implement a detailed plan to stop abuses found in the GAO 
study. The GAO report recommends that the ``VA monitor implementation 
of the guideline by VISNs and facilities to ensure that facilities' 
policies and procedures conform with the intent of the guideline by not 
restricting physicians from prescribing atypical antipsychotic drugs on 
VA's formulary.'' NAMI fully supports this recommendation and believes 
that, at a minimum, there should be:
     a directive forbidding the collection and use of 
individual physician prescribing profiles
     a directive forbidding the introduction of cost-
containment criteria into performance reviews
     a formal monitoring program to examine all instances in 
which a less expensive medication is substituted for a more expensive 
medication to assure that stable patients are not switched
     a formal program by which violations of these directives 
by overzealous pharmacy or behavioral health managers could be reported 
without fear of reprisal.
                            family education
    There is broad research that demonstrates family psychoeducation 
and support services offered to the families of veterans with severe 
mental illness should be a part of a continuum of care for veterans. 
Family psychoeducation includes teaching coping strategies and problem-
solving skills to families (and friends) of people with mental 
illnesses to help them deal more effectively with their ill relative. 
Family psychoeducation reduces distress, confusion, and anxieties 
within the family, and can often help the veteran recover. However, 
family psychoeducation is rarely offered in the VA setting and there 
are limited incentives to do so. To fill this void, NAMI has partnered 
with the VA to offer family education through the Family-to-Family 
Education Program, (a model that has proven effective at improving the 
experience of families of persons with serious mental illness). 
Research has shown that this course provides knowledge to families and 
empowers them to cope with their ill family member and the mental 
health system in a positive manner, and has lasting effects on the 
family system.
    The VA has 21 health care networks with 163 hospitals, 800+ 
community-based facilities, and 135 nursing homes and more than 454,000 
veterans service connected for a mental illness. This represents a 
critical mass of individuals who could benefit from family education. 
The SCMI Committee recommended in it 5th Annual Report to the Under 
Secretary that VA develop partnerships with community organizations 
that sponsor self help groups and that they be a specific item required 
in the annual Network Strategic plan. NAMI further recommends that VA 
encourage the use of family education and family support services in 
each Network.
              is there parity in the va for mental health?
    NAMI greatly appreciates the efforts of this Committee and Congress 
to address the loopholes that have existed in the Capacity Law. Last 
year, Congress passed the Department of Veterans Affairs Health Care 
Programs Enhancement Act of 2001 (PL 107-135) which strengthened the 
VA's capacity to serve veterans with mental illness; requiring 
improvements to the current system to ensure that veterans have access 
to the necessary treatment and services. The new law not only requires 
the Department to maintain capacity for veterans with mental illness 
but also to replace lost capacity. The FY 2003 Independent Budget (IB) 
makes several recommendations for increasing the VHA's capacity to 
serve veterans with mental illness. Moreover, the IB recommends that to 
simply achieve parity with other illnesses, the VA should be devoting 
an additional $478 million to mental illness spending. NAMI supports 
the IB recommendation for the VA to meet its responsibility to these 
high priority veterans. To achieve this goal, Congress should 
incrementally augment funding for veterans with severe mental illness 
by $160 million each year, beginning in FY 2003 through FY 2005.
    Currently, about 20% of veterans in the VA system are in need of 
mental health treatment and far below the expectations of the VA's 
capacity law. At the same time, funding for mental health has declined 
by 8% over the past five years (adjusted for inflation that decline in 
spending increases to 23%). While the VA reports that they have 
maintained capacity for veterans with severe mental illness, many 
advocates argue that the VA has not due to the high need of expanded 
services, decreased staffing levels, and budget levels that are not 
adjusted for inflation.
    Further, the VA's funding model, the Veterans Equitable Resource 
Allocation (VERA) system also provides disincentives for providing 
mental health treatment. VERA under-funds the cost of providing 
services to veterans with severe mental illness by 20%. In FY 2000, an 
additional $498 million was needed to make the VERA allocation equal to 
the costs of its mental health cohorts. NAMI strongly supports the SCMI 
Committee's recommendation that the VHA ensure that the funding model 
is cost neutral for care of veterans with severe mental illnesses.
                                research
    Even though the VA has made genuine progress in recent years in 
funding for psychiatric research, such research remains 
disproportionate to the utilization of mental illness treatment 
services by veterans. Veterans with mental illness account for 
approximately 25% of all veterans receiving treatment within the VA 
system. Despite this fact, VA resources devoted to research has lagged 
far behind those dedicated to other disorders.
    For FY 2003, NAMI urges Congress to support the recommendation of 
the Independent Budget and Friends of VA Medical Care and Health 
Research to increase the overall VA research budget by $89 million. 
Psychiatric research dedicated to chronic mental illness, substance 
abuse and PTSD has remained relatively flat for last 15 years, despite 
the fact that the number of patients in the VA system receiving mental 
illness treatment has grown. Research is one of the VA's top missions 
and NAMI is pleased that the VHA is taking steps to increase the number 
of Mental Illness Research, Education and Clinical Center (MIRECCs), 
centers designed to serve as infrastructure support for mental illness 
research. The MIRECCs are a tremendous resource for improving the 
efficacy of mental health services and improving the outcomes of 
veterans living with severe and persistent mental illnesses. Mr. 
Chairman, NAMI appreciates the efforts of Senator Specter and yourself 
to urge your Senate colleagues on the VA-HUD Appropriations 
Subcommittee to increase VA's medical and prosthetic research program 
in FY 2003.
              lost capacity for substance abuse treatment
    There has been a tremendous decline in substance abuse services. 
Since FY 1996 the number of veterans treated has declined by 14% and 
funding for services has declined by more than 50% is despite evidence 
that substance abuse disorders are increasing across the nation.
    Further, in 1999 Congress passed the Veterans Millennium Health 
Care and Benefits Act (P.L. 106-117) mandating that by FY 2000 VHA 
increase funding for both substance abuse and PTSD by at least $15 
million dollars each year. To date, VHA has yet to meet that mandate.
    NAMI supports the recommendation of the SCMI Committee ``that 
assertive management action needs to be taken to reverse the ongoing 
erosion of access to specialized substance abuse services in VHA. This 
action needs to restore services to the 1996 levels mandated in the 
Capacity Provisions of the Eligibility Reform legislation.''
                         co-occurring disorders
    National studies commissioned by the federal government estimate 
that 10--12 million Americans have co-occurring mental and addictive 
disorders. The prevailing research confirms that integrated treatment 
for co-occurring disorders is much more effective than attempting to 
treat these illnesses separately. In NAMI's view, the research clearly 
demonstrates that providing treatment and interventions for mental 
illness and addictive disorders simultaneously, at the same treatment 
site, and with cross-trained staff is more effective than sequential 
treatment (treat one disorder first, then the other) or parallel 
treatment (in which two different treatment providers at separate 
locations use separate treatment plans to treat each condition 
separately but at the same time).
    NAMI supports the research being done in the MIRECCs to improve the 
health services for patients who have co-occurring mental and addictive 
disorders. For example, the VISN 1 MIRECC has concluded that emphasis 
should be placed on integrated treatment, and that attention to a 
veteran's multiple disorders produces better outcomes. The VA needs to 
continue to develop innovative programs and appropriately train staff 
to help veterans living with a severe mental illness and an addictive 
disorder.
                               conclusion
    Mr. Chairman, NAMI appreciates your dedication to veterans with 
severe mental illness and your sponsorship of legislation to further 
improve and expand the provision of specialized mental health services 
to veterans. Our nation's veterans deserve the best treatment, 
including access to the highest quality care, supports and services. 
Veterans with severe mental illness should be afforded the same 
resources as other high priority veterans, including needed community 
based supports and access to state of the art medications. Thank you 
for the opportunity to share NAMI's views on these important issues.

    Chairman Rockefeller. Thank you. Thank you, Dr. Frese.
    And before I go to you, Mr. Armstrong, I want to ask you, 
Dr. Alarcon, two things. We have heard the words here ``mental 
illness'' and we have heard the words ``serious mental 
illness.'' I am a lay person, so just explain to me those two 
categories and how I can best understand the difference.
    Dr. Alarcon. There are maybe two levels of explaining that. 
One is what we clinically may consider a severely mentally ill 
versus a mentally ill patient, and what the rules of the SMI 
definition include. The SMI definition includes patients with 
some diagnosis such as psychosis, post traumatic stress 
disorder, substance abuse and other conditions, very 
specifically delineated diagnosed according to codes, 
instruments, et cetera et cetera. Those are the definitions of 
serious mental illness, major depression, et cetera.
    So that is what the committee addresses. And I must say, in 
a population such as the VA, that is a significant contingent 
of patients that fall into the category of SMI. There are also 
other rules that have to do, for instance, with an intensive 
case management approach, which also has other rules for what 
kinds of patients are to be included in the intensive case 
management program or assertive community treatment approach. 
So those are rules or definition.
    In terms of from the clinicians' perspective, mental 
illness and serious mental illness are considered perhaps one 
being the overall mental illness which goes from a mild 
reactive depression, so-called dysthymia, which is in response 
to some environmental factor or loss, et cetera, which after a 
couple of months can fade away, but that is a mental condition 
that at the time may require treatment. By the same token, it 
goes in different levels of gradation, severity, family 
involvement or lack of involvement, loss of social networks, 
loss of employment, and that adds up to the severity of the 
condition. In short, Mr. Chairman, mental illness is the big 
umbrella. Many people fall under that. We only see the tip of 
the iceberg in the veterans' population.
    Chairman Rockefeller. Let me ask my second question before 
I go to Mr. Armstrong. When I say the words ``American family'' 
I mean an extended family. That is not my mother, father, 
children, wife, me, et cetera, but the extended family. What 
percentage of American extended families have some form of 
mental illness? This is obviously a stigma-based type question, 
because I am angry like you both are because of the continued 
stigma of mental illness. Sometimes it is classic American 
behavior to deny what sits right in front of your face. But 
what is the answer to my question?
    Dr. Alarcon. I would have to answer with what 
epidemiological research gives us, namely that every 
epidemiological study in the community, which includes of 
course families and family units, report at least 25 percent of 
the population with some kind of diagnosable----
    Chairman Rockefeller. So it is 25 percent of the 
population.
    Dr. Alarcon. Yes.
    Chairman Rockefeller. That almost means every extended 
family, does it not?
    Dr. Alarcon. I would say so.
    Chairman Rockefeller. So that is something we need to think 
about.
    Dr. Alarcon. I would--they are saying yes, Mr. Chairman. 
And I think there is a significant support in different 
epidemiological studies in the last two or three decades, 
studies that include the recent, mid 1990's, the National 
Community Health Survey, the NCHS. And those show really the 
prevalence of mental illness across the spectrum of the 
American population, and the fact that conditions such as 
depression will be in 20 or 30 more years at the top of the 
disability factors in this country.
    Chairman Rockefeller. Thank you, doctor.
    Mr. Armstrong?

  STATEMENT OF MOE ARMSTRONG, DIRECTOR OF FAMILY AND CONSUMER 
AFFAIRS, VINFEN CORPORATION, REPRESENTING THE NATIONAL ALLIANCE 
                      FOR THE MENTALLY ILL

    Mr. Armstrong. Thank you, Mr. Chairman.
    My name is Moe Armstrong. I served with the Marine Corps, 
Third Reconnaissance Battalion in Vietnam, 1965, 1966. And on 
my way up here I was in Southwest Virginia, and I picked up a 
friend of mine who served with me in Vietnam. I would like to 
acknowledge him also. Bill Mulkiat served in Vietnam. He is 
from Harlan, Kentucky, drove over the mountains, and we came up 
from Abbington, Virginia to be here. It is an honor to be here.
    Chairman Rockefeller. Well, you are an honorary citizen of 
Southern West Virginia, by definition of where you come from.
    Mr. Armstrong. 75 people I have trained to do support 
groups down in Southwestern Virginia, as matter of fact, up to 
Bluefield where you are.
    In 1965 I kept breaking down. I was a Special Operations 
soldier. I could not believe this had happened to me. I had 
been trained as a medical corpsman to treat people for a 
sucking chest wound. I had been trained to do all kinds of 
medical interventions, and I did not know how to treat people, 
and including myself, for mental illness, and that was very 
devastating for me.
    I was evacuated to the Navy hospital in 1966 and released 
to the streets. And in those days you were either in the 
hospital or you were on the streets, and I immediately became 
homeless and moved to New Mexico, where I lived for 3 years in 
little shacks and tents, and lived marginally with help from 
town and food stamps. At that time the New Mexico Veterans 
Service Commission and the Veterans Administration picked me 
up. I am very grateful because I could have died. I was one of 
those people that is extremely disabled by my own psychiatric 
condition.
    So I went from being a tough Special Operations soldier to 
somebody who was homeless and a derelict really on the streets 
of America. From a Presbyterian Sunday School teacher to 
somebody who just almost could not even fend for themselves, 
and I could not believe this had happened to me.
    And still this is happening. For me mental illness never 
went away. There is no cure. There is no miracle out there. But 
we can learn to live with mental illness. And I think that that 
is what is the great challenge in front of the Veterans 
Administration today. I do not necessarily think it is how much 
we have but we necessarily do. There is a practice called 
psychiatric rehabilitation, psychosocial rehabilitation. It 
seems as though those of us who have a major mental illness, 
and I have been blessed to have both post traumatic stress 
disorder and schizophrenia, lose social adeptness. Just as a 
person that had a physical disability would lose range of 
motion, we lose range of social interconnectedness with people. 
To develop that back takes skills. Those skills need to be 
psychiatric rehabilitation skills in practice. Most people have 
not been spending time learning this. Agreed, Fred and I have 
just done a video across the Veterans Administration, but I 
still get my care at the VA. My social worker, I have spelled 
her out, how to do psychiatric rehabilitation so she can work 
with me. I learned psychiatric rehabilitation skills, and I 
work in the State Mental Health Authority in the State of 
Massachusetts, and we have 35 support groups going in there, 
not for other people but also for my own well being. Having a 
mental illness means I have to spend the rest of my life doing 
self maintenance and self monitoring. This is not an easy 
condition to live with.
    Psychiatric rehabilitation is very practical in nature. It 
provides people with employment opportunities and provides 
people with planning for services, linking to services and 
keeping people in services. That is very different than 
counseling and therapy, talking about how do we feel. You know, 
we need to learn what we have and how to live with it. But it 
does have a vacuum that I would like to point out.
    I feel as though peer support, which is something that I 
have gradually over the years developed, over the past 7 years 
in Massachusetts, is a real missing component for two reasons. 
First off, knowledge base. Those of us who have these 
conditions, I believe, can go back and be of service to teach 
other people how to live with these conditions so that we do 
not continuously fall apart, so we do not put our family 
through this mess that we experience internally and sometimes 
externally with this mental illness. Also we have--and I 
believe this--a moral responsibility to go back and work with 
those that are not doing well. Your Committee, through the 
Veterans Administration, put a lot of care into me through 
funding the Veterans Administration. What I got and who I am 
today I did not do on my own. I got this through a lot of care 
and a lot of support through the years, and I hope that it was 
money well spent and well funded through the VA. But you know 
what? I need to do that for other people. I have a moral 
responsibility to go back and work with those that are not 
doing as well, to make sure that they are able to be sane, 
stable, safe and sober, the four S's. If we do not do peer 
support, our staff cannot spend all of its time working with us 
that have these conditions. These conditions are very labor 
intensive. I can burn out 5 psychiatric nurses in an afternoon 
if I get on a roll, OK? [Laughter.]
    This is like big-time stuff. It takes a lot of folks to 
cool me out. The best, I think, crisis prevention, is a lot of 
education up front. That education needs to be both peer 
support and professional support, and some peers and 
professionals working together. That is where I think we need 
to go in the Veterans Administration. We have not done a very 
good job of it. In Massachusetts we are attempting to do this. 
The State of Virginia is doing a fairly good job of this with 
their Medicaid waiver. Right now my job is working in different 
states besides Massachusetts. So I kind of also get an idea of 
where different states are in their growth and development with 
psychiatric rehabilitation.
    You know, I really want to take the time to thank everybody 
for inviting me here today because I never dreamed that I would 
have this opportunity to work in mental health or have a job. 
As a matter of fact, it is very strange being with Bill who 
served with me in Vietnam because he remembers what it was like 
before I was homeless, before I was destroyed from mental 
illness, and how I have had to building my life back. This is 
not easy. We have a job ahead of us, but until we start to set 
up, I think, some levels of competency for psychiatric 
rehabilitation within the VA and start to set up, I would even 
encourage, through the compensated work therapy teams, the 
recruitment, training and development of other veterans with 
major mental illness to gradually go back and work on our own 
system. I think we are always going to be picking up pieces and 
putting out fires and taking care of crises, rather than 
educating people up front.
    I would like to thank you for inviting me and I want to 
leave you some of the buttons that we made for our Vet-to-Vet 
program. We are doing this in West Haven, and it is being 
evaluated by one of the MIRECC's. It is called Vet-to-Vet. The 
little logo I drew. And it is, ``Gladly teach, gladly learn,'' 
and that is the motto of this program, gladly teach and gladly 
learn, because to be a good teacher, I really think you have to 
be a good learner.
    Thank you.
    [The prepared statement of Mr. Armstrong follows:]
 Prepared Statement of Moe Armstrong, Director of Family and Consumer 
Affairs, Vinfen Corporation, Representing the National Alliance for the 
  Mentally Ill on Behalf of the National Alliance for the Mentally Ill
    Chairman Rockefeller, Senator Specter and members of the Committee, 
I am Moe Armstrong of Cambridge, Massachusetts. I am pleased today to 
offer the views of the National Alliance for the Mentally Ill (NAMI) on 
the Department of Veterans Affairs ability to deliver quality mental 
health care to veterans with severe mental illnesses. Specifically, I 
would like to address the programs necessary for recovery in the VA 
system as well as other best practice models and how they are being 
delivered to our nation's veterans.
    In addition to serving on the NAMI Board, I am a veteran myself and 
I also was once homeless. I was a medical corpsman attached to Third 
Reconnaissance Battalion of United States Marine Corps; I spent almost 
eleven months in Vietnam. We were in combat almost every other week. I 
never flinched. I never ran under fire. Then, one day I became mentally 
ill.
    I spent many months on the streets of America. I was trying to hold 
jobs and trying to stay in apartments. I kept breaking down on the job. 
I kept losing apartments. I would either be on the streets sleeping in 
the park or staying with friends till they got tired of me. This was 
1966, nobody knew that much about mental illness or substance abuse. 
There was no after care from the hospital. I was alone to flounder and 
fall down. I applied to the Veterans Administration for help. At the 
time, I was living in a tent in over a foot of snow when 
representatives from the VA came up in the mountains to see me. They 
cried when they saw my condition. I was dirty and disoriented. I had no 
home. I was just surviving on some unemployment money that I had saved 
and food stamps. They got me connected with VA benefits and an agency 
called the New Mexico Veterans Service Commission. The VA and the New 
Mexico Veterans Commission helped me. They saved my life by bringing me 
out of homelessness. They got me psychiatric care. They got me educated 
and working. Today, I help others living with mental illness--I work in 
the mental health field so that I can recreate for other people the 
opportunities I received from mental health care. I also currently 
serve as a member of VA's Consumer Liaison Committee on Care of 
Veterans with Serious Mental Illness Veterans.
                              who is nami?
    NAMI is the nation's largest national organization, 220,000 members 
representing persons with serious brain disorders and their families. 
Through our 1,200 chapters and affiliates in all 50 states, we support 
education, outreach, advocacy and research on behalf of persons with 
serious brain disorders such as schizophrenia, manic depressive 
illness, major depression, severe anxiety disorders and major mental 
illnesses affecting children.
    NAMI believes that while treatment is central to recovery, it is 
not an end in itself. Housing, psychosocial rehabilitation and supports 
provided by agencies such as VA play a critical role in this process. 
NAMI is therefore pleased to offer our views on the VA's ability to 
provide the services and supports necessary for recovery.
       vha capacity to treat veterans with severe mental illness
    The Independent Budget reports 454,598 veterans have a service 
connected disability due to a mental illness. Of great concern to NAMI 
are the 130,211 veterans who are service connected for psychosis--
104,593 of whom were treated in the VHA in FY 1999 for schizophrenia, 
one of the most disabling brain disorders.
    NAMI feels strongly that the VA must do more to maintain capacity 
for veterans with severe and chronic mental illness. NAMI applauds this 
Congress for reinforcing the capacity law through the Department of 
Veterans Affairs Health Care Programs Enhancement Act of 2001 (PL 107-
135). This law strengthens the VA's capacity to serve veterans with 
mental illness, requiring improvements to the current system to ensure 
that veterans have access to necessary treatment and services. The new 
law not only requires the Department to maintain capacity for serving 
veterans with mental illness but also replace lost capacity.
    The Committee on the Care of Veterans with Serious Mental Illness 
(SCMI Committee) reports that during FY 2002 VHA spent only 77% of the 
amount that it spent in FY 1996 for care of veterans with serious 
mental illness--a decrease of $478 million annually. (This was based on 
data from the FY 2002 Report to Congress on Maintaining Capacity for 
Special Populations). This reduction is despite mandates that the VHA 
focus on its high priority veterans, including veterans with serious 
mental illness.
    NAMI supports the FY 2003 Independent Budget recommendations for 
increasing the VHA's capacity to serve veterans with mental illness--
including recommending that to simply achieve parity with other 
illnesses, the VA should be devoting an additional $478 million to 
mental illness spending.
         the vha's move from inpatient to outpatient treatment
    Mr. Chairman, in NAMI's opinion, the lack of access to treatment 
and community supports for veterans with severe mental illness is among 
the greatest unmet need of the VA. Over the last five years the VHA has 
shifted its focus of serving veterans with severe and chronic mental 
illness from inpatient treatment to community based care. From FY 1994 
to FY2001 the number of veterans receiving inpatient treatment for 
severe mental illness has dropped from 58,062 to 35,888. NAMI strongly 
supports treating veterans with severe mental illness in the community 
when the proper intensive community supports and treatment are 
available and easily accessible. However, we are very concerned that 
those veterans who need inpatient care are increasingly unable to 
access needed treatment because of the limited inpatient beds, and the 
dramatic shift to outpatient treatment.
    NAMI is extremely grateful for the leadership Congress, and 
especially this Committee, has provided in holding the VA accountable 
for its inability to ensure that savings derived from the closure of 
inpatient psychiatric beds is transferred into community-based 
treatment services. The VA should not be allowed to make the same 
mistakes that so many states and communities have made over the past 
quarter century with respect to deinstitutionalization. Numerous 
studies have demonstrated that in states all across our nation dollars 
saved through the closing of state psychiatric hospitals were either 
never transferred into the community, or squandered on community-based 
services that lacked focus and accountability. The VA's Committee on 
Care of Veterans with Serious Mental Illness (SCMI committee) reports 
that from FY 1996 to FY 2001 of the 43% or $600 million total reduction 
in inpatient dollars, only 18% or $112 million of these savings were 
reinvested in expanding community support programs during this period. 
From NAMI's perspective, it is obvious that this significant decrease 
in inpatient care has not resulted in a sufficient transfer of 
resources to community-based treatment and supports for veterans with 
severe mental illnesses.
    Mr. Chairman, because of the influx of lower priority veterans 
(Category C) into the VA health system, many resources are now going to 
towards the care of an ever increasing group of veterans and away from 
special populations. The SCMI Committee reports that from FY 1996 to FY 
2001 there has been an increase of 568% in the number of low priority 
Category C veterans who are now coming to VA for what seems the 
prescription benefit. With only 23% of costs for Category C veterans 
being reimbursed by insurance--this has had a net cost to the VA of 
$747 million in FY 2001 for Category C veterans. NAMI fears that many 
resources saved from the closure of inpatient beds have not been 
effectively reinvested in community services, but rather for care of 
the growing population of Category C veterans. NAMI believes that while 
all of our nation's veterans deserve quality care, it should not come 
at the expense of high priority veterans living with severe mental 
illness.
    NAMI would continue to urge this Committee to specifically direct 
the VHA to require that all savings from cuts in inpatient psychiatric 
beds be reinvested in providing a continuum of care for veterans with 
severe mental illnesses.
            recovery for veterans with severe mental illness
    The Department of Veterans Affairs offers several specialized 
programs aimed at assisting veterans live healthy, productive lives in 
the community. Access to programs providing outreach, rehabilitation 
and supported housing are critical for veterans with severe mental 
illness. Mental Health Intensive Case Management (MHICM) can also be a 
very effective service for veterans with acute care needs. The VA also 
offers specialized services for PTSD and substance abuse--however these 
programs must be expanded to meet the needs of veterans receiving VA 
health care.
                                housing
    As you know, housing is the cornerstone of recovery from mental 
illness and a life of greater independence and dignity. In my work over 
the years in peer counseling and training consumers to work in the peer 
counseling field, I have witnessed first-hand the central role that 
decent, safe and affordable housing plays in promoting recovery, access 
to treatment and a stable life in the community. NAMI believes that no 
single program or model can meet the needs of every individual living 
with severe mental illness. NAMI feels strongly that range of options 
are needed for consumers based on their own circumstances--from 
supported housing to congregate living to tenant-based vouchers to 
homeownership--a range of options supported through VA's programs are 
needed. The VA also needs work more effectively with HUD to ensure that 
veterans with severe mental illness have access to all of HUD's 
affordable housing programs. This is especially necessary for homeless 
veterans that desperately need access to permanent supportive housing 
programs funded under the McKinney-Vento Homeless Assistance Act such 
as Shelter Plus Care.
                              medications
    NAMI members strongly support research to discover a cure for 
severe brain disorders. Until then, more than anyone else, NAMI 
consumers and families recognize the need for medications that can 
control the symptoms of these brain disorders. Our nation's veterans 
must have access to the best medications for their illness.
    NAMI believes that professional judgment and informed consumer 
choice should determine the choice of medications. Choice of treatments 
should be based on our knowledge of effectiveness and side effects and 
should be consistent with science based treatment guidelines, not 
solely on cost. NAMI members are committed to work to identify and 
remove any barriers that prevent persons with severe brain disorders 
from receiving the right medication, at the right dose, at the right 
frequency, and for the right duration. NAMI believes that the right 
medication is not only right for the veterans but it is also right for 
VA health system--there is growing evidence that access to newer 
medications may reduce the total cost of the illness by reducing other 
medical expenses such as hospitalization, by improving compliance, and 
by reducing disability.
                       vocational rehabilitation
    Research has shown that those who receive psychiatric 
rehabilitation are more likely to return to work, school and a 
productive life and are significantly less likely to be hospitalized. 
However, many veterans with severe mental illness do not receive the 
necessary vocational rehabilitation and employment services that will 
allow for transition into the workforce. The VHA has many programs that 
offer beneficial services for veterans looking to reintegrate into the 
community; however VHA must do a better job at outreach to disabled 
veterans. Further, many of VA's vocational rehabilitation policies must 
be updated and include increased integration of evidence based programs 
and supports. The VA's programs should also be reformed to more 
effectively provide ongoing job-related supports that help veterans 
with mental illness stay in a job, not just get a job. Pre-employment 
services are only as effective as the ongoing on-the-job supports 
provided over the long-term.
    Compensated Work Therapy (CWT) is a VA program that uses work 
therapy to help veterans re-enter into the community by assisting 
veterans learn important work skills, earn money, and more importantly 
improve the quality of their lives through employment. NAMI feels that 
this is a best practice model and a rehabilitative program that should 
be further expanded to allow more veterans access to employment 
opportunities. In FY 2000, 46% of veterans who completed a CWT program 
were placed in competitive employment and another 8% were placed in 
other training programs. Unfortunately, while research demonstrates 
that people with severe mental illness want gainful employment, less 
than 1% of the 82,000 veterans with psychosis under the age of 50 
participate in the CWT program. Further, each dollar that is spent in 
providing CWT services returns an average of two dollars in earnings--
remaining revenues (currently around $10 million) should not be left to 
sit in a VA account but should be used to help veterans continue to 
work with the necessary supports in place. Not only is VA missing an 
opportunity to expand community-based rehabilitation options for 
veterans, but veterans with severe mental illness are not adequately 
provided the opportunities to access supported employment. VA must do a 
better job in implementing best practice models into the community.
    NAMI recommends that Congress amend Title 38, section 1718(b) of 
the United States Code to allow VA to offer veterans in the CWT program 
such important services as job coaching, vocational placement and 
ongoing support services necessary for veterans to maintain employment. 
Congress should make the CWT program more effective and responsive to 
veterans with mental illness by allowing increased financial 
flexibility of current funds to be used to provide rehabilitative 
training and other support services to help veterans gain and maintain 
employment. NAMI also recommends that Congress require VA to report 
regularly on the number of veterans with referrals for therapeutic 
work-based rehabilitation, the number of veterans accessing CWT and the 
effectiveness of the program in implementing evidence based practices.
                      psychosocial rehabilitation
    Psychosocial rehabilitation is another key element to a continuum 
of care for veterans with severe mental illness. Psychosocial 
rehabilitation is part of a comprehensive approach in providing 
support, education, and guidance to people with mental illnesses and 
their families. Studies tell us that psychosocial treatments for mental 
illnesses can help consumers keep their moods more stable, stay out of 
the hospital, and generally function better. Peer educational supports 
should be a part of psychiatric rehabilitation services.
                              peer support
    The concept of recovery is a self-help philosophy that is the 
future of mental health care. Consumers in recovery with experience and 
knowledge of the psychiatric condition--and its concurrent social 
realities--are the people who are able to most effectively help their 
peers recover. My wife and I founded the Peer Educators' Project and 
this project believes that people who have a major mental illness or 
psychiatric condition are a resource to learn from. We have over forty-
five educational peer support groups across the Commonwealth of 
Massachusetts and employ over fifty people. We are now working with the 
VA in both Bedford, Massachusetts and West Haven, Connecticut in 
setting up Peer Educator support meetings--this program is called Vet-
to-Vet and ``Gladly-Teach, Gladly-Learn'' is the motto. Currently, the 
VA's Northeast Program Evaluation Center in New Haven, CT is conducting 
a multi-year evaluation of the Peer Educators Project in VISN 1.
    We are educators. But initially we are students in need of some 
information. So, the Peer Educators Project spends time reading books 
like the Recovery Workbook from the Boston University Center for 
Psychiatric Rehabilitation, authored by Martin Koehler and LeRoy 
Spaniol. We also read current articles about mental illness and the 
mental health system. We are also a source of information for one 
another. We think about what has happened to us and how or why we ended 
up in the mental health system.
    The Peer Educator model is designed to address three goals: (1) To 
educate people with mental illnesses on services, medications, their 
rights to make treatment decisions, and to identify barriers to 
recovery, (2) To assist people with mental illnesses focus on recovery 
and rehabilitation via role models and an expectation that people take 
responsibility for their own lives and decisions, (3) To create social 
and community connections to counter social isolation and create ones 
own healthy, natural community supports.
    There have been some misunderstandings during our time in the 
mental health system. There are also some valid reasons why we are in 
and continue to stay in the mental health system. We need to learn 
about the psychiatric condition that we have and pass that information 
on to other people. We are trying to learn about our anxieties, 
sleeplessness, depressions, and wild behaviors that got us into the 
mental health system. We need to learn about what we have and how 
coping day to day with ordinary life and mental illness is possible.
    We also learn and teach each other how to pick up on the subtle 
signs of the onset of psychiatric crisis. We talk to each other frankly 
and openly about what has happened and continues to happen to us. There 
is nothing wrong in being mentally ill. However, there is something 
wrong in not having supporting and caring mental health systems that 
provide care. Many veterans with psychiatric conditions need long term 
care and assistance--care that is provided by people working with 
people and consumers working with consumers.
                           consumer councils
    The Fourth Annual Report to the Under Secretary for Health 
submitted by the Committee on Care of Severely Chronically Mentally Ill 
Veterans dated February 1, 2000 stated in recommendation 9.1: 
``Networks should redouble their efforts to establish mental health 
stakeholders councils at all VHA facilities and at the Network level. 
Progress in establishment of such councils should be monitored and 
considered in the evaluation of key officials.''
    NAMI continues to fully support the implementation of Mental Health 
Consumer Councils and the recommendation by the SCMI committee. At the 
VISN level, Mental Health Consumer Council brings together consumers, 
family members, Veterans Service Organizations, and community agencies 
that can discuss services, policies, and issues which are important to 
veterans receiving treatment for mental illness. Approximately half of 
the VISNs have Mental Health Consumer Councils, but full participation 
by all VISNs is still needed.
                           homeless veterans
    As you know, severe mental illness and co-occurring substance abuse 
problems contribute significantly to homelessness among veterans. 
Studies have shown that nearly one-third (approximately 250,000) of 
homeless individuals have served in our country's armed services. 
Moreover, approximately 43% of homeless veterans have a diagnosis of 
severe and persistent mental illness, and 69% have a substance abuse 
disorder. NAMI strongly supports provisions that would mandate 
evaluation and reporting of mental illness programs in the VA and that 
veterans receiving care and treatment for severe mental illness be 
designated as ``complex care'' within the Veterans Equitable Resource 
Allocation system. Moreover, NAMI feels that language providing for two 
treatment trials on the effectiveness of integrated mental health 
service delivery models would be very beneficial in identifying best 
practice in serving and treating veterans with severe and persistent 
mental illness within the VA. Our nations veterans with severe mental 
illness should be in treatment and not on the street.
                               conclusion
    Thank you Chairman Rockefeller for allowing me the opportunity to 
testify before the Committee on the services and supports veterans with 
mental illness need from the VA to live full and productive lives in 
the community. I never dreamed that thirty-five years ago I would be 
able to go to school, hold a job, and come to Washington to speak 
before you, it is a testament to the impact VA services can have on a 
veteran. Thanks again for all you do on behalf of veterans with severe 
mental illness.

    Chairman Rockefeller. Extraordinarily articulate.
    Mr. Armstrong. Thank you. Not for everybody.
    Chairman Rockefeller. No, but that was good. What you said 
was so powerful. Actually I think that the testimony belittles 
questions that I might ask. I am going to send some to you.
    Mr. Armstrong. Thank you.
    Chairman Rockefeller. But I want to end this with a 
question, just one question to you, Mr. Armstrong, and also 
you, Dr. Frese. And that is again the family aspect of this. We 
have talked this morning about maintenance as opposed to 
improvement and curing, and that you cannot do either until you 
know that you have a problem. And you either know you have a 
problem and then seek treatment, or a family member coaxes you, 
and encourages you to getting treatment if they are so disposed 
or you have an episode of some sort. You spoke of your 
homelessness in New Mexico. And then somebody reaches out to 
you, and help begins that way.
    But the point is that what you care about and what is 
evident in you is not just maintenance, but getting better. 
Now, you said there is no silver bullet, and everybody 
understands that, Doctor Alarcon, you indicated sometimes 
mental illness will be there for a while and then it will 
disappear. And in many, more cases, it will be there and it 
will not go away. But it can get better. And if somebody, no 
matter what their condition, feels they are getting better, am 
I wrong to say that that can almost come somewhere close to 
feeling like you are about to be cured?
    Dr. Alarcon. Exactly, Mr. Chairman. I think in psychiatry 
and clinical psychiatry now, unfortunately, we cannot speak of 
a cure, but we can speak of improving significantly the 
functionality, the ability to interact with the social 
environment and the quality of life, and I think psychiatry and 
medicine have made a lot of progress into that and for people 
like Mr. Armstrong and Dr. Frese, the benefits are evident.
    Mr. Frese. And part of that quality of life has to be 
quality of integration into the greater society. We can no 
longer be isolated. And our families--I just did a thing for 
``Nightline'', and one of the cameraman came up to me 
afterwards and said his father had psychosis all of his life--
he was in tears--he said he could never talk about it at all. 
That is beginning to change. We are beginning to lift this veil 
of stigma, and with your help, we will be doing that in the VA 
as we are elsewhere. Thank you.
    Mr. Armstrong. My own family was very devastated by this. 
They were poor people from the rural part of Illinois. For them 
the military was their ticket, my ticket. They are retired 
janitors. I became mentally ill and was lost in America for a 
long time. There was too much time lost. I think that through 
education--and I am a big believer in education as opposed to 
traditional therapies--understanding what is mental illness, 
teaching people what we know about the mental health system. It 
is just as difficult understanding the mental health system and 
how it operates, mental illness. By setting these constructs up 
where the family comes in and receives education, not just 
family therapy, I think we can go a--and the veteran starts to 
receive this, both professional and peer education, I think we 
can get along way toward becoming sane, stable, safe and sober. 
Those are my S's. That is what we should be reaching. I do not 
think there is a silver bullet, but we can get sane, stable, 
safe and sober. And the only way I know how to do it is 
educationally.
    I would suggest that the mental health system of the 
future, it will probably look a lot more like an old-fashioned 
one-room schoolhouse than the clinical settings that we have 
today, and this ongoing educate, educate, educate, learn, 
learn, learn, teach, teach, teach, will be more of a construct. 
That is the ultimate stigma reduction, I think, when it just 
becomes like any other illness, and we just start to train 
people how to live with it and what we have.
    So that would be my take on it. Thank you, Senator.
    Chairman Rockefeller. I thank all of you. I wish that all 
of America had watched every moment of this hearing. We would 
all be better for it.
    Thank you all.
    [Whereupon, at 11:35 a.m., the committee was adjourned.]
                            A P P E N D I X

                              ----------                              

 Prepared Statement of Hon. Ben Nighthorse Campbell, U.S. Senator From 
                                Colorado
    Thank you, Mr. Chairman. I appreciate your convening today's 
hearing to examine the current range of mental health services being 
provided to our veterans. This is a very serious issue and I am pleased 
that the committee is focusing on it. I would also like to welcome 
Under Secretary Roswell and the others who are here to testify today.
    As we enter another year of limited funding for veterans health 
care, we are still being reassured by the VA that quality care for our 
veterans will not only continue, but will improve. Based on the 
feedback from many of our veterans, however, I am beginning to question 
this assertion. Like my colleagues, I am concerned that the VA respond 
satisfactorily to our veterans who need specialized care such as mental 
health services.
    Recently, the VA announced plans to overhaul its health care 
system. It will attempt to change the focus to outpatient care and get 
services closer to the people who need them. An independent nine member 
panel will make recommendations on where to cut and where to add.
    And, I understand that the VA is looking at new models that would 
integrate primary health care into the care of mental health clinics. 
Some studies find that individuals accessing medical care through 
mental health clinics receive a better quality of primary care and 
their health status is improved over time. The costs, I am told, are 
similar.
    But, all the while we say we are improving services by focusing on 
outpatient care, we seem to be cutting services for those who need 
mental health services.
    Over the past several years, the Veterans Health Administration has 
reduced funding for critical mental health services in an effort to 
reduce over all costs. Regionally, some VISNS (Veterans Integrated 
Services Network) have implemented restrictions on anti-psychotic drugs 
based on cost. I believe that reducing access to life-saving 
medications for our nation's veterans and cutting back on mental health 
services in particular are misguided attempts to reduce treatment 
costs.
    And, in my state of Colorado, under VISN 19, it is my understanding 
that though a number of mental health facilities and services are 
available, the veterans are having a hard time getting certified to 
receive those services.
    The wounds of war are not always visible. In the aftermath of war 
time combat, a great number of people have been affected and they have 
been, and are, affected in a great many different ways. Their needs 
vary with the type of trauma they experienced.
    While I commend the VA for the advances it has made to date in its 
broad policy goal of serving more veterans in outpatient settings, I 
believe we must also focus on managing symptoms and ensuring supports 
outside of an institutional setting. If serving more veterans comes at 
the expense of those with specialized needs, the gains we have made 
thus far will be lost.
    I hope that the members of this Committee, the VA and the VSOs can 
work together on this issue. We need to think creatively about how we 
can best serve our vets who need mental health services. No one wants 
to hospitalize people who no longer need it. But if we are to send our 
veterans out into the community, we need to consider a broad array of 
support services that can maintain people outside of institutional 
settings. Those vets who are facing problems because of their service 
to their country deserve no less than the best care we can provide.
    Again, I thank you, Mr. Chairman, and look forward to today's 
testimony.
                                 ______
                                 
Prepared Statement of the American Association for Geriatric Psychiatry
    The American Association for Geriatric Psychiatry (AAGP) is pleased 
to have the opportunity to provide a statement for the record of 
Veterans Affairs Committee's hearing on Mental Health Care: Can VA 
Still Deliver? AAGP is a professional organization dedicated to 
promoting the mental health and well being of older Americans and 
improving the care of those with late-life mental disorders. AAGP's 
membership consists of approximately 2000 geriatric psychiatrists as 
well as other health professionals who focus on the mental health 
problems faced by senior citizens.
    While we agree with others in the mental health community about the 
importance of Federal support for mental health research and treatment, 
AAGP brings a unique perspective to these issues because of the elderly 
patient population served by our members.
    This Committee has provided important leadership in the effort to 
provide the highest quality health care for our nation's veterans and 
for the research necessary to advance the quality of their care. AAGP 
strongly supports S. 2044, which would continue and increase funding of 
specialized VA mental health services programs for post traumatic 
stress disorder (PTSD) and substance abuse disorders. AAGP also 
welcomes the introduction of legislation to increase the number of VA 
centers for mental illness research, education, and clinical 
activities. Our nation's veterans put forth their lives for our nation 
during times of war, and they deserve access to quality health care in 
times of peace.
 the challenge of meeting the mental health needs of the aging veteran 
                               population
    AAGP is extremely concerned that the mental health needs of our 
aging veteran population is not being adequately met by current 
resources; and that the gap between needs and resources will widen 
rapidly unless Congress acts to increase support for veterans' mental 
health care, with an emphasis on older veterans.
    Of our nation's 25.5 million veterans, 9 million, approximately 35 
percent, are seniors who served in World War II or the Korean War. More 
than half a million veterans are 85 years of age or older, and the VA 
predicts that this oldest group will grow to 1.2 million by 2010. It 
has been estimated that between 35 percent and 40 percent of VA 
patients need psychiatric care, and those who are older often suffer 
from co-existing medical conditions such as heart disease, 
hypertension, diabetes, lung disease, debilitating arthritis, or other 
conditions. For these patients, treatment of their medical illnesses is 
often complicated by psychiatric disorders. Conversely, their 
psychiatric care is more complex because of the co-occurrence of 
medical illness, which commonly requires treatment with multiple 
medications. Thus, for older veterans with mental health problems, 
psychiatric treatment must be an integral component of their health 
care, and must be well-coordinated with the care they receive for other 
medical conditions.
    Between the years 1990 and 2000, the number of veterans in the 45-
54 year old age group who received mental health services from the VA 
more than tripled. These are the baby boomers who are now beginning, 
and will continue, to swell the ranks of those who require geriatric 
care. However, the most rapid growth in demand during the last decade 
was among the oldest of older veterans. During the last decade, there 
was a four-fold increase in the number of veterans aged 75-84 who 
received VA mental health services.
    Despite the increasing need for coordinated mental health services 
for growing numbers of older veterans, funding for VA mental health 
services, training, and research remains disproportionately low 
throughout the VA system. Overall, the proportion of VA spending for 
mental health care has decreased by 23 percent since 1996. Although 
more than a third of veterans need psychiatric care, less than 9 
percent of VA funds available for residency training were designated 
for psychiatric residency training in FY 2002. Of the $409 million 
slated for medical and prosthetic research in President Bush's FY 2003 
budget proposal, only $36 million, or 8.8 percent, is earmarked for 
psychiatric research. This level of support for psychiatric services, 
training and research is disproportionate to the needs of the veteran 
population.
              president's fiscal year 2003 budget proposal
    According to President Bush's budget recommendation for the 
Department of Veterans Affairs for FY 2003, approximately $25.6 billion 
of the $56.6 billion proposed for the Department would go to medical 
care programs, an increase of approximately $2 billion. It is 
commendable that most health programs would receive a boost in spending 
under the President's budget proposal. For example, outpatient care 
would receive $12.5 billion, an increase of $1.4 billion, while the 
nursing home care budget would increase to $2.2 billion, a gain of $118 
million, and medical research programs would receive $409 million, a 
$38 million increase over current spending. However, AAGP is alarmed 
that these increases would be offset by cuts in mental health and 
residential care programs. The President's proposal would require the 
VA to achieve more than $300 million in unspecified ``management 
savings,'' requiring a staffing reduction of some 800 employees. 
Historically, mental health programs are the first to suffer when ill-
defined cuts are imposed. And because the complex care so often needed 
to maintain the older patient's independence requires more--not less--
comprehensive, integrated mental health and medical management, 
``savings'' in this area will likely lead to greater dependency.
    Given that the VA health care system, and particularly its 
psychiatric and substance abuse programs, have sustained deep cuts in 
recent years, the Administration's budget proposal spells trouble. Last 
year saw the enactment of the ``Homeless Veterans Comprehensive 
Assistance Act of 2001'' that requires the VA to assure mental health 
services in every VA facility, and the ``VA Health Care Programs 
Enhancement Act of 2001'' that directs the VA to expand substantially 
the number and scope of specialized mental health and substance abuse 
programs it operates so as to afford veterans real access to needed 
specialized care and services. Apparently ignoring these statutes, the 
President's budget offers no plan for restoring lost capacity in VA 
mental health care and substance abuse programs; instead, it continues 
the reductions that have become the norm in recent years. Continued 
cutbacks will seriously jeopardize veterans' mental health services, 
and will take a serious toll on older veterans. Rather than offering 
improved access to care, this budget, if enacted by Congress, would 
reduce health care staffing and increase barriers to access for 
veterans. And to which system do we direct elderly veterans diverted 
from the VA when Medicare, Medicaid and state programs are no less 
constrained by budgetary shortfalls? There is no safety net. Elderly 
veterans with mental illness are especially vulnerable because 
employer-sponsored health plans and Medicare HMOs have limited mental 
health coverage and continue to reduce and eliminate drug benefits.
    comprehensive, integrated mental health care for aging veterans
    Mental health treatment must address the special needs of those 
older veterans with concurrent psychiatric disorders, medical illness, 
and substance use disorders, as well as those with severely 
debilitating psychotic disorders and post-traumatic stress disorder 
(PTSD). According to the Veterans Administration, of the 455,000 
veterans suffering from a service-connected mental disorder, more than 
130,000 have chronic, severe psychotic disorders such as schizophrenia, 
and approximately 130,000 have PTSD, conditions that often have emerged 
or were aggravated during time in the service. PTSD is often directly 
related to combat duty. Surely those veterans should be afforded 
services of the highest quality, with access to a comprehensive 
continuum of care that defines state-of-the-art mental health 
treatment.
    AAGP believes that the range of integrated services within the 
hospital and upon discharge to the community that is provided to 
veterans with mental disorders should serve as a benchmark for health 
care services in all public and private health care systems in our 
country. Older veterans with co-occurring medical and psychiatric 
disorders, often complicated by alcohol or drug abuse, require access 
to a well-integrated system of services. For those veterans with 
serious mental illness, state-of-the-art care for severe mental illness 
is recovery-oriented, rather than dependency-oriented, as documented in 
the U.S. Surgeon General's Report on Mental Health (1999). Such 
recovery requires an array of services that includes intensive case 
management, pharmacological treatment, access to substance abuse 
treatment, peer support and psychosocial rehabilitation such as 
housing, employment services, independent living and social skills 
training, and psychological support. Within this continuum of services, 
Readjustment Counseling Service Vet Centers are a community-based 
component that provides veterans with counseling for psychological war 
trauma, using an interdisciplinary team approach. With the growth of 
the aging veteran population, which includes Vietnam-era veterans, AAGP 
regards these Vet Centers as an important site for the provision of 
integrated geriatric psychiatric care over the next ten to fifteen 
years.
    AAGP strongly recommends that the savings from the closing of VA 
inpatient mental health programs be reinvested in Community Based 
Outpatient Clinics and the development of an outpatient continuum of 
care that includes this array of services. In particular, AAGP urges 
support of Mental Health Intensive Case Management programs in 
community and home settings. Intensive Case Management is a vital 
element of care that is needed if the VA is to maintain the sickest 
patients outside the hospital setting. By providing comprehensive, 
integrated medical and mental health care through Community Based 
Outpatient Clinics, and ensuring continuity of care across service 
sites through Intensive Case Management programs, veterans will receive 
the highest quality care, and further reductions in inpatient services 
and spending will be possible. VA mental health professionals have 
identified these as needs ``that should be the target of developmental 
efforts in the coming years'' (Report of the Committee on Care of the 
Severely Chronically Mentally Ill Veterans, February 2000, page 64).
    Despite the outstanding advocacy of VA mental health professionals, 
the Department is still struggling to furnish this comprehensive 
spectrum of services to veterans with severe mental illness today. 
Unless the VA budget for psychiatric care is increased, barriers to 
providing the full spectrum of mental health services will inevitably 
increase. Enactment of S. 2044, which would expand and improve the 
provision of specialized mental health services to veterans, would 
constitute a significant step toward strengthening mental health 
services where they are most needed. AAGP has also recommended, in 
testimony before the Senate Appropriations Committee, that Congress 
incrementally augment funding for the care of seriously mentally ill 
veterans by appropriating an additional $100 million both in FY 2003 
and in FY 2004.
                    veterans and alzheimer's disease
    AAGP would like to bring to the Committee's attention the fact that 
an estimated 30 percent of the patients in veterans' nursing home 
facilities suffer from Alzheimer's disease or another form of dementia. 
As the elderly veteran population increases, the capability of the 
traditional veterans' nursing home facilities to care for veterans with 
Alzheimer's disease will be overwhelmed. The VA should encourage 
innovation in the methods utilized by VA health personnel in treating 
veterans with Alzheimer's disease; and should also develop family and 
caregiver support programs to enable veterans to remain at home for an 
extended period, before nursing home care becomes necessary. AAGP 
recommends the creation of a new line of mental health research funding 
earmarked for the development, testing, and dissemination of 
interventions to manage the psychiatric manifestations and 
complications of Alzheimer's disease and related dementias.
                     veterans' access to medication
    AAGP is concerned about restrictions on the availability of those 
medications that are safer or better tolerated by elderly patients. 
Restricted access to such medications specifically discriminates 
against older veterans with mental illness who, as a result of the 
effects of aging, medical illness, and concurrent use of medications 
for the treatment of medical and psychiatric illnesses, are more 
susceptible to the potential adverse effects of medications. When 
safer, better-tolerated medications exist, they should be made 
available as first-line treatments and should not be subject to a 
``fail-first'' policy. The current suspension of such a policy--which 
should be made permanent--is important in averting unnecessary 
suffering, especially in older veterans who are the most vulnerable to 
drug side effects.
                          research and mireccs
    VA research on mental health remains under-funded. President Bush's 
proposal to allocate only 8.8 percent of the VA medical research budget 
to psychiatric research is inadequate, especially for the VA health 
care system, in which 40 percent of patients have a need for mental 
health care. AAGP has recommended that Congress appropriate $425 
million for medical research, and earmark $63 million of this for 
psychiatric research. This represents an increase of 15 percent over 
amount in the President's proposed budget. As the elderly veteran 
population expands, and the number with mental illness grows, 
strengthening the research base in geriatric psychiatry becomes 
increasingly urgent. VA sponsored research into mental disorders of 
aging benefits all Americans, not just our veterans.
    A vitally important VA program for coordinating mental health 
research with education and clinical care are the Mental Illness 
Research, Education, and Clinical Centers (MIRECCs). AAGP commends the 
Congress for funding eight VA MIRECCs across the country. AAGP believes 
the MIRECCs have successfully demonstrated that coordinated research 
and education projects can achieve rapid translation of new scientific 
knowledge into improved models for clinical services for veterans with 
mental illness. These programs should be continued. MIRECCs focus on 
problems highly relevant to veterans with schizophrenia, PTSD, and 
other serious mental illnesses, including those whose treatment is 
complicated by homelessness, substance abuse, or alcoholism. AAGP 
wishes to emphasize the value of those MIRECCs that focus on issues 
related to aging, including dementia, and psychiatric disorders in 
older veterans with concurrent medical illness and/or substance use 
disorders.
                               conclusion
    In conclusion, AAGP commends this Committee for its concern and 
continuing efforts to assure adequate mental health services, training, 
and research in the VA system. It is important, in the face of 
continuing budgetary pressure, to stem the tide of reductions in mental 
health services. The reductions we have seen in recent years will 
undermine the provision of proper treatment not only to elderly 
veterans, but also to those who are currently young and middle-aged--a 
course that will lead to more severe problems later in life as their 
disorders become more complicated and difficult to treat.

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