[Senate Hearing 107-793]
[From the U.S. Government Publishing Office]
S. Hrg. 107-793
MENTAL HEALTH CARE: CAN VA STILL DELIVER?
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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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83-282 WASHINGTON : 2002
____________________________________________________________________________
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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
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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?
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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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