[Senate Hearing 110-328]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-328 
 
                       HEARING ON PENDING LEGISLATIVE 
----------------------------------------------------------------------
----------------------------------------------------------------------

                                  HEARING 

                                 BEFORE THE 

                     COMMITTEE ON VETERANS' AFFAIRS 

                             UNITED STATES SENATE 

                         ONE HUNDRED TENTH CONGRESS 
                    
                                 FIRST SESSION
                                  ----------
 
                                October 24, 2007 
                                   ----------

             Printed for the use of the Committee on Veteransï¿½ Affairs 

                       Available via the World Wide Web:          
                     http://www.access.gpo.gov/congress/senate 



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40-547 PDF                       WASHINGTON : 2007 

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                      COMMITTEE ON VETERANS' AFFAIRS 

                    DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia RICHARD M. BURR, North Carolina, 
PATTY MURRAY, Washington                 Ranking Member
BARACK OBAMA, Illinois                LARRY E. CRAIG, Idaho, 
BERNARD SANDERS, (I) Vermont          ARLEN SPECTER, Pennsylvania 
SHERROD BROWN, Ohio                   JOHNNY ISAKSON, Georgia 
JIM WEBB, Virginia                    LINDSEY O. GRAHAM, South Carolina 
JON TESTER, Montana                   KAY BAILEY HUTCHISON, Texas 
                                      JOHN ENSIGN, Nevada 

                        WILLIAM E. BREW, Staff Director 
                     LUPE WISSEL, Republican Staff Director 



































                                C O N T E N T S 
                                  -----------
                                OCTOBER 24, 2007 
     
                                   SENATORS 
                                                                   Page 
Akaka, Daniel K. U.S. Senator from Hawaii .......................     1 
Burr, Richard K., U.S. Senator from North Carolina ..............     3 
Murray, Patty, U.S. Senator from Washington .....................     4 
Craig, Larry E., U.S. Senator from Idaho ........................     6 
Brown, Sherrod, U.S. Senator from Ohio ..........................     6 
Isakson, Johnny, U.S. Senator from Georgia ......................     7 


                                    WITNESSES 

Kussman, Michael L., M.D., M.S. MACP, Under Secretary for Health, U.S. 
Department of Veteransï¿½ Affairsï¿½ Accompanied by Walter Hall, Assistant 
General Counsel, U.S. Department of Veterans Affairs ............     8 
  Prepared statement ............................................    12 
  Response to written questions submitted by: 
    Hon. Daniel K. Akaka ........................................    19 
Blake, Carl, National Legislative Director, Paralyzed Veterans of 
  America .......................................................    29 
    Prepared statement ..........................................    30 
Ilem, Joy J., Assistant National Legislative Director, Disabled 
  American Veterans .............................................    32 
  Prepared statement ............................................    34 
  Response to written questions submitted by: 
    Committee on Veterans' Affairs ..............................    38 
Murdough, Brenda, MSN, RN-C, Military/Veterans Initiative Coordinator, 
American Pain Foundation ........................................    40 
  Prepared statement ............................................    42 
  Response to written questions submitted by: 
    Hon. Daniel K. Akaka ........................................    44 
Smith, Brien J., M.D., Medical Director, Comprehensive Epilepsy Program, 
Henry Ford Hospital .............................................    45 
  Prepared statement ............................................    46 
  Response to written questions submitted by: 
  Hon. Daniel K. Akaka ..........................................    49 
  Hon. Patty Murray .............................................    48 
Walker, Capt. Constance A., USN (Ret.), National Alliance on Mental 
  Illness Member, NAMI Veterans Council; President, NAMI Southern 
  Maryland ......................................................    49 
    Prepared statement ..........................................    53


                       













                        HEARING ON PENDING LEGISLATION 
                                   --------

                             WEDNESDAY, OCTOBER 24, 2007 

                                              U.S. SENATE, 
                                COMMITTEE ON VETERANS' AFFAIRS, 
                                                       Washington, D.C. 

  The Committee met, pursuant to notice, at 9:29 a.m., in room 
562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman 
of the Committee, presiding. 
  Present: Senators Akaka, Murray, Brown, Burr, Craig, and 
Isakson. 

           OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                        U.S. SENATOR FROM HAWAII 

  Chairman AKAKA. Aloha and good morning, everyone. 
  Before we begin the formal hearing, I ask for your indulgence for 
a brief ceremony. Kim Lipsky, will you please stand? Kim has no 
idea what is about to happen this morning, so you will excuse her 
for the look of confusion. 
  [Laughter.] 
  Chairman AKAKA. Congratulations, Kim, and mahalo. Thank you 
with warmest aloha for 12 years of outstanding and productive 
service to the U.S. Senate and to the Veteransï¿½ Affairs Committee. 
I am pleased that the practice of awarding a 12-year service pin 
and certificate gives me and the Committee the opportunity to recognize 
and thank you for your vital role you play in helping us to 
meet our obligations to our veterans on crucial health services 
issues. 
  To cite but a few recent examples, largely as a result of your 
efforts before and during and after our hearings in Hawaii, we have 
been able to provide the best possible access to quality care to Hawaii 
veterans as close to home as possible. We did this by improving 
care, increasing staffing, or both, throughout the Islands, Oahu, 
Maui, Molokai, Lanai, and the Big Island and Kauai. This is an 
accomplishment much appreciated by veterans who are now spared 
not only the inconveniences of going to another island, but also the 
expenses of traveling and possibly lodging. 
  I am especially pleased with the results of our hearings in Hawaii 
this year, for they lend a great deal of credibility to the Committee 
and the veteransï¿½ community and the community at large 
when we went to listen, and then acted. 
  Kim, I value your expertise and judgment, particularly on health 
issues. The force of your logic based on a deep well of knowledge 
leads to balanced solutions to problems that I find most helpful. I 
appreciate your tireless efforts to make this possible and want to 
express my heartfelt mahalo to you. 
  Having said that, I also want you to know that I value your 
friendship on a personal level and I think of you as being a part 
of the Akaka Office Ohana, which is family. I always think of you 
as a friend. As we go into this hearing today, I cannot help but 
observe what a fortuitous coincidence it is that as we recognize your 
wonderful first 12 years of service, the Committee is taking up two 
proposals which you developed to improve VA health care in the 
areas of mental health care and pain management. Thank you for 
your continuing dedication and efforts for our veterans. 
Here is the Senateï¿½s formal recognition of your first 12 years of 
service. Let me just present this to you, Kim. 
  [Applause.] 
  Chairman AKAKA. Kim, thank you again, and there is a pin and 
also a certificate. 
  Again, aloha and good morning, everyone. I want to welcome you 
to this hearing on pending legislation. 
  Today, the Committee will hear testimony on five bills from a 
number of witnesses. The bills under consideration are largely in 
response to the needs of the newest generation of veterans, but 
hold promise for all veterans. 
  Mental health issues remain an important part of our work in 
the Committee. Based upon the valuable testimony gathered at our 
mental health hearing in April, I introduced S. 2162, the Mental 
Health Improvements Act of 2007. I am pleased that Senator Burr 
has joined me as a cosponsor and, of course, I am repeating when 
I say I am so glad to have him here as our Ranking Member. Now, 
more than ever, VA must make mental health services a priority. 
New approaches and programs aimed at substance use or disorder, 
PTSD, and readjustment services are included in this legislation. 
  Also on the agenda is legislation which recognizes the need for 
improvements in VAï¿½s pain care management program. VAï¿½s current 
pain care efforts are worthwhile, but are unfortunately too 
inconsistent and are not standardized to adequately meet the needs 
of our veterans. S. 2160 will enhance VAï¿½s pain management program 
on a national, systemwide level through better clinical practices, 
research, and professional education. 
  Senator Murray and Senator Craig have proposed S. 2004, which 
would require VA to create Epilepsy Centers of Excellence. These 
centers would focus their attention upon research, education, and 
clinical care related to epilepsy. Epilepsy is anticipated to be an 
increasingly prevalent condition among veterans. We have learned 
that veterans with TBI are at a substantially increased risk to develop 
Post-Trauma seizures months or even years after their injury. 
We also have before us a bill by Senator Brown to clarify how 
non-VA emergency care needs to work. Senator Brown chaired a 
field hearing earlier this year which highlighted problems with the 
reimbursement problems for veterans and private hospitals when 
emergency care and treatment is needed. Senator Brownï¿½s bill 
would improve the emergency treatment of veterans at non-VA facilities 
by removing uncertainty through a mandatory reimbursement 
system and a clarification of transfer procedures. 
  We will have a Committee mark-up next month. My expectation 
is that we can move some of this legislation forward to the full 
Senate. 
  In closing, I note that the Committee has moved much legislation 
through its process. Several large authorization bills are on the 
Senate calendar presently. As Chairman, I am working with our 
new Ranking Member on time agreements so that we can expedite 
the path to enactment. I am hopeful that we will be able to reach 
agreement and get the pending bills to the floor by next week or 
soon after that. 
  I would like to yield to our Ranking Member, Senator Burr. 

             STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, U.S. 
                        SENATOR FROM NORTH CAROLINA 

  Senator BURR. Thank you, Mr. Chairman. I want to thank you 
for holding this hearing on five important bills that we are currently 
considering in the Committee. I also want to welcome our 
witnesses. It is always good to see them. 
  Mr. Chairman, I think the bills before us today are truly deserving 
of action by this Committee. Certainly the issues addressed by 
these bills, particularly the issues of mental health and mental 
health treatment and Traumatic Brain Injury research, are extremely 
important to our veterans. 
  I want to especially single out your bill, Mr. Chairman, which 
seeks to expand treatment and research for substance abuse and 
Post-Traumatic Stress Disorder. Unfortunately, too many veterans 
who suffer from PTSD are turning to drugs and alcohol to help 
them cope with this illness. Thanks to the recent report from the 
Institute of Medicine, we know that certain treatments work to 
help improve the lives of those suffering from PTSD. We also know 
that more research and work needs to be done in the area of treating 
veterans with co-morbid conditions, such as PTSD and substance 
abuse. Your bill speaks to the exact issue and I am proud 
to be a cosponsor of it. 
  I also want to thank you and your staff for your willingness to 
work with me and the minority staff in making some minor 
changes, I hope improvements, to the bill prior to its introduction. 
You often talk about this Committeeï¿½s long record of bipartisan 
cooperation and you have certainly shown that with this bill. 
  Mr. Chairman, as you know, recent reports to Congress from the 
Disability Commission and the Institute of Medicine have presented 
us with a challenge when it comes to the care and treatment 
of veterans with mental illness, particularly PTSD. Both of 
these distinguished groups have separately come to the same conclusion, 
that the VBA and the VHA need to approach compensation, 
treatment, and rehabilitation of veterans with PTSD and 
other mental illnesses differently. I think we owe our veterans our 
best effort to not only compensate them for their injuries and treat 
their illness, but to improve their overall health and well-being. 
  I hope that this Committee will take some time to explore these 
new findings and consider new ways we might be able to improve 
the VA system to respond to the challenge presented to us. I look 
forward to working with all of you to do that. 
  I would also like to compliment the Senator from Ohio, Senator 
Brown, for his bill on emergency care. I think his legislation is a 
fine example of what elected representatives do here in Washington. 
A flaw in the VAï¿½s reimbursement policy was brought to his 
attention. He worked with the administration to explore the source 
of the problem and now we have legislation that enjoys overwhelming 
bipartisan support to correct that law. 
  I would also like to comment for a moment on Senator Domenici's 
bill, S. 38, by saying that I think any effort to expand the 
cadre of people who can help our returning war veterans readjust 
to civilian life is worthy of support. 
  Finally, Mr. Chairman, I understand that next month you are 
planning to move forward a few naming provisions at a mark-up 
of pending legislation. I respectfully would ask of you that you 
include H.R. 2546, a bill to name the VA Medical Center in Ashville, 
North Carolina, after Private First Class Charles George. 
  George was a member of the Eastern Band of the Cherokee Indians 
from North Carolina. He was awarded the Medal of Honor for 
his actions on the night of November 30, 1952, when he pushed a 
fellow soldier out of the way of an exploding grenade. Fully aware 
of the consequences of his action, he absorbed the full blast of the 
explosion himself. Charles George is an American hero and all of 
us in North Carolina are proud to claim him as one of our heroes. 
  With that, Mr. Chairman, once again, I thank you for holding 
this hearing. I look forward to working with all the Members as we 
work toward completion of the legislation that we are here to talk 
about today, but also the legislation that we have pending. I yield. 
  Chairman AKAKA. Thank you very much, Senator Burr. 
  Senator MURRAY? 

              STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM 
                              WASHINGTON 

  Senator MURRAY. Thank you very much, Mr. Chairman, for holding 
today's hearing. 
  Veterans' Day is only a few weeks away and many of us go home 
to our States and celebrate the day with veterans at remembrance 
ceremonies and events. But we have to remember that Veterans' 
Day is not just a ceremony, a holiday. It is also a time that we 
should be asking if we have done enough for those who have served 
our country, and that is a very timely question today with so many 
veterans coming home from places like Iraq and Afghanistan, and 
with an aging population of veterans who do need more care. When 
these brave men and women signed up to serve our country, we 
agreed to take care of them. They kept their part of the bargain. 
Now it is time for us to keep our part. 
  Today's hearing is, in essence, about this country keeping its 
commitment to our veterans and ensuring that we are giving them 
everything that they need. And importantly, Mr. Chairman, this is 
the third legislative hearing that has been held by this Committee. 
The Veterans' Affairs Committee has held two previous legislative 
hearings several months ago when we considered other benefits 
and health bills, and many of the bills that were considered during 
those two hearings were eventually included in the health and benefits 
omnibus bills that have passed out of this Committee and, as 
the Chairman indicated, are awaiting floor time. 
  The fact that we have had to schedule a third legislative hearing 
is, I think, a real testament to the amount of concern all Members 
of this Committee have about the way the VA is being run, and 
near the top of that list is the VAï¿½s ability to care for veterans with 
mental health problems. 
  Last week, USA Today reported that the number of Iraq and Afghanistan 
veterans seeking care for Post-Traumatic Stress Disorder 
at the VA increased by almost 70 percent last year. And unfortunately, 
that number of returning veterans with PTSD and other mental health 
ailments is probably too low. Many of our servicemembers and veterans 
don't seek care because of the stigma surrounding treatment or because 
they fear that a mental health diagnosis may hurt their career. 
  Mr. Chairman, as troops are deployed overseas now for the third, 
fourth, and I am even hearing fifth tour of duty, the likelihood of 
PTSD and other mental health conditions increases dramatically. 
We have all heard about the lack of providers across the country 
and the lengthy delays in getting an appointment. The VA is facing 
some real challenges on this front. 
  The two mental health bills that are being considered today provide 
slightly different approaches to dealing with this challenge 
and I look forward to hearing from our witnesses about which approach 
they think is best. 
  I am also looking forward, Mr. Chairman, to talking about a bill 
that I introduced earlier this year with Senator Craig which would 
ensure that the VA is prepared and equipped to deal with what 
may be one long-term effect of Traumatic Brain Injury, the occurrence 
of epilepsy. Our bill would establish six Epilepsy Centers of 
Excellence in the VA system, and it is based on the successful MS 
Centers of Excellence and Parkinsonï¿½s Disease Research, Education, 
and Clinical Centers that are already operated by the VA. 
  At a May hearing in this Committee, Dr. John Booss, who is a 
former National Director of Neurology at the VA, testified that 
VA-funded research done with the Department of Defense found that 
more than half of veterans who suffered a penetrating TBI in Vietnam 
developed epilepsy within 15 years. For these veterans, the 
relative risk for developing epilepsy more than ten to 15 years after 
their injury was 25 times higher than non-veterans in the same 
age group. Dr. Booss expressed strong concern that the VA lacks 
a national program for epilepsy with clear guidelines on when to 
refer patients for further assessment and treatment of epilepsy. He 
urged this Committee to create a network of Epilepsy Centers of 
Excellence. 
  Now, it is too early to determine the impact of TBI-induced epilepsy 
created by the Iraq and Afghanistan wars, but we do know 
from past wars that many injuries associated with service take 
years or even decades sometimes to develop. So our bill will ensure 
that the VA is prepared to care for those veterans who need care 
down the road, and I hope to work with my colleagues to make this 
important idea a reality soon. 
  Thank you very much, Mr. Chairman. 
  Chairman AKAKA. Thank you, Senator Murray. 
  Senator CRAIG? 

              STATEMENT OF HON. LARRY E. CRAIG, U.S. SENATOR FROM 
                                   IDAHO 

  Senator CRAIG. Mr. Chairman, I will be brief. Thank you for the 
hearing and thank, of course, Ranking Member Burr for working 
with you to produce this legislative hearing. 
  The reason I will be brief is because both you and Senator Murray 
have already spoken to S. 2004, a bill that she and I cosponsored 
to create at least six Epilepsy Centers of Excellence. Now, I 
understand and realize that the VA generally opposes Congressionally 
directed research. At the same time, the hearings we have held 
determine that we really do need to focus much more on this tragic 
ailment and result of head trauma in a way that attempts to get 
to the bottom of it, and hopefully through our research and effort 
can keep men and women out of epilepsy, as Senator Murray has 
mentioned, as much as 15 years down the road. 
  We know that one cause is head trauma, or Traumatic Brain Injury, 
that certainly is related to many combat injury. So that is 
why we want to focus as we are proposing in this legislation to not 
only improving the medical treatment of many veterans, but at the 
same time hopefully deter the emergence of epilepsy later on in 
life. 
  We have every reason to be phenomenally proud of the kind of 
research ongoing at the VA. Across medical science today, VA 
fingerprints of work done inside its facilities that has gone out into 
the private sector to not only care for the veterans within its 
facilities, but citizenry outside. I believe these kinds of Centers of 
Excellence focused on epilepsy can not only help our veterans, but also 
help our civilian population at large, and I think it is the right 
thing to do and I am pleased that we are holding a hearing on it 
today. Thank you. 
  Chairman AKAKA. Thank you, Senator Craig. 
  Senator BROWN? 

               STATEMENT OF HON. SHERROD BROWN, U.S. SENATOR FROM 
                                        OHIO 

  Senator BROWN. Thank you very much, Mr. Chairman. 
  There are several important pieces of legislation on todayï¿½s agenda, 
but in the interest of time, I would like to focus on S. 2142, the 
Veterans Emergency Care Fairness Act. 
  Earlier this year, I received a letter from Terry Carson, the CEO 
of Harrison Community Hospital in rural Southeastern Ohio. Harrison 
is a 25-bed community hospital in Cadiz. The community of 
Cadiz is the home of Clark Gable and General Custer, I might add. 
Terry alerted me to a reimbursement problem with the VA that 
was taking a financial toll on his hospital. 
  In late May, Representative Zack Space and I held a joint field 
hearing on issues facing veterans in rural Appalachia and we invited 
Terry to be a witness. He spoke of his experience serving veterans 
coming to the hospital for emergency treatment. Often after 
the veteran has received the initial urgent care, the hospital 
encounters problems when they attempt to transfer the veteran to an 
appropriate VA facility for further treatment. Mr. Carson testified 
that the hospital can wait days for transfer approvals, and in some 
instances, those approvals are withdrawn during the actual transfer 
of the veteran. Current law does not take this into consideration. 
Under current law, non-VA facilities are reimbursed for the cost 
of stabilizing a veteran who needs emergency care and then they 
are expected to transfer the patient to a veteransï¿½ facility. If no 
facility is available, no veteransï¿½ facility is available, there is a 
coverage gap. The veteran still needs care, the hospital still provides 
the care, but the VA is not required to cover any associated costs. 
  This anomaly in the law is unfair to veterans and hospitals alike. 
This bill closes the loophole and requires the VA to cover the cost 
of care provided while a transfer is pending as long as the hospital 
documents reasonable attempts to complete that transfer. I want to 
thank Chairman Akaka and Ranking Member Burr and the Veterans 
Administration for working with me on this legislation. 
  I thank you, Mr. Chairman. I apologize for having to leave early 
today. The farm bill is being marked up, so I appreciate the good 
work you do in this Committee. Thank you. 
  Chairman AKAKA. Thank you, Senator Brown. 
  Senator ISAKSON?
 
                STATEMENT OF HON. JOHNNY ISAKSON, U.S. SENATOR FROM 
                                    GEORGIA 

  Senator ISAKSON. Thank you, Chairman Akaka. Thank you, 
Ranking Member Burr, for the bill that you have introduced focusing 
on mental health. 
  I took the month of August on our break to visit the VA hospitals 
in Georgia for a couple of reasons: One, to see firsthand what was 
going on, and second, to lend moral support, if I could, because I 
understand the tremendous pressure those hospitals are under and 
the VA is under. And while there are problems with that pressure, 
I saw some remarkable things happening in those hospitals. 
  At the Uptown Augusta Medical Center, which is near the Eisenhower 
Medical Center, I saw a seamless transition from DOD to 
Veterans Health Care. I had the privilege of meeting a young lady, 
Sergeant Harris, who on the second day of duty in Iraq was in an 
IED explosion in her Humvee and suffered a Traumatic Brain Injury. 
The Department of Defense released her from duty because 
of her injury. She went to the Uptown Augusta Medical Center 
where doctors there corrected the damage from the Traumatic 
Brain Injury and she reenlisted in the United States Army, which 
is a testimony to what the VA health care is doing at the Uptown 
Augusta facility in dealing with TBI. 
  But we have got a long way to go and I think it is very appropriate 
that we have this hearing today with the focus on mental 
health, epilepsy, and emergency services. It is very important to 
see to it that we give the VA not only the direction, but the financial 
support and the moral support to meet the challenges they will 
have not just in the months and years ahead, but in the rest of the 
first half of this century with the results of the injuries coming 
back from the War in Iraq and the War in Afghanistan. 
  I look forward to hearing from our witnesses and I thank you for 
the time, Mr. Chairman. 
Chairman AKAKA. Thank you very much, Senator Isakson. 
I want to welcome the first panel from the Department of Veterans 
Affairs, Dr. Michael Kussman, Under Secretary for Health at 
VA. This is the first time that you have been before the Committee 
since our field hearings in Hawaii, and again, I want to thank you 
so much for your participation in those hearings. 
Dr. Kussman is accompanied by Walter Hall. Mr. Hall is the Assistant 
General Counsel at VA. Dr. Kussman, before you begin 
your prepared testimony, will you please tell the Committee about 
the impact the Southern California fires have had on our VA operations. 

          STATEMENT OF MICHAEL J. KUSSMAN, M.D., M.S., MACP, 
            UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF 
            VETERANS AFFAIRS; ACCOMPANIED BY WALTER HALL, 
            ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF 
            VETERANS AFFAIRS 

  Dr. KUSSMAN. Aloha, Mr. Chairman, and mahalo nui loa. It is a 
pleasure to be here. If you indulge me for just a second, I would 
like to thank Kim Lipsky for all her support with us and the collegial 
working relationship we have had with her over the years. I 
particularly wanted to thank her for inviting me for the field trip 
to Hawaii. I know she was responsible for that. 
  [Laughter.] 
  Dr. KUSSMAN. Mr. Chairman, you asked for a quick update on 
the California wildfires. So far, this tragic event that is unfolding, 
there have been no injuries to employees or veterans in VA facilities, 
no damage to VA facilities as of the latest report that I have 
gotten. The Loma Linda Health Care System is fully operational, 
but there has been some road access and some other things that 
have been a challenge with the fires. 
  The VA San Diego Health Care System is operational and has 
initiated emergency response activities. There have been some 
challenges with limited staffing because a significant number of 
members have been required to evacuate their homes and it has 
been hard for them to get to work, but it hasnï¿½t so far denigrated 
the services that we can provide at the facility. We have housed 
more than 95 people as a shelter in place and 13 patients, all 
veterans, have been transferred to us from the local community. 
  The Greater Los Angeles Health Care System has had no major 
impacts. Some staff have evacuated their homes and are on standby 
to evacuate. 
  If you will bear with me, I will talk a little bit about the VBA 
and the NCA, too, even though their under secretaries are not 
here. The San Diego Regional Office Director reports that all employees 
have been accounted for and has opened with 12 essential 
personnel. The National Cemetery Administration has continued to 
cancel burials at the Riverside Cemetery and the Rosencrantz National 
Cemetery is closed due to road closures related to the fire. 
But so far, we have been lucky. 
  There haven't been any, we know of any damage to our facilities 
as well as no veterans, but we are watching it very closely and we 
all pray that the winds will calm down and shift and the brave fire 
fighters and all the people working on that will be able to get control 
of these several fires that are going on. 
  Again, good morning, Mr. Chairman and Members of the Committee. 
Thank you for inviting me here today to present the administration's 
views on five bills that would affect the Department of 
Veterans Affairs' programs. With me today, as mentioned, as Walter 
Hall, the Assistant General Counsel. I would like to request 
that my written statement be submitted for the record. 
  Chairman AKAKA. Without objection, it will be. 
  Dr. KUSSMAN. S. 2142, the Veterans Emergency Care Fairness 
Act of 2007, would make mandatory enhanced VA authorities to 
pay for a veteran's receipt of emergency treatment in a non-VA 
facility. 
  The authorities under which VA may currently pay these 
claims are discretionary in nature and use different standards to 
define a medical emergency. 
  VA strongly supports S. 2142. It would standardize authorities 
by applying the prudent layperson definition of emergency treatment 
to all claims and define emergency treatment as continuing 
until the point in time where the veteran is stabilized and is 
transferred to a VA or other Federal facility, or until such time as 
a VA facility or Federal facility agrees to accept the transfer. I am 
happy to be ``Dr. Yes'' on that, versus ``Dr. No,'' or ``Dr. Maybe.'' 
  In regards to S. 38, the Veterans Mental Health Outreach and 
Access Act of 2007, while we strongly support Section 3, we do not 
support Section 2. Section 2 would require VA to establish a program 
to provide OEF/OIF veterans with peer outreach services, 
peer support services, readjustment counseling services, and mental 
health services along with related family support services to assist 
in the veteran's readjustment to civilian life, the veteran's recovery, 
and the readjustment of the family following return of the 
veteran. The bill would require VA to contract with community 
mental health centers and other qualified entities to provide covered 
services in areas the VA determines are not adequately 
served. 
  Mr. Chairman, veterans of OEF/OIF combat operations are already 
qualified for readjustment counseling services and related 
mental health services under existing authority. VAï¿½s readjustment 
counseling authority provides for mental health services, consultation, 
professional counseling, and training for combat veterans, immediate 
family members as needed for the veteranï¿½s effective and 
successful readjustment back to civilian life. Veterans Centers are 
also authorized to contract for readjustment counseling services 
and related mental health services. Veterans Centers routinely rely 
on contracted services to meet the readjustment needs of veterans 
residing in rural areas. Also, veterans centers already provide veteran 
peer outreach and counseling services. 
  In 2004, VA began an aggressive outreach effort which included 
the hiring of OEF/OIF combat theater veterans to provide outreach 
services and peer counseling to their fellow veterans. To date, the 
veterans center program has hired 100 OEF/OIF outreach workers, 
and Al Bottras, who runs the program, is in the process of hiring 
a second 100 OEF/OIF outreach peer counselors. Combat theater 
veterans who enroll in VAï¿½s health care system are also eligible for 
all needed mental health services as part of VAï¿½s medical benefits 
package. Family support services are currently available to a veteran's 
immediate family members as necessary in connection with 
VA's treatment of the veteranï¿½s service-connected disability. 
  Section 3 of S. 38 would extend from 2 to 5 years combat theater 
veterans' window of eligibility to enroll without regard to whether 
they have a service-connected disability or their income level. As 
the leading researcher in PTSD medicine, VA has known the onset 
of symptoms or adverse health care effects related to PTSD and 
even mild to moderate brain injury can often be delayed and not 
manifested clinically for more than 2 years. VA strongly supports 
this provision, since it will provide combat theater veterans with an 
additional 3 years within which they can enroll in VA's health care 
system. 
  S. 2004 would require VA to designate at least six VA facilities 
as Epilepsy Centers of Excellence. VA does not support this bill. As 
a clinician as well as the Under Secretary of Health, I am concerned 
about statutory mandates for disease-specific centers have 
the potential to fragment care in which this otherwise well-designed 
world class health care integrated system is based. I am increasingly 
concerned about the proliferation of these disease-specific 
models and its impact on patient care in VA's integrated 
health care system. As it relates to a particular disease, I believe 
it is much more important for VA to be sure to demonstrate the 
best evidenced practice across the whole system than to establish 
centers that provide for care of a particular disease. In essence, 
every one of our centers ought to be a Center of Excellence for 
these diseases. 
  S. 2160, the Veterans Pain Care Act of 2007, would require VA 
to carry out an initiative on pain care management at each VA 
health care center. We do not support this bill, as well. Pain 
management is already a subject of systematic and systemic-wide 
attention in the VA health care system. In 2003, VHA established a 
national Pain Management Strategy to provide a systemwide approach 
to pain management to reduce pain and suffering for veterans. 
Under that strategy, VA uses a system-wide standard of 
care for pain management, ensures pain assessment is performed 
in a consistent manner, and ensures pain treatment is prompt and 
appropriate, provides for continual monitoring and improvement in 
outcomes of pain treatment, and ensures VA clinicians are prepared 
to assess and manage pain effectively. In addition, pain management 
protocols have been established and implemented in all 
our settings and VA health care facilities have implemented processes 
for measuring outcomes in the quality of the pain management. 
  Title 1 of S. 2162, the Mental Health Improvement Act of 2007, 
includes multiple provisions related to VA treatment programs for 
substance abuse disorders and mental health disorders, particularly 
PTSD. While VA respects the attention this Committee is giving 
these critical issues, we do not support Title 1. It attempts to 
mandate the type of treatments to be provided to covered veterans, 
the treatment settings, and the composition of the treatment 
teams. Treatment decisions need to be based on professional medical 
judgments, and experienced health care providers and managers are in 
the best position to decide how best to deliver needed health care 
services at the local level. 
  Title 2 of S. 2162 deals with mental health accessibility 
enhancements, including the requirements for VA to establish a 3-year 
pilot program to assess the feasibility and advisability of providing 
eligible OIF/OEF veterans with peer outreach services, peer support 
services, and readjustment counseling services, and other 
mental health services. VA would be required to contract these 
services with community mental health services and Indian Health 
Service facilities for veterans residing in rural areas. As we 
discussed in connection with Section 2 of S. 38, these services are 
already available to OIF/OEF veterans, including those who served 
in the National Guard or the Reserves. As such, we don't believe 
these needs to exist for a pilot program with additional authorities 
which are duplicative of current existing authorities. 
  Title 3 of S. 2162 would require that the VA carry out a program 
of research into co-morbid PTSD and substance abuse disorders 
and would charge VA's National Center for PTSD with the responsibility 
for carrying out and overseeing this program. This is overly 
prescriptive and unnecessary. Therefore, with the exception of the 
extension of the Special Committee on PTSD through 2012, we are 
unable to support the provisions of Title 3. VA is a world recognized 
leader in the care of both PTSD and substance abuse disorders, 
particularly when these conditions coexist in an individual. 
The activities required by Title 3 are duplicative of the VHA's ongoing 
efforts in this area, particularly in research efforts being carried 
out by the VA's National PTSD Center and the VA's Office of 
Research and Development. We would be happy to meet with the 
Committee staff to provide them information on these ongoing efforts. 
  Title 4 of S. 2162 addresses assistance for families of veterans. 
However, it is unclear how these readjustment and transition assistance 
services the bill would require VA to pilot are intended to 
differ from or interact with the readjustment counseling services 
and related mental health services already made available to veterans 
and their families through the veterans centers. In our view, 
this provision would conflict with many aspects with the VA's existing 
authorities and lend confusion to what is otherwise a highly 
successful program. Client satisfaction with the veterans centers is 
the highest in the VA's program, at 98 percent. The services they 
provide already include marriage and counseling services to family 
members as necessary to further the veteran's adjustment. 
  Second, we do not agree that there is a need for additional study 
of the merits of using organizations for the provision of these 
services. Let me again assure you that our veterans centers readily 
contract with appropriate organizations and providers to ensure 
veterans and their families receive covered family services when 
necessary. In sum, we do not believe this provision would enhance 
current authorities and the veterans center activities. Rather, we 
see that it has a serious potential to create confusion and disruption 
for both VA and our beneficiaries. 
  I appreciate the Committee's continued interest and support in 
meeting the needs of our veterans. I know we share a common interest 
in providing the best care to veterans and we would welcome 
the opportunity to brief the Committee on VAï¿½s ongoing programs 
and activities in these areas as well as the Office of Mental Health 
on overseeing PTSD and substance abuse programs. 
  This concludes my prepared statement and I would be pleased to 
answer any questions you or other Members of the Committee 
might have. Mahalo. 
  [The prepared statement of Dr. Kussman follows:] 

           PREPARED STATEMENT OF MICHAEL J. KUSSMAN, M.D., MS, MACP, 
                      UNDER SECRETARY FOR HEALTH 

Good morning Mr. Chairman and Members of the Committee: 
Thank you for inviting me here today to present the Administration's 
views on several bills that would affect Department of Veterans Affairs 
(VA) programs that provide veterans benefits and services. With me 
today is Walter A. Hall, Assistant General Counsel. I will address the 
five bills on todayï¿½s agenda and then I would be happy to answer any 
questions you and the Committee Members may have. 

        S. 2142 ``VETERANS' EMERGENCY CARE FAIRNESS ACT OF 2007'' 

  S. 2142 would make mandatory, standardize, and enhance the two 
existing authorities the Secretary has to pay for expenses incurred in 
connection with a veteran's receipt of emergency treatment in a non-VA 
facility. The two authorities under which the Secretary may currently 
pay these claims are discretionary in nature (``may reimburse'' as 
opposed to ``shall reimburse'') and cover different veteran 
populations and use different standards to define a medical emergency. 
  As background, the Secretary is authorized to pay the reasonable 
expenses incurred by a veteran for non-VA emergency treatment of a 
service-connected disability, a non-service-connected disability 
aggravating a service-connected disability, any disability of a 
veteran with a permanent and total disability, or for a covered 
vocational rehabilitation purpose. In these claims, VA medical 
professionals must determine whether a medical emergency existed 
(i.e., if there was an actual emergency of such nature that delay in 
obtaining treatment would have been hazardous to life or health.) 
Expenses incurred after the medical emergency has ended, that 
is, after the point in time the veteran could have been transferred 
safely to VA or another Federal facility, may not be reimbursed. 
  The Secretary may also reimburse or pay a veteran for expenses 
incurred for non-VA emergency treatment of a non-service connected 
disability. In these claims, the law requires use of a prudent 
layperson standard to determine the need for the non-VA emergency 
treatment. Thus, if it turns out that the veteran's condition was not 
an actual medical emergency, VA can still pay the expenses if a prudent 
layperson would have thought it reasonable for the veteran to seek 
immediate medical treatment.   This happens, for instance, when a 
veteran goes to the nearest emergency room because of the belief he or 
she is having a heart attack, but turns out only to have a severe case 
of heartburn. Similar to claims for service-connected conditions, the 
Secretary is only authorized to pay for the emergency treatment 
expenses, and the emergency ends at the point the veteran can be 
transferred safely to a VA facility or other Federal facility. 
  S. 2142 would amend both existing authorities by requiring the 
Secretary to pay the expenses of any veteran who meets eligibility 
criteria. It would also standardize these programs by applying the 
prudent layperson definition of ``emergency treatment''
in both situations. And most importantly it would define ``emergency 
treatment'' as continuing until (1) the point in time the veteran can 
be transferred safely to a VA or other Federal facility, or (2) such 
time as a VA facility or other Federal facility agrees to accept such 
transfer if, at the time the veteran could have been transferred 
safely, the non-VA provider makes and documents reasonable attempts 
to transfer the veteran to a VA facility or other Federal facility. 
  VA strongly supports S. 2142; effective emergency room reimbursement 
has been an issue of concern to the Department. In fact, VA is in the 
process of drafting regulations to address these concerns within the 
authority it has under current law. 
  It is VA's expectation that facilities aggressively work to accept 
the transfer of a veteran in these situations. We are aware, however, 
that there have been cases where VA has been unable to find a facility 
that had the bed, capability, staff, or resources needed to furnish the 
care required by the veteran. In those cases, which we believe are the 
exception and not the norm, the non-VA providers ultimately billed the 
veterans for those expenses. This can impose a serious monetary 
hardship for our beneficiaries. 
  S. 2142 would properly put the financial onus on the Department to 
provide appropriate care either in the VA or Federal system or at the 
non-VA facility. Enrolled veterans are eligible for needed hospital or 
medical care. Good medical practice demands we furnish such care in a 
manner that advances a seamless continuum of care and reduces 
fragmentation of such care. Clearly these goals are best achieved 
by bringing the veteran into the VA health care system as soon as 
possible. In those rare cases where VA cannot immediately agree to 
accept the patient transfer, it would be entirely appropriate for VA to 
be responsible for the expenses related to the veteran's needed 
continued hospital care in the private facility until the point 
VA can take over. 
  When VA initiated drafting regulations for this program choice, it 
determined funds were available within the FY 2008 President's Budget 
level for this expanded benefit. 
  As a final and more technical matter, I would like to clarify that if 
a veteran currently meets the eligibility criteria on which his or her 
claim is based, VA invariably pays the claim. Thus, changing the 
Secretary's authority from ``may'' to ``shall'' for purposes of both 
types of claims would have no practical effect. Nevertheless, we do 
not object to such a change. 

S. 38 ``VETERANS' MENTAL HEALTH OUTREACH AND ACCESS ACT OF 2007''

                           SECTION 2 OF S. 38 

  Section 2 of S. 38 would require the Secretary to establish, not 
later than 180 days after enactment of the bill, a program to provide 
veterans of Operation Enduring Freedom and Operation Iraqi Freedom 
(OEF/OIF) ``peer outreach services, peer support services, readjustment 
counseling services, and mental health services.'' As part of this 
program, the Secretary would be required to furnish education, support, 
counseling, and mental health services to a veteranï¿½s immediate family 
members to assist: in the veteran's readjustment to civilian life, the 
veteran's recovery, and the readjustment of the family following the 
return of the veteran. 
  S. 38 would also require the Secretary to contract with community 
mental health centers and other qualified entities to provide the peer 
related, readjustment, and mental health services in areas the 
Secretary determines are not adequately served by VA health care 
facilities. Such contracts would require, to the extent practicable, 
that veterans providing peer related services receive training from a 
national not for-profit mental health organization, which contracts 
with VA for this purpose. In addition, the contractorï¿½s clinicians 
would be required to (1) complete mandated training to ensure the 
clinicians can provide services in a manner that recognizes 
factors that are unique to the experience of OEF/OIF veterans and (2) 
to utilize best practices and technologies. 
  The centers and entities would have to comply with applicable VA 
protocols before incurring any liability on behalf of the Department; 
submit specified reports and certain clinical information to the 
Secretary; and meet any other requirements established by the 
Secretary. 
  VA supports many of the initiatives and certainly the stance of 
aggressive outreach that underlies this provision. VA does not, 
however, support section 2 as it is unnecessary and duplicative of 
current authorities. Veterans of OEF/OIF combat operations already 
qualify for readjustment counseling services and related mental health 
services under existing authority. (While limited mental health 
services are available in the Vet Center program, Vet Centers refer 
veterans with complex mental health conditions to VA medical centers.) 
VA's readjustment counseling authority provides for the furnishing of 
mental health services, consultation, professional counseling, and 
training to the combat veteran's immediate family members as 
needed for the veteran's effective and successful readjustment back to 
civilian life. 
  Vet Centers are also authorized to contract for the provision of 
readjustment counseling services and related mental health services. 
Vet Centers routinely rely on contracted services to meet the 
readjustment needs of veterans residing in rural areas. Hence, the 
additional authorities related to the provision of readjustment 
counseling services and related mental health services for OEF/OIF 
veterans (either through the Vet Centers or by contract) are generally 
duplicative and simply not needed. 
  Vet Centers are already providing veteran-peer outreach and 
counseling services. In 2004, VA began an aggressive outreach effort, 
which included the hiring of OEF/OIF combat-theater veterans to provide 
outreach services and peer-counseling to their fellow veterans. To 
date, the Vet Center program has hired 100 OEF/OIF out-reach workers. 
The Vet Center program is also undergoing the largest expansion in 
its history. This expansion complements the Vet Center peer outreach 
services initiative. 
  These efforts together enable our Vet Centers to ensure there are 
sufficient staff and resources to provide the professional readjustment 
services needed by the new veterans as they return home. 
  OEF/OIF combat-theater veterans are also already eligible to enroll 
within 2 years of the date of discharge or release from active duty in 
VA's health care system and receive VAï¿½s comprehensive medical benefits  
package. 
  As to family support services, VA is already required to provide 
immediate family members of a veteran being treated for a 
service-connected disability with such mental health services, 
consultation, professional counseling, and training as necessary 
in connection with that treatment. 
  If a veteran is being treated for a non-service connected disability, 
the law currently authorizes the Secretary to provide family services 
if: the services are initiated during the veteran's hospitalization and 
the continued provision of these services on an outpatient basis is 
essential to permit the discharge of the veteran from 
the hospital. 
  We believe no additional authority is needed as the vast majority of 
family members of returning OEF/OIF veterans already qualify for these 
services. However, neither existing authority extends to providing a 
veteran's family members with mental health services for their 
individual mental health needs that are separate and apart 
from the veteran's treatment needs. It is unclear whether S. 38 is 
intended to authorize individual mental health benefits for family 
members beyond services needed to assist the veteran's treatment and 
readjustment. If that is the case, we could not support that provision 
for the following reasons. 
  Mental health conditions often manifest with physical symptoms or 
sequella. In those cases, providing only mental health services to 
assist in a family member's readjustment could result in fragmented and 
inadequate treatment. The receipt of other medical care could be equally 
essential for that memberï¿½s successful readjustment, and the failure to 
receive such care could impair the ability of the family as 
a whole to successfully readjust to the veteran's return. For that 
reason, we believe it would be more reasonable, from a health care 
perspective, to continue linking family support services to those that 
are essential for the veteran's readjustment. Family members should 
continue to receive needed mental health services from their regular 
providers who can treat them from a whole-person perspective and 
concurrently address all of their medical needs. 
  Also, when VA contracts for services in the community, community 
health centers may compete for those contracts. The provision to 
require VA to contact specifically with that entity may reduce the 
opportunity for the veteran to be cared for by the most highly 
qualified competent contractor. 
  We also note that OEF/OIF veterans who are permanently and totally 
disabled from a service-connected disability are able to sponsor their 
spouses and children in VA's Civilian Health and Medical Program 
(commonly referred to as ``CHAMPVA''). Once enrolled in that program, 
their family members will be eligible to receive relatively 
comprehensive VA medical benefits. 
  As a final comment on this section, we are uncertain what is meant 
by the provision requiring centers to comply with VA protocols before 
incurring any liability on behalf of the Department. 

                            SECTION 3 OF S. 38 

  Section 3 of S. 38 would extend from 2 to 5 years, combat-theater 
veterans' window of eligibility to enroll without regard to whether 
they have a service connected disability or their income level. VA 
strongly supports section 3. As the leading researcher in PTSD 
medicine, VA has known that the onset of symptoms or adverse health 
effects related to PTSD and even Traumatic Brain Injury can often be 
delayed and not manifest clinically for more than 2 years after a 
veteran has left active service. As a result, OEF/OIF may not seek VA 
health care benefits until after their 2-year window of eligibility has 
already closed. Without that basis of eligibility, they may be 
ineligible to enroll because of the current bar on enrolling new 
veterans in Category 8. 
  We are also aware that many of these veterans are not career military 
and are less familiar with veterans benefits and the procedures for 
obtaining them. For that reason they may fail to enroll in a timely 
fashion. 
  Providing combat-theater veterans with an additional 3 years within 
which to enroll in VA's health care system will help ensure that none 
of them is denied the care they need and deserve for reasons wholly 
beyond their control. VA estimates the costs associated with enactment 
of section 3 to be $15.7 million in Fiscal Year 2008, and this 
expansion can be accommodated within the FY 2008 President's Budget 
level. This estimate includes both expenditures and lost co-payment 
revenue. 
  
               S. 2004 ``EPILEPSY CENTERS OF EXCELLENCE''

  S. 2004 would require the Secretary, not later than 120 days after 
enactment of this provision, to designate at least six Department 
health-care facilities as epilepsy centers of excellence based on the 
recommendation of the Under Secretary for Health (USH). The mandate to 
establish and operate these centers, however, would be subject to the 
availability of appropriations for this purpose. 

  The bill defines an ``epilepsy center of excellence'' as a Department 
health-care facility that has (or in the foreseeable future can 
develop) the necessary capacity to function as a center of excellence 
in research, education, and clinical care activities in the diagnosis 
and treatment of epilepsy. To qualify as a center, the facility would 
need: 
  affiliation with an accredited medical school that provides 
education and training in neurology (or may reasonably be anticipated 
to develop such an affiliation). 
  The ability to attract scientists of ingenuity and 
creativity. 
  An advisory committee composed of veterans and appropriate 
health-care and research representatives of the facility and of the 
affiliate. 
  The capability to effectively evaluate the activities of the 
centers. 
  The capability to coordinate the centers education, clinical 
care, and research activities. 
  The capability to develop a national consortium of providers 
with interest in treating epilepsy at VA medical centers; the 
consortium would have to include a designated epilepsy referral 
clinical in each Veterans Integrated Service Network. 
  The capability to assist in the expansion of VA's use of 
information systems and databases to improve the quality and delivery 
of care. 
  The capability to assist in the expansion of VAï¿½s tele-health 
program to develop, transmit, monitor, and review neurological 
diagnostic tests. 
  The ability to perform epilepsy research, education, and 
clinical care activities in collaboration with VAï¿½s Poly Trauma 
Centers. 
  A number of specific requirements governing the competitive selection 
of the six facilities are set forth in the bill, including a 
requirement that the Secretary consider appropriate geographic 
distribution when making the selections. 
  S. 2004 would further mandate the designation of an individual in VHA 
to act as a national coordinator for VHAï¿½s epilepsy programs. The bill 
includes a list of duties for that position, including that such 
individual report to the VHA official responsible for neurology. 
  The bill would authorize $6 million for each of fiscal years 2008 
through 2012 to establish and operate the centers; such sums as may be 
necessary for operating the centers for each fiscal year after fiscal 
year 2012 would also be authorized. For the first 3 years of the 
centers operation, the bill would require that the centers be 
designated as a special purpose program in order to avoid funds for the 
centers being allocated through the Veterans Equitable Resource 
Allocation system. In addition to those amounts, the USH would be 
required to allocate such amounts as he deems appropriate from other 
funds made available to VHA. The bill includes a separate authorization 
of appropriations to fund the national coordinator position. 
  VA does not support S. 2004. As I have discussed in the past, I am 
concerned that statutory mandates for ï¿½ï¿½disease specificï¿½ï¿½ centers have 
the potential to fragment care in what is otherwise a well-designed, 
world-class integrated health care system. I am increasingly concerned 
about the proliferation of this disease-specific model and its impact 
on patient care and VAï¿½s integrated health care model. As it relates to 
a particular disease, I believe that it is much more important for VA 
to disseminate the best in evidence-based practices across its health 
care system than to establish centers that provide care for a 
particular disease. 
  Treating epilepsy, like every other serious condition, requires an 
interdisciplinary approach. By mandating new ï¿½ï¿½education, research, and 
clinical centersï¿½ï¿½ that are disease-specific, flexibility to respond to 
changing combinations of related conditions is reduced. The centers' 
mandated collaboration with VAï¿½s Poly trauma Centers would not cure 
this short-coming. 
  It is also important to note that the ï¿½ï¿½modelsï¿½ï¿½ on which these 
Epilepsy Centers are based, the successful Geriatric Research, 
Education and Clinical Center (GRECC) and Mental Illness Research, 
Education and Clinical Center (MIRECC) programs, are not narrowly 
focused on a disease process but address a wide gamut of issues facing 
a significant portion of the veteran population. 
  
                S. 2160 ``VETERANS PAIN CARE ACT OF 2007''

  S. 2160 would require the Secretary to carry out an initiative on 
pain care management at each VA health care facility. Under the 
initiative, each individual receiving treatment in a VA facility would 
receive: (1) a pain assessment at the time of admission or initial 
treatment and periodically thereafter, using a professionally 
recognized pain assessment tool or process; and (2) appropriate pain 
care consistent with recognized means for assessment, diagnosis, 
treatment, and management of acute and chronic pain, including, when 
appropriate, access to specialty pain management services. The 
initiative would have to be implemented at all VA health care 
facilities by not later than January 1, 2008, in the case of inpatient 
care and by not later than January 1, 2009, in the case of outpatient 
care. 
  The bill would further require the Secretary to carry out a program 
of research and training on acute and chronic pain within VHAï¿½s Medical 
and Prosthetic Research Service. These programs would be directed to 
meet the purposes specified in the bill. The Secretary would also be 
required to designate an appropriate number of facilities as 
cooperative centers for research and education on pain. Each such 
center would focus on research and training in one or more of the 
following areas: acute pain; chronic pain, or a research priority 
identified by VHA. The Secretary would also need to designate at 
least one of those centers as a lead center for research on pain 
attributable to central and peripheral nervous system damage commonly 
associated with the battlefield injuries characteristic of modern 
warfare. Another center would be the lead for coordinating the pain 
care research activities conducted by the centers and responsible for 
carrying out a number of other duties specified in the bill. 
  The measure would permit these centers to compete for funding from 
amounts appropriated to the Department each year for medical and 
prosthetics research. It would also charge the USH with designating an 
appropriate official to oversee their operation and to evaluate their 
performance. 
  VA health care is delivered in accordance with patient-centered 
medicine. Fundamental to this is effective pain management. In 2003 VHA 
established a National Pain Management Strategy to provide a 
system-wide approach to pain management to reduce pain and suffering 
for veterans experiencing acute and chronic pain associated with a wide 
range of illnesses. The national strategy uses a system-wide standard 
of care for pain management; ensures that pain assessment is performed 
in a consistent manner; ensures that pain treatment is prompt and 
appropriate; provides for continual monitoring and improvement in 
outcomes of pain treatment; uses an interdisciplinary, multi-modal 
approach to pain management; and ensures VA clinicians are prepared to 
assess and manage pain effectively. The national strategy also called 
for pain management protocols to be established and implemented in all 
clinical settings and directed all VHA medical facilities to implement 
processes for measuring outcomes and quality of pain management. 
  To oversee implementation of the National Pain Management System, VHA 
established an interdisciplinary committee. Part of the Committee's 
charge is to ensure that every veteran in every network has access to 
pain management services. The committee is also responsible for making 
certain that national employee education is provided to VHA clinicians 
so that they have the needed expertise to provide high quality pain 
assessment and treatment and for identifying research opportunities 
and priorities in pain management. It also facilitates collaborative 
research efforts and ensures that VHA pain management standards have 
been integrated into the curricula and clinical learning experiences of 
medial students, allied health professional students, interns, and 
resident trainees. 
  Because pain management is already a subject of systematic and 
system-wide attention in the VHA health care system, S. 2160 is 
superfluous and duplicative of what is already happening in VA 
healthcare. We would be very happy to meet with the Committee to 
discuss VA's ongoing pain management program and activities. 

             S. 2162 ``MENTAL HEALTH IMPROVEMENTS ACT OF 2007''

          TITLE I. SUBSTANCE USE DISORDERS AND MENTAL HEALTH CARE 

  Mr. Chairman, title I of this bill focuses on VA treatment programs 
for substance use disorders and mental health disorders, particularly 
PTSD. Section 102 would require the Secretary to ensure the provision 
of the following services for substance use disorders at every VA 
medical center: 
Short term motivational counseling services. 
Intensive outpatient care services. 
Relapse prevention services. 
Ongoing aftercare and outpatient counseling services. 
Opiate substitution therapy services. 
Pharmacological treatments aimed at reducing cravings for drugs 
and alcohol. 
Detoxification and stabilization services. 
Such other services as the Secretary deems appropriate. 

  The Secretary could, however, exempt an individual medical center or 
Community-Based Outpatient Clinic (CBOC) from providing all of the 
mandated services. 
  Annually the Department would have to report to Congress on the 
facilities receiving an exemption under this provision, including the 
reason for the exemption. 
  Section 103 would require the Secretary to ensure that VA treatment 
for a veteran's substance use disorder and a co-morbid mental health 
disorder is provided concurrently by a team of clinicians with 
appropriate expertise. 
  Section 104 would require the Secretary to carry out a program to 
enhance VA's treatment of veterans suffering from substance use 
disorders and PTSD through facilities that compete for funds for this 
purpose. Funding awarded to a facility would be used for the six 
purposes specified in the bill, in addition to the conduct of peer 
outreach programs through Vet Centers to re-engage OEF/OIF veterans who 
miss multiple appointments for PTSD or a substance use disorder. 
Another specified purpose for the funds would be to establish 
collaboration between VA's urgent care clinicians and substance use 
disorder and PTSD professionals to ensure expedited referral of 
veterans who are diagnosed with these disorders. 
  Not later than 1 year after the billï¿½s enactment, the Secretary would 
need to submit a report to Congress on this program and the facilities 
receiving funding. 
  S. 2162 would provide for funding by requiring the Secretary to 
allocate $50 million from appropriated funds available for medical care 
for each of fiscal years 2008, 2009, and 2010. The bill would require 
the total expenditure for PTSD and substance use disorder programs to 
not be less than $50 million in excess of a specified baseline amount. 
(The bill would define the baseline as the amount of the total 
expenditures on VA's treatment programs for PTSD and substance use 
disorders for the most recent fiscal year for which final expenditure 
amounts are known, as adjusted to reflect any subsequent increase in 
applicable costs to deliver those programs.) 
  Section 105 would require the Secretary to establish not less than 
six national centers of excellence on PTSD and substance use disorders. 
These centers would provide comprehensive inpatient treatment and 
recovery services to veterans newly diagnosed with these disorders. 
Sites for the centers would be limited to VA medical centers that 
provide inpatient care; that are geographically situated in an area 
with a high number of veterans that have been diagnosed with both PTSD 
and substance use disorder; and that are capable of treating PTSD and 
substance use disorders. 
  This provision would also direct the Secretary to establish a process 
to refer and aid the transition of veterans receiving treatment in 
these centers to programs that provide step down rehabilitation 
treatment. 
  Section 106 would require the Secretary, acting through the Office of 
the Medical Inspector (MI), to review all of VAï¿½s residential mental 
health care facilities and to submit to Congress a detailed report on 
the MI's findings. 
  Section 107 would provide for title I of this bill to be enacted in 
tribute to Justin Bailey, an OIF veteran who died while under VA 
treatment for PTSD and a substance use disorder. 
  While VA respects the attention this Committee is giving these 
critical issues, Title I is overly prescriptive and attempts to mandate 
the type of treatments to be provided to covered veterans, the 
treatment settings, and the composition of treatment teams. Treatment 
decisions should be based on professional medical judgments in light of 
an individual patientï¿½s needs, and experienced health care managers 
are in the best position to decide how best to deliver needed health 
care services at the local level. With regard to the proposed centers 
of excellence, we reiterate our concerns about disease-specific 
treatment centers and models, although we appreciate the Committee's 
efforts thereby to hasten the eradication of those particular diseases. 
For all of the above reasons, we do not support this title. 

           TITLE II. MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS 

  Section 201 would require the Secretary to establish a 3-year pilot 
program to assess the feasibility and advisability of providing 
eligible OEF/OIF veterans with peer outreach services, peer support 
services, and readjustment counseling services, and other mental health 
services. This pilot would begin not later than 180 days after the 
bill's enactment. Eligible veterans would include those who are enrolled 
in VA's health care system and who, for purposes of the pilot program, 
receive a referral from a VHA health professional to a community mental 
health center or to a facility of the Indian Health Service (IHS). 
  In providing readjustment counseling services and other mental health 
services to rural veterans who do not have adequate access to VA 
services, section 201 would require the Secretary, acting through the 
Office of Rural Health, to contract for those services with community 
mental health centers (as defined in 42 CFR  410.2) and IHS 
facilities. 
  Sites for the pilot would need to include at least two Veterans 
Integrated Service Networks (selected by the Secretary), and at least 
two of the sites would have to be located in rural areas that lack 
access to comprehensive VA mental health services. 
  A center or IHS facility that participates in the pilot program must, 
to the extent practicable, provide readjustment counseling services and 
other mental health services to eligible veterans through the use of 
telehealth services. It would also need to provide the services using 
best practices and technologies and meet any other requirements 
established by the Secretary. A participating center or IHS facility 
would also have to comply with applicable VA protocols before incurring 
any liability on behalf of the Department and provide clinical 
information on each veteran to whom it furnishes services. 
  The Secretary would be required to carry out a national program of 
training for (1) veterans who would provide peer outreach and peer 
support services under the pilot program; and (2) clinicians of 
participating centers or IHS facilities to ensure they can furnish 
covered services and that such services will be provided in a manner 
that accounts for factors unique to OEF/OIF veterans. This provision 
would also establish detailed annual reporting requirements for 
participating centers and facilities. 
  As we discussed in connection with section 2 of S. 38, all of these 
services are already available to OEF/OIF veterans, including those who 
served in the National Guard or the Reserves. As such, no demonstrated 
need exists for the pilot program or these additional authorities, 
which are duplicative of currently existing authorities. And VA is 
already working with other entities to provide treatment to veterans 
at the local level if VA is not able to provide the needed care; 
therefore, the requirement to contract specifically with a community 
health center or IHS facility would limit the local VA providers' 
flexibility in finding the most appropriate care for our veterans. 

                           TITLE III. RESEARCH 

  Section 301 would require the Secretary to carry out a program of 
research into co-morbid PTSD and substance use disorder. The purpose of 
this program would be to address co-morbid PTSD and substance use 
disorder; provide systematic integration of treatment for these two 
disorders; develop protocols to evaluate VA's care of veterans with 
these disorders; and, facilitate the cumulative clinical progress of 
these veterans. This provision would charge VAï¿½s National Center for 
PTSD with responsibility for carrying out and overseeing this program, 
developing the protocols and goals, and coordinating the research, data 
collection, and data dissemination. 
  Section 301 would also authorize $2 million to be appropriated for 
each of fiscal years 2008 through 2011 to carry out this program and 
specifically require these funds be allocated to the National PTSD 
Center. The funds made available to the Center would be in addition to 
any other amounts made available to it under any other provision of 
law. 
  Section 302 would continue the Special Committee on PTSD (which is 
established within VHA) through 2012; otherwise the Committeeï¿½s mandate 
would terminate after 2008. 
  While well-intended, this title is overly prescriptive and more 
importantly altogether unnecessary. Therefore, with the exception of 
the extension of the Special Committee, VA does not support the 
provisions in title III. VA is a world-recognized leader in the care of 
both PTSD and substance use disorders, particularly when these 
conditions co-exist in an individual. The activities required by title 
III are essentially duplicative of VHA's on-going efforts in this area, 
particularly the research efforts being carried out by VAï¿½s National 
PTSD Center. We would welcome the opportunity to brief the Committee on 
VA's achievements and efforts in this area, plus the role of the Office 
of Mental Health in overseeing the PTSD and substance abuse programs. 

              TITLE IV. ASSISTANCE FOR FAMILIES OF VETERANS 

  In connection with the family support services authorized in chapter 
17 of title 38, United States Code (i.e., mental health services, 
consultation, professional counseling, and training), section 401 would 
amend the statutory definition of ``professional counseling'' to 
expressly include marriage and family counseling. This provision 
would also ease eligibility requirements for these family support 
services by authorizing the provision of these services when considered 
appropriate (as opposed to essential) for the effective treatment and 
rehabilitation of the veteran. Section 401 would further clarify that 
these services are available to family members in Vet Centers, VA 
medical centers, CBOCs, or other VA facilities the Secretary considers 
necessary. 
  Section 402 would require the Secretary to carry out, through a 
non-VA entity, a 3-year pilot program to assess the feasibility and 
advisability of providing ``readjustment and transition assistance'' to 
veterans and their families in cooperation with Vet Centers. 
Readjustment and transition assistance would be defined as readjustment 
and transition assistance that is preemptive, proactive, and 
principle-centered. It would also include assistance and training for 
veterans and their families in coping with the challenges associated 
with making the transition from military to civilian life. 
  This provision would require services furnished under the pilot 
program to be furnished by a for-profit or non-profit organization(s) 
selected by the Secretary (pursuant to an agreement). To participate in 
the pilot, a participating organization(s) must have demonstrated 
expertise and experience in providing those types of services. 
  The pilot program would have to be carried out in cooperation with 10 
geographically distributed Vet Centers, which would be responsible for 
promoting awareness of the assistance available to veterans and their 
families through the Vet Centers, the non-VA organization(s) conducting 
the pilot, and other appropriate mechanisms. 
  Section 403 would establish detailed reporting requirements and 
authorize $1 million to be appropriated for each of fiscal years 2008 
through 2010 to carry out the pilot program. Such amounts would remain 
available until expended. 
  VA does not support title IV. First, it is unclear how these 
``readjustment and transition assistance'' services are intended to 
differ from, or interact with, the readjustment counseling services and 
related mental health services already made available to veterans and 
their families through the Vet Centers. In our view, this provision 
would conflict in many respects with VA's existing authorities to 
provide readjustment counseling and related mental health services and 
lend confusion to what is otherwise a highly successful program 
(particularly with respect to client outreach). Indeed, client 
satisfaction with the Vet Centers is the highest of VA's programs (98 
percent). The services they provide already include marriage and 
counseling services to family members as necessary to further the 
veteran's readjustment. 
  We also do not understand the perceived need for reliance on non-VA 
organizations for the provision of these services. Let me again assure 
you that our Vet Centers readily contract with appropriate 
organizations and providers to ensure veterans and their families 
receive covered family support services. In sum, we do not see how this 
provision would effectively enhance current authorities or Vet Center 
activities; rather, we see that it has serious potential to create 
confusion and disruption for both VA and our beneficiaries. 
  We are currently developing cost estimates on the provisions of these 
bills, which we will share with the Committee once completed. This 
concludes my prepared statement. I would be pleased to answer any 
questions you or any of the Members of the Committee may have. 

      RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY MICHAEL J. KUSSMAN, 
        M.D., TO HON. DANIEL K. AKAKA, CHAIRMAN, SENATE COMMITTEE OF 
                             VETERANS' AFFAIRS 

  Question 1. Please highlight the current VA research programs that 
are examining how to treat veterans who suffer from both substance use 
disorder and PTSD. 
  Response. The Department of Veterans Affairs (VA) continues to be a 
leader in supporting research related to the mental and physical health 
consequences of military service, including Post Traumatic Stress 
Disorder (PTSD). VA researchers and clinicians are working together to 
understand how co-occurring disorders like substance abuse and PTSD 
affect a patient's treatment, and are striving to develop the most 
effective treatments through rigorous research. VAï¿½s National Center 
for PTSD and several of VAï¿½s mental illness research education and 
clinical centers (MIRECCs) are engaged in studies of PTSD and 
co-occurring substance use disorders. 
  Examples of some of the current ongoing research programs sponsored 
by the Office of Research and Development include: 
  VA scientists supported by VA and the Department of Defense 
(DDD), have collected risk factor and health information from military 
personnel prior to their deployments to Iraq. Compared to the 
retrospective studies of past conflicts, this landmark study represents 
the first time scientists will be able to prospectively examine 
differences between pre-deployment and post-deployment performance and 
health outcomes, including PTSD and other health conditions; 
  VA's Alcoholism Research Center is recognized as one of the 
world leaders in understanding genetic contributions to substance 
abuse. Currently, this center is exploring novel treatments for 
reducing withdrawal symptoms and drinking; 
  VA scientists are exploring the genetic determination of 
traits related to ethanol withdrawal severity, considered important to 
reducing relapse events; 
  VA scientists are examining the effectiveness of opioid 
substitution therapy to reduce substance abuse; 
  VA's quality enhancement research initiative (QUERI) is 
sponsoring an initiative to improve the detection and treatment of 
misuse of psychoactive substances in many co-occurring conditions; and 
  VA is supporting research to identify risk factors in 
subgroups of smokers who are at risk for both increased smoking and 
difficulty in smoking cessation that could lead to important prevention 
and intervention efforts. 

                 SOME RECENT ADVANCES BY VA INVESTIGATORS INCLUDE: 

  In the largest randomized clinical trial to date involving 
women veterans with PTSD, VA investigators found that 
prolonged-exposure therapy--a type of cognitive behavioral therapy--was 
effective in reducing PTSD symptoms and that such reductions 
remained stable over time (JAMA, 2007;297(8):820-830). 
  Investigators found that prazosin, an inexpensive generic 
drug already used by millions of Americans for high blood pressure and 
prostate problems, improves sleep and reduces trauma nightmares for 
veterans with PTSD (Biological Psychiatry. 2007; 61 (8):928-934). A 
large, multi-site study is underway to confirm the drug's 
effectiveness. 
  VA researchers found that opioid substitution therapy is as 
effective at reducing substance use in PTSD patients as it is in 
patients without PTSD, but additional services are needed for treatment 
of psychological problems that are largely unchanged by treatment for 
addiction (J Stud Alcohol. 2006 Mar;67(2):228-35). 
  Question 2. The Institute of Medicine's report ``Treatment of PTSD: 
An Assessment of the Evidence'' released on October 18, 2007 makes a 
number of observations and recommendations on the need for more 
research. Accordingly, is VA prepared to assume the leadership role in 
PTSD research suggested, and does VA have plans to collaborate with the 
full panoply of Federal and private health organizations focused upon 
this area to define outcome measures and coordinate future research? 
  Response. VA, in the continuing role as leader for combat-related 
PTSD research and treatment, has a well-developed plan to collaborate 
with other organizations to define outcome measures and coordinate 
future research. We are particularly proud of the VA scientists who 
contributed to establishing the evidence supporting the effectiveness 
of prolonged-exposure therapy which is a psychotherapeutic approach 
highlighted as the treatment with the highest level of evidence in the 
Institute of Medicine's (IOM) report. We gratefully acknowledge the 
veterans who willingly participated in this scientific research. 
  The IOM report details important research recommendations that will 
guide future PTSD interventional studies in meeting the highest 
accepted standards for randomized controlled trials. The 
recommendations include: (a) standardizing the measures used to 
determine a modality's effectiveness; and (b) analysis and design 
improvements that will lead to more solid conclusions about 
effectiveness of a treatment modality. These issues are best addressed 
within the scientific and clinical communities. Accordingly, VA has 
already begun organizing the working group, which will be convened by 
VA with other Federal research funding agencies early in 2008. Specific 
outcomes from the working group will be guidance for the scientists 
developing PTSD interventional studies, as well as for expert peer 
review panels evaluating research proposals. 
  Question 3. Clearly, VA and the Committee agree upon the important 
role families play in providing care for veterans. As VA invests more 
energy and resources into caring for veterans in their home it is 
imperative to respond to the needs of the family members fulfilling the 
role of care giver. At this time, what services is VHA providing to 
veterans' families? Do you believe these services are being provided 
consistently throughout VA? 
  Response. In areas such as mental health and rehabilitation of 
veterans with multiple wounds from blast injury, for example, support 
of families can be essential to the veteran's rehabilitation, Many VA 
psychologists and social workers are trained and credentialed family 
therapists. Innovative supports for family members include home health 
care services and the use of tele-health approaches to make care of 
wounded or otherwise severely disabled veterans easier for caregivers 
at home. VA is continuing to explore ways to make these services more 
``family friendly'' in particular for families of severely wounded 
veterans who bear a heavy burden of care giving. 
  Family counseling is available at Vet Centers, as needed, in 
connection with readjustment counseling services furnished to a combat 
theatre veteran for his or her psychological or social readjustment 
problems. Providing family counseling services at Vet Centers is not 
time limited and is available as necessary for the veteran's 
readjustment throughout the life of the veteran. The Vet Center program 
has an extensive cadre of licensed clinical social workers, 
psychologists and nurse psychiatric clinical specialists that provide 
family assessments, education, preventive health care information, 
supportive social services, basic counseling and referrals. A number of 
the program's licensed mental health providers also have the 
professional expertise to provide marriage and family counseling. The 
Vet Centers have a cadre of other counselors with master degrees who 
hold a license in marriage and family counseling. 
  The polytrauma system of care (PSC) has developed consistent and 
comprehensive procedures for patients and their families. Families of 
injured servicemembers require particular assistance in making the 
transition from the acute medical setting to a rehabilitation setting, 
including home care. This support encompasses medical care, 
psychosocial support, and logistical support. For psychosocial support, 
the proactive case management system provides ongoing support and 
problem solving in the home community while continually assessing for 
new and emerging problems. Finally, in terms of logistical support, 
each polytrauma rehabilitation center (PRC) team carefully assesses the 
expected needs at discharge for transportation, equipment, home 
modifications, and other such needs and makes arrangements to provide 
the needed services to meet the assessed needs. 
  The Veterans Health Administrationï¿½s Polytraumal Traumatic Brain 
Injury (TBI) system of care is designed to assure lifelong care and 
support for injured soldiers and veterans. As part of this commitment, 
VA assesses the unique needs of all polytraumal TBl patients and, where 
indicated, engages the expertise of the private sector. Depending upon 
the severity of the injury, the needs of veterans with TB] are met 
either through long-term care for veterans who cannot return home and 
require institutional care or through extended care support services 
for veterans who can return to their communities, but not live 
independently. 
  The types of non-institutional care that VA currently provides for 
veterans who can return to their communities, but cannot live 
independently, include: home based primary care (HBPC); adult day 
health care (ADHC); respite cam/purchased skilled home health care; 
homemaker/home health aid (H/HHA); and care coordination/home 
tele-health (CC/HT). 
  Question 4. While I am glad to hear that VA supports S. 2142, I 
remain concerned over VA's record on emergency treatment. VAï¿½s Office 
of General Counsel (OGC), in a memorandum dated November 16, 2005, 
concluded that VA may deny reimbursement for care furnished by a non-VA 
facility when a patient is stabilized, despite the fact that a transfer 
to a VA facility cannot take place due to the lack of an available bed. 
What assurance can you provide the Committee that, in the future, VA 
will take care of all veterans eligible for this benefit? 
  Response. Although VA makes every effort to accept transfer of a 
stabilized patient as soon as possible, the Departmentï¿½s current 
interpretation of regulations, as stated in the November 16, 2005 GGC 
memorandum, does not allow VA to provide reimbursement or payment for 
the non-VA hospital care expenses that are incurred while the 
stabilized patient is awaiting transfer to VA care. 
  As VA has testified on the Hill, VA fully supports S. 2142, which, in 
general, would amend VA's statutory authority to reimburse or pay for 
emergency treatment furnished by a non-VA provider when the veteran is 
stabilized and awaiting transfer to VA. Prior to this bill's 
introduction, VA had independently decided to amend current regulations 
to implement an alternate, valid interpretation of VA's existing 
statutory authority that would achieve the same overall goal as the 
pending legislation. Please note, however, that those proposed 
regulation changes are only in the very early stages of drafting and 
still subject to all the procedures and requirements of the 
Administrative Procedures Act. But this beginning effort should make 
clear that VA and the Congress are, indeed, of the same mind in 
attempting to ensure a stabilized veteran in need of continued 
hospitalization is not penalized (by incurring personal financial 
liability for the costs of the continued care) due to VAï¿½s inability 
to immediately effect a transfer of the patient to a Department 
facility. 
  Question 5. Your prepared testimony described S. 2160 as 
``superfluous and duplicative'' of VA's current efforts on pain care. 
However, other witnesses at the hearing raised a number of concerns 
over the adequacy of VA's current efforts. I share in the concern over 
the lack of uniformity and the apparent variance in the quality of pain 
care services available at different facilities. Specifically, I 
question whether all veterans, including those in rural areas, are 
receiving an adequate level of pain care services? 
  Response. VA has made pain management a national priority and 
continues to work aggressively to assure timely access to the highest 
quality pain care for all veterans seen at VA healthcare facilities, 
including access in more remote, rural areas. Assuring all veterans 
(including those returning from Afghanistan and Iraq and those who have 
experienced polytrauma) are provided immediate and appropriate access 
to effective pain care, is a top priority for VA. 
  VA implemented a National Pain Management Strategy in 1998 and 
published a directive on pain management in 2003 to promote a 
system-wide approach to pain management. Several publications document 
the broad successes of this strategy. Of particular note, external peer 
review data document that routine screening for the presence and 
intensity of pain, pain plans of care, and reassessment of the 
effectiveness of the interventions occur with consistency across all VA 
settings of care. 
  Extensive educational efforts have been ongoing for the past several 
years to support the development of provider competency in the area of 
pain management, including national, Veterans Integrated Service 
Network (VISN), and facility educational conferences, monthly 
educational teleconferences, a national pain management website, 
dissemination of evidence-based information letters and toolkits on 
pain assessment and management. Practice guidelines have been developed 
and disseminated to promote safe and effective chronic opioid therapy, 
post-operative pain care, and management of low back pain. Patient and 
family educational resources have been developed and disseminated. VA's 
support for basic science and clinical research on pain and pain 
management has grown by 500 percent over the past 5 years. 
  VA remains committed to ensuring that quality pain care services are 
available to all veterans receiving care through the Department. 
  Question 6. Regarding S. 2160, does providing a statutory basis for 
VA's pain initiative cause a problem for the Department? 
  Response. Because pain management is already a subject of system-wide 
attention in VA, statutorily mandating a pain initiative is not 
necessary. Creating fenced research centers and legislatively mandating 
specific clinical activities will limit the ability of the Department 
to adjust health care allocations in response to changes in health care 
needs. 
  Question 7. Is VA prepared for the anticipated increase in veterans 
suffering from chronic pain, especially those who are suffering with 
polytrauama? 
  Response. Yes. VA is already engaged in numerous new initiatives 
designed to build on prior successes and to further improve consistency 
of pain care for veterans. 
  For example, VA now has a revised computerized pain assessment and 
reassessment polytrauma template/reminder system, which is currently 
being implemented in two of the four Polytrauma Rehabilitation Centers 
prior to more widespread dissemination. Also, there are multiple 
research and clinical programs underway to address pain in patients 
with PTSD or TBI. Finally, a multi-pronged, multi-disciplinary project 
to enhance the safe and effective use of opioid medications for pain 
has recently begun. 
  Chairman AKAKA. Mahalo. Thank you very much, Dr. Kussman. 
  Because of time, I am going to try to move this along. I was just 
notified that we expect a number of votes beginning at 11. So as a 
result, I am going to ask you just one question and I will ask the 
other members, as well. 
  Dr. Kussman, you testified that you do not support the provisions 
of S. 2162 but that you do support the goals and intentions 
of this mental health legislation. So to be clear, there is agreement 
that there is a demonstrated need for changes in mental health 
services. However, Congress has yet to receive the draft legislation 
from VA regarding improvements to mental health. Do you believe 
that there are no deficiencies in VA mental health services and 
that you have all the legal tools available to reach all veterans in 
need? 
  Dr. KUSSMAN. Mr. Chairman, thank you for the question and let me try 
to be very clear with this. I never would suggest that we are perfect. 
I would never suggest that we donï¿½t need to improve. That is what we 
do. That is why we developed our Mental Health Strategic Plan. That is 
why we have all the programs that we do, and those are viable growing, 
building programs. 
  What I was saying is that I believe that we do need to continue 
to improve. I do not believe that there are any legislative impediments 
for us to continue to improve and I donï¿½t think that the legislation 
is needed and that is why we havenï¿½t put any legislation 
forward. I believe we already have the ability, legally or otherwise, 
to provide good care for our veterans. 
  Chairman AKAKA. Thank you, Dr. Kussman. I will submit my other 
questions to you and call on Senator Burr for his questions. 
  Senator BURR. Thank you, Mr. Chairman. I will be brief, as well. 
  Dr. Kussman, specifically the pain care legislation. Advocates 
believe, and I think with good reason, that there are inconsistencies 
within the VA relative to the pain care and how it varies from location 
to location. In some cases, it is good. In others, it is not as good. 
Do you agree with the view that the delivery of pain care is 
inconsistent across the system, and if not this approach, what 
suggestions do you have to bring that consistency? 
  Dr. KUSSMAN. Thank you, Senator Burr. I would never suggest that, 
whether it is pain care or others, that there isn't potential for 
inconsistency around our system. We are a large system with 1,400 sites 
of care. I believe that if we are not providing what we say we are 
providing and there are inconsistencies or inappropriate or inadequate 
care, that is my job and the VHAï¿½s job to be sure that that is being 
done, and we would be happy to meet with advocacy groups from wherever 
or Members of the Committee to determine what those inconsistencies 
are. 
  Pain management is a very important thing for us, as you know, and 
that is why we set up our standard in 2003. We have a Committee that 
meets regularly to look at what we are doing. We are developing 
performance standards to ensure that there is consistent delivery of 
care. 
  We are reviewed regularly by this. This is one of the tenets of the 
Joint Commission on Health Care Organizations. They always come and 
look at whether you are in pain. Every time I go to the doctor, they 
ask me, ``Are you in pain at this time?'' It is part of the 
introductory evaluation. I keep asking, what kind of pain are you 
talking about, physical, mental, or whatever kind of pain, not to make 
light of what we are talking about. 
  But I think that if we are not doing the job and we have 
inconsistencies or inadequacies in what we are doing, it is my job to 
fix it and that we will look aggressively on that and work with the 
advocacy groups. I donï¿½t think that the legislation itself will solve 
that. 
  Senator BURR. Mr. Chairman, I am going to hold myself to one 
question, but I also want to make this statement relative to S. 2162, 
given the nature of your last answer and you will hold yourself to what 
is proven. The Institute of Medicine found that the literature that 
existed as it related to the Veterans Affairs process on PTSD and 
co-morbidity conditions, such as anxiety, substance abuse, and 
depression along with PTSD, that the literature was uninformative. 
  So I heard your objection to S. 2162. We have an independent IOM 
study that suggested there are deficiencies. I will hold you to exactly 
the answer you gave me on the last one. If that is, in fact, an 
accurate assessment by IOM, then I would hope you would make the 
correct changes. 
  Dr. KUSSMAN. Senator Burr--can I answer that question? Are you asking 
me something? 
  Senator BURR. It was not in the form of a question, so I am going 
to let the Chairman control this. 
  Dr. KUSSMAN. Can I have the opportunity to respond? 
  Chairman AKAKA. If it is brief. 
  Dr. KUSSMAN. I will try to be brief, although everybody says I talk 
too much. But we chartered the study. It was done by the VHA asking the 
IOM to look at what we were doing. I believe what the IOM said was that 
the literatureï¿½not just the VHA literature, only 10 of the 50 studies 
that they have looked at were VHA studies, they looked at the whole 
country's studies on mental health, particularly PTSD. And what they 
said was there are gaps in the adequacy and the peer review of these 
studies, and they didn't suggest that the treatment we were doing was 
inadequate. They just said that the outcomes of the studies couldn't 
prove that it was adequate, but they weren't suggesting what we were 
doing didn't work. The only one that they said that there was good 
scientific study was a study done by us with the immersion and 
cognitive therapy. But we are doing studies already to get better 
results, particularly with drugs and other therapy, on PTSD and 
substance abuse. So it is already going on. Thank you, sir. 
  Chairman AKAKA. Thank you. Senator Murray? 
  Senator MURRAY. Thank you very much, Mr. Chairman. 
  Dr. Kussman, while you are here, I wanted to ask you, I saw an 
article from the Charlotte Observer that was out recently that was 
really disconcerting about wait times for veterans and it said that 
most VA hospitals showed lags in delivering outpatient care for serious 
problems. And according to that newspaperï¿½s analysis, 24 percent of 
appointments nationwide for Traumatic Brain Injury care exceeded the 
30-day mark last summer. At the Salisbury VA Hospital, 61 percent of 
appointments for the seriously wounded were scheduled more than 30 days 
out of the summer, one of the worst records nationwide. And at the 
Charleston VA in South Carolina, 13 of 14 patients slated to be seen 
for brain injury waited for more than a month. 
  I was really discouraged to see this and I was even more discouraged 
to see that the VA's response to that report was really attacking their 
own data, saying that the reports can't be used to judge service 
because they don't show all appointments. So I am compelled to ask you, 
why is the VA spending money on these reports if that is the case? 
  Dr. KUSSMAN. Senator Murray, thank you for the question. As you and I 
have talked before, waiting times is a very important issue to me. I 
have been concerned for a long time about what the information I get 
and what is perceived and real out there. 
  We believe and have responded to the newspaper and had dialogue 
with them greatly, we believe that their interpretation of the 
data did not reflect what is going on. But it is a very--complex 
issue and I will be happy to--
  Senator MURRAY. Why doesnï¿½t it reflect what is going on? 
  Dr. KUSSMAN. Because we believe that there were snapshots in time 
and did not reflect the way that the data is accurately collected and 
what it reflected in the true waiting times for people. But I will be 
happy to come and talk to you about that-- 
  Senator MURRAY. Well, let me ask--
  Dr. KUSSMAN.ï¿½but if I could finish, just for a second, as you know, 
these are very important things, whether waiting times for TBI or 
anything else that we are doing. The issue of the electronic wait 
list, we have pretty much eliminated. Those were things that came up 
early on about the number of people who couldnï¿½t even get an 
appointment to be seen, and I believe that that number now is around 
200 people systemwide. 
  But because of all these issues related to wait times, I have 
contracted with a group to look at our whole wait times measure to find 
out and tell me whether there are inadequacies or breakdowns in how we 
are collecting the data, because I have no interest, as you know--I am 
a veteran and a retiree myself--to come up and tell you that data is 
not accurate. 
  Senator MURRAY. So you canï¿½t tell us right now how long it actually 
takes veterans to see a doctor, not just schedule an appointment 
but, actually see a doctor? 
  Dr. KUSSMAN. Yes, I can, and I donï¿½t believe that the numbers 
that were used by the Charlotte reflect the accurate numbers and 
we will be happy to get that to you. 
  Senator MURRAY. What do you think that number is? 
  Dr. KUSSMAN. I believe that, as we have reported, 95 percent of our 
patients get their appointment within 30 days of when they want it or 
was clinically appropriate. 
  Senator MURRAY. Can you tell this Committee how long wait times are 
for different generations of veterans, for different priority groups, 
for different types of injuries or illnesses? Do you have that 
information? 
  Dr. KUSSMAN. We do have a breakout, and I will have to get it to you, 
for OIF/OEF, but I donï¿½t think we have it by age group, but I will have 
to get back to you on that. 
  Senator MURRAY. OK. Can you give us today what the wait times are? 
  Dr. KUSSMAN. For? 
  Senator MURRAY. For all veterans. Can you tell us what the wait time 
is? 
  Dr. KUSSMAN. As I reported, we believe on the basis of the data that 
we have, 95 percent of the 39 million appointments that we see every 
years are done within the 30-day expectation. These are not urgent or 
emergency appointments, but routine appointments and things for 
veterans within 30 days of when they ask for it. 
  Senator MURRAY. Can you give me a reason why the Charlotte Observer's 
information is so different? 
  Dr. KUSSMAN. I will have to get back to you on that. I think it is a 
very involved issue of how they interpret the data versus snapshots in 
time versus continuum, but we have tried to work with the Charlotte and 
other people to get an accurate assessment. 
  Senator MURRAY. You can't give me a couple sentences, any view that 
might make that real for us? 
  Dr. KUSSMAN. As I said, they used a snapshot in time, not a 
continuum, and I believe that is a fundamental problem with that. But I 
will be happy to get the subject matter experts to talk to you about 
what the differences are. 
  Senator MURRAY. What I would like you to do is give it to this 
Committee, because I believe that--
  Dr. KUSSMAN. I would be happy to do that. 
  Senator MURRAY.--We all have a very deep concern about the 
wait times, and it is not just a newspaper article. We continue to hear 
that from our veterans. They donï¿½t care whether they are a snapshot or 
a continuum. They actually care that they are waiting a very long time, 
and it is deeply disconcerting when we--
  Dr. KUSSMAN. And as you know--
  Senator MURRAY.--continue to hear this and we continue to see it. 
  Dr. KUSSMAN. It is disconcerting to me, too, and that is why I said 
we have contracted with somebody to come in and do an objective 
assessment of how we are trying to collect data on wait times and 
identify any glitches in how we do our business. 
  Senator MURRAY. OK. Mr. Chairman, I am compelled to ask, as well. We 
have been 3 months without a Secretary or even a nominee for the VA. I 
am beginning to hear from a lot of veterans who are very, very 
concerned that a lack of a nominee sent to the Senate signals that the 
administration doesn't have a priority for veterans, at a time when we 
are at war and we know we have issues with wait times and mental health 
problems and all the other things this Committee has been discussing. 
Dr. Kussman, do you have any idea why we have not had a nominee sent 
over for the Secretary of the VA yet? 
  Dr. KUSSMAN. No, Senator, I don't, but I can assure you that we 
are still doing our job to take care of veterans. 
  Senator MURRAY. I know everybody is working their hardest, but we 
need somebody at the top that is accountable, and whoever is listening 
out there, we need an independent, someone who is going to stand up for 
our veterans when we are at a time of war, and I hope that we get an  
administration soon that will take this as a priority, Mr. Chairman. 
  And just really quickly, on the legislation that we are talking about 
today, I wanted to ask you about Senator Craig's and my bill on the 
TBI-induced epilepsy. Dr. John Booss, who is a former Director of 
Neurology at the VA, testified before this Committee in May that there 
would be a dramatic increase in epilepsy due to TBI and that the VA has 
no national plan to cover it. Does the VA anticipate an increase in the 
number of veterans that develop epilepsy as a result of TBI? 
  Dr. KUSSMAN. Senator, I know John Booss very well, obviously, 
and I have not talked to him. I believe that the literature that exists 
says that 53 percent of people with penetrating wounds of the head, 
severe TBI, as we would call it, have an increased incidence of--they 
will develop epilepsy 53 percent of the time after suffering a 
penetrating wound. 
  Senator MURRAY. So more than half the time? 
  Dr. KUSSMAN. With a penetrating wound. I think everybody understands 
that and we are watching those people very closely. As you know, these 
are the ones who transfer from the military health system to our 
polytrauma centers. There have been about 413 of them that have been 
transferred. Everybody acknowledges and knows that any time there is a 
penetrating wound to the head, there is an increased incidence of 
seizure disorder and--
  Senator MURRAY. Just so I understand, there are 413 with penetrating 
wounds? 
  Dr. KUSSMAN. With severe TBI. I donï¿½t know the number of penetrating 
wounds versus severe non-penetrating wounds. 
  Senator MURRAY. Do you know how many people have come into the VA 
with Traumatic Brain Injury at this time? 
  Dr. KUSSMAN. Well, if you want to talk about the full spectrum of 
TBI, because it is not all the same, as you know, the mild to moderate 
TBI is one that is hard to diagnose and we have in place a screening 
mechanism to try to identify those people because that is very 
important to us to develop the registries and follow people because it 
appears with mild to moderate, the incidence of seizure disorder or 
long-term sequelae is much less than it is for the more severe, the 
moderate to severe TBI. But the literature doesn't help us with that 
very much and so we need to put in place research and longitudinal 
studies, good epidemiologic studies to follow these people. 
  Senator MURRAY. Is that what you have done? 
  Dr. KUSSMAN. We are doing that, yes. 
  Senator MURRAY. And do you know how many people that is? 
  Dr. KUSSMAN. I would have to--again, we are screening everybody and I 
don't have the recent data of how many people screened positive. 
  Senator MURRAY. For any TBI, severe, mild--
  Dr. KUSSMAN. Yes, that is correct. 
  Senator MURRAY. When would we be able to get that? 
  Dr. KUSSMAN. As soon as I have that data, I will be happy to give it 
to you. 
  Senator MURRAY. Thank you so much, Mr. Chairman. 
  Chairman Akaka. Thank you very much, Senator Murray. 
  Senator ISAKSON? 
  Senator ISAKSON. I will be very brief. I really have one question. 
You know, in all my experience on this Committee, my travels to Iraq, 
and my visits to veterans' hospitals, I can't remember a complaint 
about the quality of care the physicians render or the facilities do. 
The complaints generally--not generally, almost always involve 
accessibility, appointments, and time. 

  The example I used in my opening remarks about Augusta's Uptown 
facility and the Eisenhower Medical Center in Augusta, they 
created a seamless transition which solved a lot of those problems. 
In fact, Sergeant Harris that I mentioned whose TBI was moderate 
to mild, as you put it, was actually corrected and she went back 
into active duty, which is an example of that seamless transition 
and no skip in quality or accessibility of service. 
  Now, I know you have veterans all over the country and there 
are not a lot of cities that have two, a veteransï¿½ hospital and a 
military hospital, but there are a number, San Antonio and others 
around the country. Are you all working on some of those innovations 
like what took place in Augusta to replicate them around the 
country? 
  Dr. KUSSMAN. Sir, this is one of the most important things for 
us, is to be sure that both severe and other injured veterans, 
servicemembers, come to us with a minimum or none, no complications 
of the bureaucracies. I believe we put in place a very significant 
infrastructure with VA benefits counselors and social workers 
at the major military treatment facilities, military people at our 
facilities, and we areï¿½it will never be perfect because things happen, 
but I believe the infrastructure is there to do exactly what you are 
describing in Augusta throughout the country. 
  Senator ISAKSON. Thank you, Mr. Chairman. 
  Chairman AKAKA. Thank you very much, Senator Isakson. 
  I want to thank our first panel very much for being here. We will 
place in the record further questions that we have for you to respond 
to. I want to thank you for your service. We are looking forward 
to working together to try to improve it throughout our country. The 
signs are beginning to show where there is strain and we need to 
correct these. So we look forward to continuing to work with you. Thank 
you. 
  Dr. KUSSMAN. Mahalo, Mr. Chairman. 
  Chairman AKAKA. Mahalo. 
  I want to introduce our second panel and extend a warm aloha and 
welcome to the second panel. I want you to know that I appreciate each 
of you being here today and look forward to your testimony. 
  First, I welcome Carl Blake. Mr. Blake is the National Legislative 
Director for Paralyzed Veterans of America. 
  I welcome Joy Ilem. Ms. Ilem is the Assistant National Legislative 
Director for Disabled American Veterans. 
  I also welcome Brenda Murdough, who is a registered nurse and holds a 
Masters of Science in Nursing. She is the Coordinator of the 
Military/Veterans Initiative of the American Pain Foundation. 
  I also welcome Dr. Brien Smith. Dr. Smith is Director of the Epilepsy 
Monitoring Unit at Henry Ford Hospital in Detroit, Michigan. 
  Finally, I welcome Constance Walker. She is a retired Navy Captain 
and is the President of the Southern Maryland Chapter of the National 
Alliance on Mental Illness. She also serves on the Maryland Governor's 
Task Force on Improving State Programs directed at Iraq and Afghanistan 
veterans and their families. 
  Each of your statements will appear in the record of today's hearing 
and I ask that you limit your direct testimony to no more than 5 
minutes so that we have time for questions. 
  Mr. Blake, will you please begin. 

               STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE 
                 DIRECTOR, PARALYZED VETERANS OF AMERICA 

  Mr. BLAKE. Chairman Akaka, Ranking Member Burr, and Members of the 
Committee. I would like to thank you on behalf of PVA for the 
opportunity to testify today. In the interest of time, I will keep my 
statement as short as possible. 
  PVA supports the provisions of S. 38 that direct the Secretary to 
establish a program for peer support and counseling, readjustment 
counseling, and mental health services. We particularly believe in the 
importance of peer counseling in the rehabilitation and readjustment 
process. This is something that PVA as an organization does in all of 
the Spinal Cord Injury Centers around the country. Every PVA chapter 
designates individual members to pair up with the newly injured 
veterans to help them get through the early stages of recovery and 
beyond. 
  PVA principally supports S. 2004, a bill that would create six 
Epilepsy Centers of Excellence within the VA health care system. Much 
like the MS Centers and Parkinsonï¿½s Disease Centers of Excellence 
permanently authorized last year, this proposal recognizes the 
successful strategy of the Veterans Health Administration to focus its 
systemwide service and research expertise on a critical care segment of 
the veteran population. 
  PVA generally supports the provisions of S. 2142, the Veterans 
Emergency Care Fairness Act, as the legislation is in accordance with 
the recommendations of the Independent Budget for FY 2008. However, we 
remain concerned about some of the eligibility criteria that determine 
what veterans are eligible for this reimbursement. In accordance with 
the IB for fiscal year 2008, we believe that the requirement that a 
veteran must have received care within the past 24 months should be 
eliminated. Furthermore, we believe that the VA should establish a 
policy allowing all veterans enrolled in the health care system to be 
eligible for emergency services at any medical facility, whether the VA 
or private facility, when they exhibit symptoms that a reasonable 
person would consider a medical emergency. 
  First, I would like to say that PVA generally supports S. 2162, which 
improves services provided by the VA to veterans with PTSD and 
substance use problems. However, PVA does remain concerned with the 
pilot program outlined in Title 2 of the bill. While we certainly 
support the emphasis placed on peer counseling and outreach, as 
expressed in our written statement earlier, we maintain our concerns 
about contract services with community mental health centers. The VA 
should be able to provide the services described in this legislation 
through judicious application of its already existing fee-basis 
authority. 
  We do, however, appreciate the emphasis on ensuring that the non-VA 
facilities are compliant with VA standards, particularly through 
additional training managed specifically by the VA, a requirement that 
is also included in S. 38. However, we still believe that at this time, 
the energy and money that would be expended here could best be used to 
upgrade the VA system itself. 
  Mr. Chairman and Members of the Committee, PVA would once again like 
to thank you for the opportunity to testify and I would be happy to 
answer any questions that you might have. 
  [The prepared statement of Mr. Blake follows:] 

    PREPARED STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR, 
                      PARALYZED VETERANS OF AMERICA 

  Chairman Akaka, Ranking Member Burr, and members of the Committee, on 
behalf of Paralyzed Veterans of America (PVA) I would like to thank you 
for the opportunity to testify today on the proposed health care 
legislation. The scope of issues being considered here today is very 
broad. We appreciate the Committee taking the time to address these 
important issues, and we hope that out of this process meaningful 
legislation will be approved to best benefit veterans. 

            S. 38, THE ``VETERANS MENTAL HEALTH AND OUTREACH ACT''

  PVA supports the provisions of this legislation that directs the 
Secretary to establish a program for peer support and counseling, 
readjustment counseling, and mental health services. We particularly 
believe in the importance of peer counseling in the rehabilitation and 
readjustment process. This is something that PVA as an organization 
does in all of the Spinal Cord Injury Centers around the country. Every 
PVA chapter designates individual members to pair up with newly injured 
veterans to help them get through the early stages of their recovery. I 
know first hand that being able to talk to someone who has experienced 
what you have experienced and has dealt with the same problems you are 
dealing with can help you overcome bouts of depression, sadness, and 
anger as you first come to grips with your condition. The peer 
counselor serves as a motivator to get you moving in the right 
direction. I credit my own peer counselor while I went through spinal 
cord rehabilitation with driving me to help other veterans. 
  PVA opposes the provisions of this legislation which would authorize 
VA to contract with community mental health centers to meet the needs 
of veterans dealing with mental illnesses. As we testified earlier this 
year, we oppose any effort to allow the VA to contract out care when it 
can do a better and more cost effective job in its own system. 
Furthermore, by allowing the VA to send these veterans out of the 
system to receive their care, it effectively relieves itself of the 
obligation it has to these men and women. The VA must be appropriated 
adequate funding and it must be provided in a timely manner if it is 
going to have any chance of meeting these veterans' needs. 
  Moreover, Congress must continue to conduct aggressive oversight to 
ensure that funding specifically allocated for mental health 
initiatives is properly spent. As explained in the Government 
Accountability Office (GAO) report of November 2006, the VA did not 
allocate all of the funding it planned to commit in fiscal year 2005 
for new mental health initiatives, nor did it spend all of the funds 
planned for fiscal year 2006. VA must be held accountable to ensure 
that it lives up to the goals established in its National Mental Health 
Strategic Plan. Until such time as the VA meets these goals, the burden 
for mental health care should not be shifted to the community. 
  PVA does support the provision of this legislation which would extend 
the eligibility for hospital care, medical services, and nursing home 
care from 2 to 5 years for a veteran who served on active duty in a 
theater of combat operations during a period of war after the Persian 
Gulf War or in combat against a hostile force after November 11, 1998. 
This provision has proven especially important to the men and women who 
have recently served in Iraq and Afghanistan and have exited military 
service. 

                S. 2004, EPILEPSY CENTERS OF EXCELLENCE 
  
  PVA principally supports S. 2004, a bill that would create six 
Epilepsy Centers of Excellence within the VA health care system. Much 
like the Multiple Sclerosis (MS) and Parkinson's disease Centers of 
Excellence permanently authorized last year, this proposal recognizes 
the successful strategy of the Veterans Health Administration (VHA) to 
focus its system-wide service and research expertise on a critical care 
segment of the veteran population. The designation of these six Centers 
of Excellence will provide open access to centers engaged in marshaling 
VA expertise in diagnosis, service delivery, research and education. 
Furthermore, these programs will be available across the country 
through the ``hub and spokes'' approach. We also hope that this 
legislation will sow the seeds for broader based research and 
development into Traumatic Brain Injury (TBI), as we believe the same 
concept could be crucial for better treatment for veterans in the 
future. 

           S. 2142, THE ``VETERANS' EMERGENCY CARE FAIRNESS ACT'' 

  PVA generally supports the provisions of S. 2142, the ``Veterans 
Emergency Care Fairness Act,'' as the legislation is in accordance with 
the recommendations of The Independent Budget for FY 2008. However, we 
remain concerned about some of the eligibility criteria that determine 
what veterans are eligible for this reimbursement. In accordance with 
The Independent Budget for FY 2008, we believe that the requirement 
that a veteran must have received care within the past 24 months should 
be eliminated. Furthermore, we believe that the VA should establish a 
policy allowing all veterans enrolled in the health care system to be 
eligible for emergency services at any medical facility, whether at a 
VA or private facility, when they exhibit symptoms that a reasonable 
person would consider a medical emergency. 

             S. 2162, THE ``MENTAL HEALTH IMPROVEMENTS ACT'' 
 
  First, I would like to say that PVA generally supports this proposed 
legislation which improves services provided by the VA to veterans with 
Post-Traumatic Stress Disorder (PTSD) and substance use problems. 
Current research highlights that Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF) combat veterans are at higher risk for 
PTSD and other mental health problems as a result of their military 
experiences. In fact, the most recent research indicates that 25 
percent of OIF/OEF veterans seen at a VA facility have received mental 
health diagnoses. 
  We are pleased with the provisions of Section 102 and 103 of the 
legislation. In fact, The Independent Budget is set to recommend that 
VA provide a full continuum of care for substance use disorders 
including additional screening in all its health care facilities and 
programs--especially primary care. We also believe outpatient 
counseling and pharmacotherapy should be available at all larger VA 
community-based outpatient clinics. Furthermore, short-term outpatient 
counseling including motivational interventions, intensive outpatient 
treatment, residential care for those most severely disabled, 
detoxification services, ongoing aftercare and relapse prevention, self 
help groups, opiate substitution therapies and newer drugs to reduce 
craving, should be included in VAï¿½s overall program for substance abuse 
and prevention. 
  Although we support the creation of PTSD Centers of Excellence 
outlined in Section 105 of the legislation, we wonder whether this step 
is necessary. The VA already maintains a broad network of PTSD 
treatment  centers. Furthermore, in 1989, the VA established the 
National Center for Post-Traumatic Stress Disorder as a focal point to 
promote research into the causes and diagnosis of this disorder, to 
train health care and related personnel in diagnosis and treatment, and 
to serve as an information clearinghouse for professionals. The Center 
offers guidance on the effects of PTSD on family and work, and notes 
treatment modalities and common therapies used to treat the condition. 
This center already functions as a center of excellence. At the very 
least, it should be incorporated into this new network of centers of 
excellence. 
  PVA has some concerns with the pilot program outlined in Title II of 
the bill. While we certainly support the emphasis placed on peer 
counseling and outreach, as expressed in our statement earlier, we 
maintain our concerns about contract services with community health 
centers. The VA should be able to provide the services described in the 
legislation through judicious application of its already existing fee 
basis authority. We do, however, appreciate the emphasis on ensuring 
that the non-VA facilities are compliant with VA standards, 
particularly through additional training managed specifically by the 
VA. 
  While we also support Title III of the legislation regarding research 
into comorbid PTSD and substance use disorder, we wonder if this is 
duplicative with activities already taking place at the National Center 
for PTSD. However, PVA has long supported research initiatives into 
various types of conditions and the treatments associated with them. 
  Finally, we recognize the unique challenge associated with providing 
mental health services to families of veterans. This is an area that 
the VA has had little experience with in the past. Likewise, we see no 
problem with the VA examining the feasibility of providing readjustment 
and transition assistance to veterans and their families. It is 
certainly an issue that has become more apparent as more men and women 
return from conflicts abroad broken and scarred. The impact that this 
has on the veteran and his or her family cannot be overstated. 

                S. 2160, THE ``VETERANS PAIN CARE ACT'' 

  PVA supports the draft legislation that would establish a system-wide 
pain care initiative within the VA. We agree with the finding that 
comprehensive pain care in not consistently provided across the entire 
system. We have seen firsthand the benefits of pain care programs as 
each VA facility that supports a Spinal Cord Injury (SCI) unit also 
maintains a pain care program. Veterans with Spinal Cord Injury know 
all to well the impact that pain, including phantom pain, can have on 
their daily life. The pain care programs that SCI veterans have access 
to have greatly enhanced their rehabilitation and improved their 
quality of life. 
  The one concern we have is the expectation that every facility in the 
VA should have a pain care program. Does this suggest that every 
community-based outpatient clinic (CBOC) should have a similar program? 
This might be an unreasonable expectation. We do support the idea of 
cooperative centers for research and education on pain. The work done 
at these locations can only benefit the provision of pain care services 
throughout the system. 
  Mr. Chairman and Members of the Committee, PVA once again thanks you 
for the opportunity to testify. We look forward to working with you to 
ensure that veterans continue to have access to the best health care 
services in America. 
  I would be happy to answer any questions that you might have. 
  William Carl Blake National Legislative Director Paralyzed Veterans 
of America at PVA's National Office in Washington, D.C. He is 
responsible for the planning, coordination, and implementation of PVA's 
relations with the U.S. Congress and Federal departments and agencies. 
He develops and executes PVA's Washington agenda in areas of budget, 
appropriations, health care, and veterans' benefits issues. He also 
represents PVA to Federal agencies including the Department of Defense, 
Department of Labor, Small Business Administration, and the Office of 
Personnel Management. 
  Carl was raised in Woodford, Virginia. He attended the United States 
Military Academy at West Point, New York. He received a Bachelor of 
Science Degree from the Military Academy in May 1998. 
  Upon graduation from the Military Academy, he was commissioned as a 
Second Lieutenant in the Infantry in the United States Army. He was 
assigned to the 504th Parachute Infantry Regiment (1st Brigade) of the 
82nd Airborne Division at Fort Bragg, North Carolina. He graduated from 
Infantry Officer Basic Course, U.S. Army Ranger School, U.S. Army 
Airborne School, and Air Assault School. His awards include the Army 
Commendation Medal, Expert Infantrymanï¿½s Badge, and German Parachutist 
Badge. Carl retired from the military in October 2000 due to injuries 
suffered during a parachute operation. 
  Carl is a member of the Virginia-Mid-Atlantic chapter of the 
Paralyzed Veterans of America. 
  Carl lives in Fredericksburg, Virginia with his wife Venus, son 
Jonathan and daughter Brooke. 
  Chairman AKAKA. Thank you very much. 
  Ms. ILEM? 
  
                   STATEMENT OF JOY J. ILEM, ASSISTANT, NATIONAL 
                  LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS 

  Ms. ILEM. Mr. Chairman and Members of the Committee, thank you for 
inviting the DAV to testify today at this legislative hearing. In the 
interest of brevity, I will focus my oral remarks on two mental health 
bills being considered by the Committee. 
  S. 38, the Veterans Mental Health Outreach and Access Act of 2007, 
would require VA to establish a VA-contracted peer outreach, peer 
counseling, and mental health program for veterans who served in 
Operations Iraqi and Enduring Freedom who are not adequately served by 
VA. The bill would also authorize members of the immediate families of 
such veterans to receive mental health services to assist in the 
readjustment of the veteran and their family. 
  The final provision in the bill would extend eligibility for VA 
health care services from 2 to 5 years for this group. 
  We appreciate the billï¿½s intent to better serve veterans in rural 
areas, which has historically been a challenge for VA. Although DAV 
believes that VA contract care is an essential tool in providing timely 
access to medical services, we feel strongly that VA should use this 
authority judiciously. 
  Our main concern with this bill is that VA over the past several 
years has received a significant amount of new funding targeted to 
providing better access to mental health services to enrolled veterans. 
  Over the past few years, VA has hired 3,500 new mental health 
providers and established a significant number of new initiatives and 
programs within the system to address the mental health needs of 
enrolled veterans, including OEF/OIF veterans. Before Congress 
authorizes a program such as the one envisioned in S. 38, we recommend 
VA determine a degree of unmet need after it has done as much as 
practical to meet that need directly. Additionally, we point out that 
VA's Office of Rural Health has already been charged with evaluating 
and presenting solutions to address the needs of this population. 
  For these reasons, with the exception of the extension of eligibility 
for health care for combat veterans from 2 to 5 years, we cannot 
support this measure at this time. 
  We have also been asked to comment on S. 2162, the Mental Health Care 
Improvements Act of 2007, a comprehensive bill that focuses on programs 
for treatment of veterans who suffer from both PTSD and substance use 
disorders. This measure would require VA to offer a complete package of 
services for substance use disorders at all VA facilities unless 
specifically exempted. It would also establish six new national Centers 
of Excellence on PTSD and substance use disorders to provide a 
comprehensive inpatient treatment and recovery services, as well as a 
targeted research program in co-morbid PTSD and substance use 
disorders, and a ten-site pilot program for providing specialized 
mental health transition assistance in coordination with veterans 
centers to veterans and their families. 
  Title 2, Section 201 of the measure would authorize a pilot program 
of peer readjustment counseling and other mental health services at 
non-VA community mental health centers for OEF/OIF veterans not 
adequately served by VA. While we support the peer counseling concept, 
we continue to have concerns about contracting with non-VA mental 
health providers for specialized PTSD. While we appreciate the 
Chairman's efforts to address unmet needs of veterans in underserved 
areas, we have the same concerns about this provision that we 
expressed regarding contract care in S. 38. 
  Mr. Chairman, like you, we are concerned that over the past decade, 
VA has drastically reduced its substance use treatment and related 
rehabilitation services and has made little progress in restoring them, 
even in the fact of increased demand for such services from veterans 
returning from current conflicts. There are multiple indications that 
PTSD and readjustment issues in conjunction with the misuse of 
substances will continue to be a significant problem for our newest 
generation of combat veterans, and therefore we agree VA should adopt 
new programs and services to meet these unique needs. 
  We are especially pleased about the provisions in the bill expanding 
mental health services for family members at VA facilities. These 
families of these veterans are suffering, too, and are the core support 
for veterans struggling to rehabilitate and overcome readjustment 
issues related to their military service. We hope at the same time 
previous generations of veterans and their families can also benefit 
from these expanded programs and services. 
  Thus, with the exception of the sections in the bill dealing with 
contracted care, we believe these are very timely provisions and we 
fully support them. 
  For the record, we believe the remaining measures being considered by 
the Committee today would also be beneficial to sick and disabled 
veterans and, therefore, have no objection to their passage, 
specifically S. 2004, which seeks to establish six Epilepsy Centers of 
Excellence within VA, S. 2142, the Veterans Emergency Care Fairness Act 
of 2007, and S. 2160, the Veterans Pain Care Act of 2007. We refer the 
Committee to our written statement for DAV's complete analysis of these 
bills. 
  Mr. Chairman, again, DAV appreciates the opportunity to appear before 
you today to give our testimony and view on these bills and we are 
pleased to answer any questions you may have. Thank you. 
  [The prepared statement of Ms. Ilem follows:] 

     PREPARED STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE, 
                   DIRECTOR OF THE DISABLED AMERICAN VETERANS 

  Mr. Chairman, Ranking Member Burr and other Members of the Committee: 
  Thank you for inviting the Disabled American Veterans (DAV) to testify 
at this important legislative hearing of the Committee on Veterans 
Affairs. DAV is an organization of 1.3 million service-disabled 
veterans, and devotes its energies to rebuilding the lives of disabled 
veterans and their families. 
  You have requested testimony today on five bills primarily focused on 
health care services for veterans under the jurisdiction of the 
Veterans Health Administration, Department of Veterans Affairs (VA). 
This statement submitted for the record reviews our positions on all of 
the proposals before you today. The comments are expressed in numerical 
sequence of the bills, and we offer them for your consideration. 

     S. 38--THE VETERANSï¿½ MENTAL HEALTH OUTREACH AND ACCESS ACT OF 2007 

  S. 38 would require the VA Secretary to establish a VA-contracted 
peer outreach, peer counseling and mental health care program to 
provide readjustment and certain mental health services to veterans who 
served in Operations Iraqi and Enduring Freedom (OIF/OEF), and are not 
adequately served by VA. It would also require VA to train peer 
counselors and professional providers to ensure their cultural 
competency to care for veterans of OIF/OEF, and specifically those who 
live remotely from VA facilities in circumstances in which they have no 
access to direct VA programs. 
  The bill would also authorize, for a 3-year period immediately 
following combat deployment to Iraq and Afghanistan, members of the 
immediate families of such veterans to receive VA services, such as 
orientation and education, support, counseling and mental health 
services, to assist in the readjustment of veterans and their families, 
especially in the case of a veteran who sustained injury or illness 
during military deployment. 
  We appreciate the intent of the bill in serving veterans in rural 
areas, which has historically been a challenge for VA. On a positive 
note, this bill would be consistent with VA's principles to use 
coordinated contract care only when services are unavailable in the 
VA--a firm position that DAV holds. At the same time, the legislation 
would address the needs of the veteranï¿½s immediate family as it relates 
to his or her recovery and would build on the tested concept of having 
peers with similar personal military experiences from which they have 
recovered, to provide outreach and support--an approach that probably 
would increase the likelihood of engaging veterans in readjustment and 
treatment and may provide new vocational rehabilitation options for 
some veterans who provide this counseling. 
  Although DAV believes that VA contract care is an essential tool in 
providing timely access to quality medical care, we feel strongly that 
VA should use this authority judiciously. Current law limits the use of 
VA purchased care to specific instances\1\ so as not to endanger VA 
facilitiesï¿½ ability to maintain a full range of specialized services 
for enrolled veterans and to promote effective, high quality care for 
veterans, especially those disabled in military service and those with 
highly sophisticated health problems such as blindness, amputations, 
spinal cord injury or chronic mental health conditions. 
  Unfortunately, in most cases where VA authorizes care to veterans by 
contract providers, VA has not established a systematic approach to 
monitor that care, consider any alternatives to its high cost, analyze 
patient care outcomes, or even establish patient satisfaction measures. 
In fact, VA knows very little about the care for which it now 
contracts. 
  Any bill that would authorize contract care by VA without addressing 
these concerns would essentially shift medical resources and veterans 
from VA to the private sector, to the detriment of the VA health care 
system and eventually would be deleterious to the interests of sick and 
disabled veterans themselves. DAV could not support this or any similar 
bill without such protections. It is unclear how the services that 
would be authorized by this bill would be triggered and controlled by 
an accountable VA health care professional. Typically, a veteran is 
authorized contract care after VA establishes that it cannot provide a 
particular service or that the veteran is geographically or otherwise 
hampered from access to VA services. A VA health care professional 
makes this determination. Also, legal eligibility determination is a 
necessity to ensure an individual veteran is eligible for VA care. 
  Our main concern with this bill is that VA, over the past several 
years, has received significant new funds targeted to providing better 
mental health services to all veterans. VA has been especially 
concerned about ensuring services to OIF/OEF veterans, particularly 
those who live in rural and remote areas without good access to care. 
VA has developed a national mental health strategic plan, to deploy 
several new programs within all the normal strictures in which the 
system is required to operate. DAV believes VA should rapidly deploy 
those plans and exhaust those program possibilities, and then determine 
the degree of unmet need in rural areas--rather than being required to 
contract out these services before those programs are given a chance to 
materialize. Before Congress authorizes a program such as the one 
envisioned here for rural veterans, we recommend VA determine the 
degree of unmet need after it has done as much as practicable to meet 
that need directly. Since Congress recently enacted legislation that 
established VA's new Office of Rural Health, we believe that office 
should be charged with implementing and managing these matters in 
conjunction with VA's Office of Mental Health Services. 

S. 2004--A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO ESTABLISH NOT 
  LESS THAN SIX EPILEPSY CENTERS OF EXCELLENCE IN THE VETERANS HEALTH 
  ADMINISTRATION OF THE DEPARTMENT OF VETERANS AFFAIRS, AND FOR OTHER 
  PURPOSES. 

  These Centers are intended to function as centers of excellence in 
research, education, and clinical care activities in the diagnosis and 
treatment of epilepsy and include training of medical residents and 
other VA providers to ensure better access to state-of-the art 
treatments throughout the VA health care system. Provisions in the bill 
also include a peer review panel, consisting of experts on epilepsy, 
complex multi-trauma associated with combat injuries, including 
Post-Traumatic Epilepsy, to assess the scientific and clinical merit of 
research and treatment proposals that are submitted to the Centers. 
  While DAV has no adopted resolution from our membership on this 
matter, we have been briefed by professional associations concerned 
about the decline of availability of epilepsy services in the VA. Also, 
literature is emerging to suggest co-morbid epilepsy in veterans with 
Traumatic Brain Injury. Therefore, this is timely legislation to fill a 
real need, and DAV would have no objection to its passage. 

  \1\(1) When VA facilities are incapable of providing necessary care 
to a veteran. (2) When VA facilities are geographically inaccessible to 
a veteran for necessary care. (3) When medical emergency prevents a 
veteran from receiving care in a VA facility. (4) To complete an 
episode of VA care. (5) For certain specialty examinations to assist VA 
in adjudicating disability claims. (6) For the services in VA facilities 
of scarce medical specialists. 

          S. 2142--THE VETERANS EMERGENCY CARE FAIRNESS ACT OF 2007 

  The intent of S. 2142 is to amend Sections 1725 and 1728 of title 38, 
U.S.C., to require the Secretary of Veterans Affairs to reimburse 
veterans receiving emergency treatment in non-VA facilities. In 
addition to applying the prudent layperson definition of ``emergency 
treatment'' under both Sections, the bill intends to clarify the 
current VA practice of denying payment for emergency care provided to a 
veteran by a private facility for any period beyond the date on which 
VA determines the veteran can be safely transferred. Specifically, it 
would amend the definition of reimbursable emergency treatment to 
include the time when VA or other Federal facility does not agree to 
accept a stabilized veteran who is ready for transfer from a non-VA 
facility and the non-VA provider has made reasonable attempts (with 
documentation) to make such transfer. 
  The DAV supports the intent of this bill as outlined above in accord 
with the mandate from our membership and with the recommendations in 
the Independent Budget for Fiscal Year 2008 to improve the 
reimbursement policies for non-VA emergency health care services for 
enrolled veterans. Having consulted with the author of this important 
measure and with pertinent parties, it is our understanding that the 
current language may require additional modification. The DAV thanks 
those involved for their efforts to ensure the improvements to this 
essential benefit as contemplated by this bill is properly implemented. 

               S. 2160--THE VETERANS PAIN CARE ACT OF 2007 

  This measure would amend title 38, U.S.C., to establish a pain care 
initiative in all VA health care facilities. Specifically, it would 
require the Secretary to ensure that all patients receiving treatment 
be assessed for pain at the time of admission or initial treatment and 
periodically thereafter, and that pain care management and treatment, 
including specialty pain management services, are provided as deemed 
clinically appropriate. Pain care initiatives in this measure would be 
required to be established by January 2008 for inpatient care and 
January 2009 for outpatient care service lines. The bill would also 
require the establishment of research centers and training of 
healthcare professionals in assessment, diagnosis, treatment and 
management of acute and chronic pain. 
  There is increasing interest by healthcare providers in the 
specialized field of pain management, and a number of advances in 
medicine and technologies from that interest are benefiting severely 
wounded service personnel and veterans. A recent study of OIF/OEF 
servicemembers receiving treatment in VA Polytrauma Centers found that 
pain is highly prevalent among this group. It also noted in its 
clinical implications that pain should be consistently assessed, 
treated, and regularly documented. The report concluded that polytrauma 
patients are at potential risk for development of chronic pain, and 
that aggressive and multidisciplinary pain management (including 
medical and behavioral specialists) is necessary. The report suggested 
the phenomenon of pain is a new opportunity for VA research in 
evaluating long term outcomes; developing and evaluating valid pain 
assessment measures for the cognitively impaired; and, developing and 
evaluating education or policy initiatives designed to improve the 
consistency of assessment and treatment across the VA continuum of 
care. 
  VA has been a leader in assessment and treatment of pain management; 
having issued a National Pain Management Strategy in 1998 (its current 
iteration is VHA Directive 2003-021). We understand that the overall 
objective of VA's national strategy is to develop a comprehensive, 
multicultural, integrated, system-wide approach to pain management that 
reduces pain and suffering for veterans experiencing acute and chronic 
pain associated with a wide range of illnesses, including terminal 
illness. However, we are concerned that implementation of pain 
management programs has not been consistent throughout VA's nationwide 
health care system. 
  DAV does not have a specific resolution adopted in support of 
establishing a legislated system-wide pain initiative at all VA medical 
facilities, but we believe the goals of the bill are in accord with 
providing high quality, comprehensive health care services to sick and 
disabled veterans and thus, would be strongly supported by our 
membership; therefore; we have no objection to this measure and look 
forward to its enactment. 

             S. 2162--THE MENTAL HEALTH IMPROVEMENTS ACT OF 2007 

  This measure would establish new program requirements and new 
emphases on programs for treatment of Post-Traumatic Stress Disorder 
(PTSD) and substance use disorder--with special regard for the treatment 
of veterans who suffer from comorbid associations of these disorders. 
Sections 102ï¿½104 of the bill would require VA to offer a complete 
package of continuous services for substance use disorders, including: 
counseling; intensive outpatient care; relapse prevention services; 
aftercare; opiate substitution and other pharmaceutical therapies and 
treatments; detoxification and stabilization services; and any other 
services the Secretary deemed necessary, at all VA medical centers and 
community-based outpatient clinics unless specifically exempted. The 
measure would require that treatment is provided concurrently for such 
disorders by a team of providers with appropriate expertise. This 
section describes allocation funding to facilities for these new 
programs, as well as how facilities would apply for such funding. 
  Sections 105 and 106 would require establishment of not less than six 
new National Centers of Excellence on Post-Traumatic Stress Disorder 
and Substance Use Disorder, that provide comprehensive inpatient 
treatment and recovery services for veterans newly diagnosed with both 
 PTSD and a substance use disorder. The bill would require the 
Secretary to establish a process of referral to step-down 
rehabilitation programs at other VA locations from a center of 
excellence, and to conduct a review and report on all of VA's 
residential mental health care facilities, with guidance on required 
data elements in the report. 
  Title II--Section 201 of the measure seeks to make mental health 
accessibility enhancements. This provision would require the 
establishment of a pilot program of peer outreach, peer support, 
readjustment counseling and other mental health services for OIF/OEF 
veterans who reside in rural areas and do not have adequate access 
through VA. Services would be provided using community mental health 
centers (grantee organizations of the Substance Abuse and Mental Health 
Services Administration, Department of Health and Human Services), and 
facilities of the Indian Health Service, through cooperative agreements 
or contracts. This pilot program would be carried out in a minimum of 
two Veterans Integrated Service Networks (VISNs) for a 3-year period. 
Provisions would require the Secretary to carry out a training program 
for contracted mental health personnel and peer counselors charged to 
carry out these services for OIF/OEF veterans. All contractors would be 
required to comply with applicable protocols of the Department and 
provide, on an annual basis, specified clinical and demographic 
information including the number of veterans served. 
  Title III--Section 301 of the bill would establish a new, targeted 
research program in co-morbid PTSD and substance use disorders, and 
would authorize $2 million annually to carry out this program, through 
VA's National Center for PTSD. 
  Title IV--Sections 401 and 402 of the measure seek to clarify 
authority for VA to provide mental health services to families of 
veterans coping with readjustment issues. The bill would establish a 
ten-site pilot program for providing specialized transition assistance 
in Vet Centers to veterans and their families, and would authorize $3 
million to be used for this purpose. The bill would require a number of 
reports on all these new authorities. 
  Current research highlights that OEF/OIF combat veterans are at 
higher risk for PTSD and other mental health problems, including 
substance use disorder, as a result of their military experiences. Mr. 
Chairman, like you, we are concerned that over the past decade VA has 
drastically reduced its substance abuse treatment and related 
rehabilitation services, and has made little progress in restoring 
them--even in the face of increased demand from veterans returning from 
these current conflicts. There are multiple indications that PTSD and 
readjustment issues, in conjunction with the misuse of substances will 
continue to be a significant problem for our newest generation of 
combat veterans and therefore; we need to adapt new programs and 
services to meet their unique needs. We are especially pleased with the 
provisions pertaining to mental health services for family members. The 
families of these veterans are suffering too and are the core support 
for veterans struggling to rehabilitate and overcome readjustment 
issues related to their military service. We hope at the same time 
previous generations of veterans and their families can also benefit 
from these newly proposed programs and services. 
  Although DAV has no approved resolution calling for a joint treatment 
program for PTSD and substance use disorders from our membership, we 
believe the overall goals of the bill are in accord with providing high 
quality, comprehensive health care services to sick and disabled 
veterans. Thus, with only two exceptions, stated below, we believe 
these are very timely provisions, and we fully support them. 
  It is our understanding that the National Center for PTSD is focused 
primarily on research in PTSD, while your intentions for these six new 
centers would focus them on direct clinical care, as regional referral 
specialty centers in the care of these co-morbid conditions. Should 
this bill be enacted, we hope that the seven facilities would work in 
tandem to advance both the clinical and research fields associated with 
PTSD and substance use disorders. An additional concern relates to 
Title II Section 201 of the billï¿½while we support the peer counseling 
concept we continue to have concerns about contracting with non-VA 
providers for specialized PTSD treatment. While we appreciate the 
Chairman's efforts to address unmet needs in underserved areas we refer 
you to the comments we provided on S. 38, the Veterans' Mental Health 
Outreach and Access Act of 2007. We would value the opportunity to work 
with the Committee staff to make further adjustments to the provisions 
in this section of the bill so that we can fully support this 
well-intended measure. 
  Mr. Chairman, again, DAV appreciates the opportunity to appear before 
you today and present our views these bills. I will be pleased to 
respond to any questions you or other Committee Members may have. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY JOY ILEM, ASSISTANT, 
  NATIONAL LEGISLATIVE DIRECTOR OF THE DISABLED AMERICAN VETERANS TO 
  THE COMMITTEE ON VETERANSï¿½ AFFAIRS 

  Question. During our hearing DAV expressed concern about section 201 
of S. 2162, related to a proposed pilot program to develop peer support 
and outreach for OEF/OIF veterans living in rural areas and for 
readjustment counseling at community mental health centers and the 
Indian Health Service. You indicated in your statement that DAV is not 
opposed to contracting for mental health services when such services 
are not available from VA, and that VA already has sufficient authority 
to contract for care. You also expressed concern about maintaining the 
quality of care that would be provided by non-VA providers under this 
new authority. Our bill includes a provision to ensure VA would provide 
training to qualify contractors to address this challenge. 
  Given these provisions of the bill, why do you believe that quality of 
care would not be protected for these rural veterans? 
  Response. Mr. Chairman, we appreciate the opportunity to clarify our 
position on your bill. First and foremost, DAV believes that veterans 
deserve the highest quality health care available to them--whether 
provided by VA, purchased on a fee basis, or through contractors under 
VA auspices. Because of its long history in providing effective 
readjustment counseling services that are culturally sensitive to 
veterans and their unique military combat experiences, unquestionably 
VA is the optimum source for readjustment services for our newest 
veterans. However, when VA is not able to meet demand for services for 
legitimate reasons, it is clear that VA must use other options. As DAV 
testified, VA already has ample authority to provide services through 
fee basis and contract care programs. The question is how VA should 
provide that contract care. 
  There have been disturbing reports that some private mental health 
providers are not only insensitive to the veteran culture but have 
attempted to assign blame to veterans for having been a part of the 
military establishment, and thus are culpable for their own mental 
health problems induced by combat exposure during that service. The 
Committee bill would require that participating community mental health 
clinics (CMHC) and the Indian Health Service (IHS) receive VA provided 
culturally sensitive, relevant clinical training in order to deliver 
effective post deployment readjustment counseling and treatment for 
Post Traumatic Stress Disorder (PTSD); thus, we believe the Committee 
is acknowledging there may be deficits in the private mental health 
community and the IHS in treating veterans for military-related 
readjustment disorders. 
  As stated in our testimony, DAV wants to ensure that all veterans 
receiving care from VA or through its fee basis or contract programs 
are treated in accordance with VA's standards. In its 2001 report, 
``Crossing the Quality Chasm: A New Health Care System for the 21st 
Century,'' the Institute of Medicine (IOM) put forward six aims that 
now underpin the standard of care for U.S. providers. The IOM aims are 
that health care will be safe (avoiding errors and injury), effective 
(based on the best scientific knowledge), patient-centered (respectful 
of, and responsive to patient preferences, needs and values), timely 
(reduced waiting time and harmful delay), efficient (avoiding waste), 
and equitable (unvarying, based on race, ethnicity, gender, geography, 
or socioeconomic status). VA embraces the IOM aims and therefore should 
manage rural veterans' health care issues in a way that addresses all 
of the aims collectively. 
  DAV believes that while section 201 of S. 2162 would address 
timeliness and equity of mental health services, two important IOM 
aims, it would do so to the potential detriment of the others. In fact, 
without evidence that CMHCs have relevant capacity, it is questionable 
whether even the timeliness or access goals of this legislation can be 
achieved. DAV understands that several years ago VA tried to explore a 
partnership with these clinics, but it appeared that most CMHCs had no 
excess capacity. In addition, it is unclear if these clinics would be 
able to provide the range of post-deployment mental health services 
that new veterans may require. Specifically, these veterans may need 
services for depression; stress and anxiety reactions, including PTSD; 
individual or group counseling; specialized intensive outpatient 
treatment for severe PTSD--including cognitive behavioral best 
practices; services for relationship problems (including marital and 
family counseling); psychopharmacology services; and, substance-use 
disorder interventions and treatment, including initial assessment and 
referral, brief intervention and/or motivational counseling, 
traditional outpatient counseling and intensive outpatient 
substance-use disorder care. DAV is not confident they will be able to 
rise to such a formidable challenge, given the small population that 
would be assigned to each CMHC and the amount of training and other 
resources that would be required to prepare them for this patient care 
workload. 
  VA holds itself out to veterans to be their health care system, a 
direct provider of care. DAV observes, like the Committee, that VA 
currently lacks an integrated approach to address the unique health 
care challenges of OEF/OIF veterans living in rural, remote and 
frontier areas. To remedy this gap, VA should identify an effective and 
creative approach to make health careï¿½including mental health 
care--available to our newest generation of wartime veterans 
irrespective of their locations of residence. Many of these veterans 
have co-morbid physical and mental health conditions related to 
military service therefore; we want VA to address the veteran's needs 
in a holistic manner. Additionally, VA needs to develop performance 
measures and quality standards to assess the care that is provided 
through contract or fee-basis arrangements. VA should also be held 
accountable by Congress to provide a continuum of services for these 
veterans whether provided directly or through contracts. 
  DAV believes that reform in rural, remote and frontier VA care can be 
achieved with the same overarching principles that have accompanied the 
transformation of the Veterans Health Administration (VHA) over the 
past decade. Necessary actions to achieve this reform would include: 
  Issuance of clear VHA policy that local facilities and 
Networks, through their mental health leadership, are responsible for 
creating a VHA-sponsored system that provides a stipulated array of 
services reasonably accessible to as many OEF/OIF veterans as possible 
who need these services. 
  Provision of direct services wherever VHA has a large enough 
concentration of veterans needing such services, and has an existing 
VHA site of care. This would require VA to upgrade access to marital 
counseling and develop brief interventions for substance 
abuse--services that VHA does not make easily accessible in even some 
of its largest facilities. 
  Contracting for care where there is not a large enough 
concentration of veterans needing readjustment counseling services, 
after local and Network leadership assess the availability and quality 
of alternative service providers (e.g. Vet Centers, State veterans 
services), including the availability and quality of services which 
could be purchased in the community, and assuring that a full array of 
services is made readily available. 
Oversight by Congress of this policy, with evidence that it is 
coordinated with the VHA Office of Mental Health Services and the newly 
established Office of Rural Health. 
  A critical aspect of health care quality is patient-centered care 
that is respectful of veterans' preferences, values and culture but is 
also holistic and provides care coordination. Coordination of the full 
range of services for every enrolled veteran should be a key 
characteristic of VA care. This will not occur unless VA remains 
integrally involved in the veterans overall health care. 
  Additionally, VA should make available to all its health care 
contractors gateways to VA's computerized patient record system (CPRS) 
so that they can provide clinical information on the care of patients 
assigned to them and so that they are aware of the veterans' entire 
medical history, diagnoses, and prescribed medications. VA must 
develop a strategic plan to achieve true continuity of care for its 
contract care patients. 
  Any organization that wants to partner or contract with VA in 
providing health services, including mental health services, should be 
willing to provide performance measurement data on each IOM quality aim 
and other requirements that VA may need to validate quality. They would 
need to develop the ability to collect, track and submit data on the 
technical quality process and outcome measures, patient satisfaction, 
and wait times, as well as clinical data. This information should be 
collected and reported publicly on a quarterly basis. 
  Finally, Mr. Chairman, we appreciate the Committeeï¿½s efforts in 
attempting to address this difficult issue, and this opportunity to 
further expand on our thoughts regarding mental health care options for 
rural, remote and frontier veterans. During your hearing on October 
24th one Member suggested by his question that DAV and others would 
prefer veterans to remain unserved rather than having care provided by 
private contractors. To the contrary, DAV members--all service-disabled 
veterans--are the prime users of VAï¿½s fee-basis and contract health 
care programs. We want for our members, and for our newest generation 
of combat wounded veterans, the very best care VA can provide or obtain 
whether from another Federal agency or grantee, or from private 
providers through contracts. We believe our policy, and our thoughts 
expressed here, are consistent with that goal. 
  Chairman AKAKA. Thank you very much. 
  Ms. MURDOUGH? 
 
      STATEMENT OF BRENDA MURDOUGH, MSN, RN-C, MILITARY/VETERANS 
        INITIATIVE COORDINATOR, AMERICAN PAIN FOUNDATION 

  Ms. MURDOUGH. Good morning. My name is Brenda Murdough. 
  Mr. Chairman, Ranking Member Burr, Members of the Committee on 
Veterans Affairs, I am here to provide testimony to support the 
Veterans Pain Care Act of 2007, S. 2160, on behalf of the American Pain 
Foundation and our Military/Veterans Pain Initiative. 
  I would like to thank Chairman Daniel Akaka and his dedicated staff 
for their leadership in introducing this important legislation. 
  I am the Coordinator of this initiative for the American Pain 
Foundation, and I am a certified nurse specialist in pain management. 
  I am also a member of the American Society for Pain Management 
Nursing, having worked in the field of pain management for the last 
71/2 years. 
  I am also here on behalf of the more than one million families 
who have members currently serving or who have served in the Armed 
Forces on active duty or in the National Guard and Reserve. My husband 
retired from active duty in the Army after 23 years of active service. 
His father is a World War II veteran. We have had family members serve 
in almost every armed conflict in the United States back to the 
Revolution, with the most recent being our son, who served 15 months in 
the Army in Iraq, returning last December. He is still on active duty. 
  My sister's two daughters serve on active duty in the Army, with one 
currently serving in Afghanistan, the other scheduled for deployment to 
Iraq most likely in February with her husband of 4 months, who also 
serves. My oldest brother's son is also currently serving in the Army 
in Iraq. My brother served for 30 years on active duty and retired last 
year, after having served in the First Gulf War. My younger brother 
served in the Army in the early 1980's, and my husbandï¿½s brother is on 
active duty in the Air Force. I could go on, but I think my point is 
clear. 
  Military service has been an important and influential part of my 
life and I care deeply for the members of the Armed Services and their 
families, particularly those who have suffered the horrors of 
battlefield injury. I am proud of their service and I am honored to 
know so many individuals personally. 
  But it is for all military personnel, active and retired, and all 
veterans from all armed conflicts that this important legislation for 
effective pain management must be enacted. The Veterans Pain Care Act 
of 2007 is designed to ensure improvement in pain care services, 
research, education, and training for the benefit of the veteran 
population. It is the least we can do for those who have given so much 
for the service of their country. 
  Founded in 1997, the American Pain Foundation is the Nation's leading 
independent nonprofit organization serving people with pain. Several 
years ago, with support from the Disabled American Veterans Charitable 
Service Trust, APF began reaching out to veterans with pain. The goal 
of APF's Military/Veterans Pain Initiative is to improve the quality of 
life of military veterans who suffer from pain by collaboratively 
working with other organizations to provide resources, information, and 
support to veterans with pain, their loved ones and caregivers, and to 
advocate for quality acute chronic pain care and increased research. 
  I know firsthand the importance of early and effective pain 
management in acute pain care to prevent the development of chronic 
painful conditions. Newsweek recently had an article highlighting this. 
Our men and women serving in Iraq and Afghanistan are surviving 
battlefield injuries that previously would have been fatal, thanks to 
improvements in battlefield medicine and evacuation. The most recent 
complete study of soldiers enrolled in VA polytrauma centers show that 
more than 90 percent have chronic pain. Most have pain from more than 
one part of the body, and that pain is the most common symptom in 
returning soldiers. 
  Advances in neuroscience, such as neuroimaging, now demonstrate that 
unrelieved pain, regardless of its initial cause, can be an aggressive 
disease that damages the nervous system, causing permanent pathological 
changes in sensory neurons and in the tissues of the spinal cord and 
brain. We need to be sure these painful shrapnel wounds, traumatic 
amputations, closed head traumas, and other battlefield injuries are 
receiving the most immediate and effective pain management at the time 
of acute injury to prevent chronic painful conditions from developing, 
and we need to make sure that all veterans that have developed chronic 
pain are receiving proper comprehensive, multi-modal pain care. 
  Perhaps more than any other Federal agency, the VA has been a leader 
in focusing institutional resources on the assessment and treatment of 
pain. The Veterans Health Administration has made pain management a 
national priority. However, although many of our military and veterans' 
treatment facilities offer the highest level of skilled expertise in 
treating these painful conditions suffered by our wounded Armed 
Servicemen and women, we need to ensure that all of our veterans' 
facilities are consistently providing the highest level of 
comprehensive pain management to prevent long-term suffering and 
disability. 
  We know the high multi-dimensional costs of untreated or undertreated 
pain on individuals and on families. Chronic pain conditions, such as 
those that can come from Traumatic Brain Injury, multiple fractures, 
traumatic amputation, crush injuries, and other battlefield injuries 
can be devastating to individuals and their families as they try to 
cope with the impact physically, mentally, socially, psychologically, 
and economically. 
  Pain can be acute and effectively treated by short-term 
interventions, or it can be chronic, often without effective cures, and 
sometimes without consistent and effective means of alleviation. 
Chronic pain symptoms and Post-Traumatic Stress Disorder frequently 
co-occur and may intensify individualsï¿½ experience of both conditions. 
Those who suffer severe chronic pain see their daily lives disrupted, 
sometimes forever. Their pain and their constant search for relief 
affects their function, their relationships, and those they love, their 
ability to do their work effectively, and often their self-esteem. 
Chronic pain is often accompanied by or leads to sleep disorders, 
emotional distress, anxiety, depression, and even suicide. We need to 
provide our Armed Servicemen and women with the resources necessary to 
provide effective pain relief within the Veterans Administration Health 
Care System. 
  The APF has recently developed ï¿½ï¿½Treatment Options: A Guide for 
Living With Painï¿½ï¿½ for people living with pain, written and reviewed by 
leading pain specialists. Our guide provides credible, comprehensive 
information about many options for care. Pain is complex and unique to 
each individual and is usually best managed by a combination of 
treatments, such as medication, psychological assistance, physical 
rehabilitation, injection infusion therapies, implanted devices, such 
as spinal cord stimulators, or continuous infusion catheters and 
complementary alternative medicines. 
  I recently had the privilege and honor of meeting and speaking with 
soldiers at Walter Reed Medical Center on the regional anesthesia acute 
pain care team rounds and words cannot do justice to the courage and 
determination I witnessed. All were amputees. All were injured in the 
conflicts in Iraq and Afghanistan. And all will be veterans with 
painful, lifelong consequences of their battlefield injuries. They 
fought for others. Now it is our time to fight for them. They deserve 
freedom from pain. 
  With this in mind, I ask you to pass the Veterans Pain Care Act of 
2007, S. 2160, so that all--
  Chairman AKAKA. Ms. Murdough, will you please summarize your 
statement? 
  Ms. MURDOUGH. Thank you. All veterans, all of our men and women who 
have served, past, present, and future, who have suffered wounds of 
battle deserve consistent, high-quality pain management, deserve 
freedom from pain, and it is our obligation to provide it to them. It 
is the least we can do. 
  Thank you. I apologize. 
  [The prepared statement of Ms. Murdough follows:] 

     PREPARED STATEMENT OF BRENDA MURDOUGH, MSN RN-C, MILITARY/VETERANS 
       INITIATIVE COORDINATOR, AMERICAN PAIN FOUNDATION 

  Mr. Chairman and Members of the Committee on Veteran's Affairs, my 
name is Brenda Murdough, MSN RNï¿½C. I am here to provide testimony to 
support the Veterans Pain Care Act of 2007, on behalf of the American 
Pain Foundation and our Military/Veterans Pain Initiative. I am the 
Coordinator of this Initiative for the American Pain Foundation and I 
am a certified nurse specialist in pain management. I am also a member 
of the American Society for Pain Management Nursing, having worked in 
the field of pain management for the last seven and a half years. 
  I am also here on behalf of the more than one million families who 
have members currently serving or who have served in the armed forces 
on active duty or in the National Guard and Reserve. My husband retired 
from active duty in the Army after 23 years of service. His father is a 
WWII veteran. We have had family members serve in almost every armed 
conflict in the United States back to the Revolution, with the most 
recent being our son, who served 15 months in the Army in Iraq, 
returning last December. He is still on active duty. My sister's two 
daughters serve on active duty in the Army with one currently in 
Afghanistan and the other scheduled for deployment to Iraq most likely 
in February with her husband of 4 months, who also serves. My oldest 
brother's son is also currently serving in the Army in Iraq. My brother 
served for 30 years on active duty and retired last year after having 
served in the first Gulf War. My younger brother served in the Army in 
the early 80's and my husbands' brother is on active duty in the Air 
Force. I could go on, but I think my point is clear. Military service 
has been an important and influential part of my life and I care deeply 
for the members of our armed services and their families, particularly 
those who have suffered the horrors of battlefield injury. I am proud 
of their service and honored to know so many individuals personally. 
But it is for all military personnel, active and retired, and all 
veterans from all armed conflicts that this important legislation for 
effective pain management must be enacted. The Veterans Pain Care Act 
of 2007 is designed to ensure improvement in pain care services, 
research, education, and training for the benefit of the veteran 
population. It's the least we can do for those who have given so much 
in the service of their country. 
  Founded in 1997, the American Pain Foundation (APF) is the Nation's 
leading independent nonprofit organization serving people with pain. 
Three years ago, with support from the Disabled American Veterans 
Charitable Service Trust, APF began reaching out to veterans with pain. 
The goal of APF's Military/Veterans Pain Initiative is to improve the 
quality of life of military/veterans who suffer from pain by 
collaboratively working with other organizations to provide resources, 
information and support to veterans with pain, their loved ones and 
caregivers; and to advocate for quality acute and chronic pain care and 
increased research. 
  I know first hand the importance of early and effective pain 
management in acute pain care to prevent the development of chronic 
pain conditions. Our men and women serving in Iraq and Afghanistan are 
surviving battlefield injuries that previously would have been fatal, 
thanks to improvements in battlefield medicine and evacuation. The most 
recent complete study of soldiers enrolled in VA Polytrauma Centers 
show that more than 90 percent have chronic pain, that most have pain 
from more than one part of the body, and that pain is the most common 
symptom in returning soldiers. Advances in neuroscience, such as 
neuroimaging, now demonstrate that unrelieved pain, regardless of its 
initial cause, can be an aggressive disease that damages the nervous 
system, causing permanent pathological changes in sensory neurons and 
in the tissues of the spinal cord and brain. We need to be sure that 
these painful shrapnel wounds, traumatic amputations, closed head 
traumas and other battlefield injuries are receiving the most immediate 
and effective pain management at the time of acute injury to prevent 
chronic painful conditions from developing. And we need to make sure 
that all veterans that have developed chronic pain are receiving 
proper, comprehensive, multi-modal pain care. 
  Perhaps more than any other Federal agency, the VA has been a leader 
in focusing institutional resources on the assessment and treatment of 
pain. The Veterans Health Administration has made pain management a 
national priority. However, although many of our military and veterans 
treatment facilities offer the highest level of skill and expertise in 
treating these painful conditions suffered by our wounded armed service 
men and women, we need to ensure that all of our veterans' facilities 
are consistently providing the highest level of effective, 
comprehensive pain management to prevent long term suffering and 
disability. 
  We also know the high, multidimensional costs of untreated or under 
treated pain on individuals and their families. Chronic pain conditions 
such as those that can come from Traumatic Brain Injury, multiple 
fractures, traumatic amputation, crush injuries and other battlefield 
injuries can be devastating to individuals and their families as they 
try to cope with the impact physically, mentally, socially, 
psychologically and economically. Pain can be acute and effectively 
treated by short term interventions, or it can be chronic, often 
without effective ï¿½ï¿½curesï¿½ï¿½ and sometimes without consistent and 
effective means of alleviation. Chronic pain symptoms and Post 
Traumatic Stress Disorder frequently co-occur and may intensify an 
individual's experience of both conditions. Those who suffer severe 
chronic pain see their daily lives disruptedï¿½sometimes forever. Their 
pain and their constant search for relief affects their function, their 
relationships with those they love, their ability to do their work 
effectively, and often their self esteem. Chronic pain is often 
accompanied by or leads to sleep disorders, emotional distress, 
anxiety, depression, and even suicide. We need to provide our armed 
service men and women with the resources necessary to provide effective 
pain relief within the Veterans Administration Health Care system. 
  The APF has recently developed Treatment Options: A Guide for People 
Living with Pain. Written and reviewed by leading pain specialists, our 
guide provides credible, comprehensive information about many options 
for care. Pain is complex and unique to each individual and is usually 
best managed using a combination of treatments such as medication, 
psychological assistance, physical rehabilitation, injection and 
infusion therapies, implantable devices such as spinal cord stimulators 
or continuous infusion catheters, and complementary and alternative 
medicine. 
  I recently had the privilege and honor of meeting and speaking with 
soldiers at Walter Reed Medical Center on the Regional Anesthesia Acute 
Pain Care team rounds and words cannot do justice to the courage and  
determination I witnessed. All were amputees, all were injured in the 
conflicts in Iraq and Afghanistan and all will be veterans with 
painful, lifelong consequences of their battlefield injuries. They 
fought for others rights and now it's our time to fight for theirs. 
Freedom from pain is their right. 
  It is with this in mind that I ask you to pass the Veterans Pain Care 
Act of 2007. This bill requires that all facilities within the 
Department of Veterans Affairs are held accountable for the adequacy 
and consistency of pain treatment across programs and geographic 
regions; that pain assessment, diagnosis and treatment be prompt and 
integral to veterans health care; and that the VA increase its research 
into the areas of acute and chronic pain. Our veterans, all of our men 
and women who have served, past, present and future, who have suffered 
the wounds of battle, have earned the right to consistent high quality 
pain management--have earned the right to freedom from pain--and it is 
our obligation to them to provide it. It is the least we can do. 
  Additional information is available at American Pain Foundation, 201 
N. Charles Street, Suite 710 Baltimore, MD 21201-4111 P: 410-783-7292 
www.painfoundation.org 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO 
  BRENDA MURDOUGH, MSN, RN-C, MILITARY/VETERANS INITIATIVE COORDINATOR, 
  AMERICAN PAIN FOUNDATION 

  1. In your testimony, you raised concerns over the implementation of 
VA's pain management program, in that it has not been consistent across 
the entire system. 
  Can you comment further on this, and discuss the areas most urgently 
in need of improvement? 
  There are VA facilities that have excellent pain care programs--an 
example is the Tampa Florida center, which was recently highlighted in 
the news. Unfortunately, this high quality, multidiscipline, 
comprehensive approach to pain management is not available to those who 
must travel long distances, only to find that the person treating them 
has had no training in Pain Management, is not educated in prescribing 
the medications necessary to manage pain effectively, or that the 
resources necessary are not available in the area. Consequently, the 
areas most urgently in need of attention are ensuring available, 
consistent, high quality, multimodal pain care treatment and an 
increase in individuals who are appropriately educated and trained in 
the specialty of Pain Management. We hear from Veterans often about the 
disparity of Pain Management across the VA system. 

  2. As you have testified, pain is complex and unique to each 
individual. How can VA most effectively prioritize their research to 
address the array of acute and chronic pain conditions veterans face? 
How much focus should there be upon treatment versus other priorities? 
  Research opportunities should focus on two main categories: improved 
acute pain management either in the battlefield or at the time of 
injury to prevent the possible development of chronic pain conditions, 
and the improvement in treatment options for chronic pain conditions, 
including the pain specific to Traumatic Brain Injury, traumatic 
amputation, shrapnel wounds, and other concussive injuries which may 
have long term pain associated with them. Research should focus on the 
most effective means of decreasing pain and improving quality of life, 
including the most effective multi modal approaches for accomplishing 
these goals. Research should also explore the high co-prevalence of 
psychiatric disorders (such as PTSD and depression) with pain. 
  Chairman AKAKA. Thank you. 
  Dr. SMITH? 

            STATEMENT OF BRIEN J. SMITH, M.D., MEDICAL DIRECTOR, 
              COMPREHENSIVE EPILEPSY PROGRAM, HENRY FORD HOSPITAL 

  Dr. SMITH. Mr. Chairman and distinguished Members of the Committee, 
thank you very much for the opportunity to be here today. My name is 
Brien Smith and I am the Medical Director of the Comprehensive Epilepsy 
Program at Henry Ford Hospital in Detroit, Michigan. I am pleased to 
speak today in support of S. 2004, the VA Epilepsy Centers of 
Excellence Act of 2007. 
   Epilepsy is a medical condition that produces seizures affecting a 
variety of mental and physical functions. The seizure happens when a 
brief strong surge of electrical activity affects part or all of the 
brain. When a person has two or more seizures, the condition is then 
considered epilepsy. Epilepsy affects 1 percent of the U.S. population, 
or three million people. 
  One of my first experiences with Post-Traumatic Epilepsy as a 
clinician is when I met George Bussell in 1994. Mr. Bussell's Traumatic 
Brain Injury occurred in 1944 while he served as a combat engineer 
during World War II and he was taking up a mine field between France 
and Germany. A fragment from a shell struck him in the frontal region, 
blowing off his helmet and leading to hospitalization. He seemed to 
recover fully, but subsequently developed seizures 16 years later 
arising from the area of injury. Despite multiple attempts to control 
his seizures, his life was dramatically altered by daily seizures until 
he was presented to my clinic in 1994, 34 years later, for surgical 
evaluation. Fortunately, we were able to help him with surgery and he 
gained a new sense of independence for the last 10 years of his life. 
  Mr. Bussell is one of many similar stories. We know that trauma to 
the brain, whether mild or severe, is clearly a defined risk factor for 
epilepsy. Studies from the Vietnam War and from the Iran-Iraq War show 
that 32 to 50 percent or more of service-related TBI victims develop 
epilepsy within 1 to 15 years Post-Trauma. Let me clarify that this 
statistic is for penetrating injuries which occur when a foreign object 
or piece of fractured skull enters the brain. 
  Today's story is a bit different. The common head trauma in Iraq is 
the result of the shockwave effect of high pressure that reverberates 
through the body and head from an explosion like those from an 
improvised explosive device, or IED. Researchers fear that incidence of 
Post-Traumatic Epilepsy could increase exponentially given this 
mechanism of injury. The 2003 data from Walter Reed Army Medical Center 
found evidence of brain injury in 61 percent of returning soldiers who 
had been exposed to IED blasts according to the Defense and Veterans 
Brain Injury Center, a partnership between the VA and Department of 
Defense. It is because of such alarming statistics that the Epilepsy 
Foundation and epileptologists like me believe that S. 2004 is 
critically needed. 
  We have to make sure that VA is prepared for the influx of 
Post-Traumatic Epilepsy. In essence, that is what S. 2004 is all about. 
The VA currently lacks a national program for epilepsy with clear 
guidelines on when to refer patients for further assessment and 
treatment of epilepsy. What the VA does have is a great model. Centers 
of Excellence have been developed over the years to address other 
disabling and chronic diseases in the veteran population such as 
Parkinson's disease and multiple sclerosis. Through such Centers of 
Excellence, the VA has been able to address many of the other common 
consequences of TBI, such as psychological changes and vision problems, 
but not Post-Traumatic Epilepsy. 
  The VA did establish epilepsy centers in the 1970's, but they have 
languished with few staff and no national budget, leaving veterans with 
Post-Traumatic Epilepsy, like Mr. Bussell, at the mercy of an 
inadequate system. Many veterans are denied services in locations 
without the necessary epilepsy facilities and the centers are not 
linked together. Sadly, the potential of these centers to be the 
backbone of a national epilepsy program never materialized. 
  The new centers created by S. 2004 would be linked with prestigious 
medical schools and research centers, thus attracting outstanding 
clinicians and scientists capable of driving innovation in the 
prevention and treatment of Post-Traumatic Epilepsy. A highlight of 
this legislation is that it contains a telemedicine component whereby 
the review of neurologic diagnostic tests, such as EEGs and MRIs, will 
be able to take place through transmission of the tests from the 
veteran's local care facility to one of the six centers. Thus, the 
centers would provide a nationwide monitoring program to improve the 
quality of life for veterans who live in rural areas that are far from 
a center. 
  Mr. Chairman, I strongly believe that we must strike while the iron 
is hot. As a Nation, we became more aware of TBI as a consequence of 
war when news anchor Bob Woodruff shared his personal story with the 
Nation. But while we now have people understanding that TBI is 
occurring at high rates, most people do not understand the high 
probability of epilepsy as a consequence of TBI or that epilepsy may 
manifest many years later. 
  Congress has the opportunity right now to make a difference for our 
veterans and for their future. Without proper diagnosis and care, their 
lives and livelihoods are affected forever. By enacting S. 2004, we 
will be finally putting into place a national network of centers to 
address the effects of TBI and epilepsy for the war heroes of today who 
will be citizens living in your towns tomorrow. 
  Thank you for this opportunity today. 
  [The prepared statement of Dr. Smith follows:] 

        PREPARED STATEMENT OF BRIEN J. SMITH, MD, MEDICAL DIRECTOR, 
            COMPREHENSIVE EPILEPSY PROGRAM HENRY FORD HOSPITAL 

  Mr. Chairman and Distinguished Members of the Committee: 
  Thank you very much for the opportunity to be here today. My name is 
Brien Smith and I am Medical Director of the Comprehensive Epilepsy 
Program at the Henry Ford Hospital in Detroit, Michigan. I am pleased 
to speak in support of S. 2004, the VA Epilepsy Centers of Excellence 
Act of 2007 and to share with you some thoughts about why these Centers 
are critically needed. 
  Epilepsy is a medical condition that produces seizures affecting a 
variety of mental and physical functions. A seizure happens when a 
brief, strong surge of electrical activity affects part or all of the 
brain. When a person has two or more seizures the condition is then 
considered epilepsy. Epilepsy affects about 1 percent of the U.S. 
population or 3 million people. 
  Nearly half a million people are involved in some kind of accidental 
brain injury each year--typically through a car accident or a fall--and 
80,000 of them require hospitalization due to moderate or severe 
Traumatic Brain Injury. Mortality and morbidity as a consequence of TBI 
are a major public health problem and Post-Traumatic Epilepsy is linked 
to psychosocial disability and is probably a contributing factor to 
premature death after penetrating head injury. 
  One of my first experiences with Post-Traumatic Epilepsy as a 
clinician is when I met George Bussell in 1994. Mr. Bussellï¿½s Traumatic 
Brain Injury occurred in 1944 when he served as a combat engineer 
during World War II and he was taking up a mine field between France 
and Germany. A fragment from a shell struck him in the frontal region 
blowing off his helmet and leading to hospitalization. He seemed to 
recover fully, but subsequently developed seizures 16 years later 
arising from the area of injury. His wife recalls witnessing the first 
event with him screaming out, becoming confused, strange movements of 
his arms and legs, clicking of his tongue and undressing himself. 
Despite multiple attempts to control his seizures his life was altered 
by these recurrent, almost daily events until he presented to our 
clinic in 1994 for surgical evaluation. With good fortune, surgical 
intervention at age 69 provided him with a new sense of independence 
for the last 10 years of his life. 
  Mr. Bussell is one of many similar stories. We know that the risk for 
our service men and women is very real--even if we cannot predict the 
exact number of soldiers who will be harmed, we know that trauma to the 
brain, whether mild or severe, is a clearly defined risk factor for 
epilepsy. Past studies from the Vietnam War referenced in my written 
testimony, show that more than 50 percent of service related TBI 
becomes epilepsy within 1-15 years Post Trauma. This statistic is for 
penetrating injuries which occur when a foreign object or piece of 
fractured skull enters the brain. Another study conducted between 1980 
and 1988 in Iran looking at soldiers in the Iran-Iraq war showed 32 
percent of penetrating head injury TBI became epilepsy within 6 months 
to 2 years. 
  Today's story is a bit different. The common head trauma in Iraq is 
the result of a ``shock wave'' effect of high pressure that 
reverberates through the body and head from an explosion like those 
from the Improvised Explosive Devices or IEDs. Researchers fear that 
incidence of Post-Traumatic Epilepsy could increase exponentially given 
the shock wave effect from IEDs. 
  2003 data from Walter Reed Army Medical Center found evidence of 
brain injury in 61 percent of returning soldiers who had been exposed 
to blasts according to the Defense and Veterans Brain Injury Center 
(DVBIC), a partnership between the VA and Department of Defense. It is 
because of such alarming statistics that the Epilepsy Foundation and 
epileptologists like me believe that S. 2004 is critically needed.
  The legislation has three major goals: 
  
  1. (re)Establish 6 Centers to specialize in Post Traumatic Epilepsy 
and make them part of a national network of Centers that can serve 
veterans; 
  2. Conduct research that will lead to an ability to prevent epilepsy 
as an outcome of TBI as well as research for better seizure control and 
an eventual cure for all epilepsy; 
  3. Allow veterans living in rural communities or far from VA 
hospitals access to the care they need. 
  Given the high rate of Post-Traumatic Epilepsy that veterans with TBI 
are likely to endure, the Epilepsy Foundation and the American Academy 
of Neurology believes that Congress should take a strong role in 
veterans' health care by authorizing this bill that would direct the VA 
to establish a strong national epilepsy program with research, 
education, and clinical centers that will provide state-of-the-art care 
for our brave soldiers. 
  As this Committee heard in May from Dr. John Booss, a former national 
director of neurology for the VA, the VA lacks a national program for 
epilepsy with clear guidelines on when to refer patients for further 
assessment and treatment of epilepsy. VA Centers of Excellence have 
been the model of innovation in the delivery of highly specialized 
health care and research for other disabling and chronic diseases in 
the veteran population such as Parkinsonï¿½s disease and Multiple 
Sclerosis. The VA has the infrastructure to address many of the other 
common consequences of TBI such as psychosocial changes and vision 
problems but not Post-Traumatic Epilepsy. 
  The VA established Epilepsy Centers as early as 1972, but these 
Centers have languished over the years with few staff and no national 
budget. The net result of allowing these Centers to fall by the wayside 
is that veterans with post TBI epilepsy are at the variable mercy of a 
system with markedly uneven distribution of epilepsy services. This 
often results in denial of services in locations without the necessary 
epilepsy facilities and in which administrators are hard pressed to 
meet their budget. Sadly, the potential of these Centers to be the 
backbone of a national epilepsy program never materialized. 
  Under this bill, the VA would designate six new Centers that would be 
linked with prestigious medical schools and research centers thus 
attracting outstanding clinicians and scientists capable of driving 
innovation in the prevention and treatment of Post-Traumatic Epilepsy. 
State-of-the-art care is what our veterans deserve. Research is the key 
to discovering ways to better predict when TBI victims will develop 
epilepsy. 
  To date, research has been focused primarily on the seizures 
themselves and what drugs might control or eliminate them. My colleague 
Marc Dichter, M.D., Ph.D. professor of neurology and pharmacology at 
the University of Pennsylvania says, ``We basically wait for epilepsy 
to happen and then see if we can treat it, which is in stark contrast 
to how we tackle other public health problems such as cancer or heart 
disease where we identify risk factors and try to prevent disease from 
occurring.'' 
  Another grave concern we have is that many returning veterans live in 
rural areas or far from a VA Center. S. 2004 contains a component on 
telemedicine whereby the review of neurological diagnostic tests such 
as EEG's and MRI's will be able to take place through transmission of 
such tests from the veteranï¿½s local care facility to one of the 6 
ECoEs. Thus, the ECoEs would provide a nationwide monitoring program to 
improve the quality of life for veterans with Post-Traumatic Epilepsy 
who live in rural areas. 
  Mr. Chairman, I strongly believe that we must strike while the iron 
is hot. As a Nation we became more aware of TBI as a consequence of war 
when news anchor Bob Woodruff shared his story of experiencing TBI with 
the Nation. But while we now have people understanding that TBI is 
occurring at high rates, most people do not understand the high 
probability of epilepsy as a consequence of the TBI or that the 
epilepsy may manifest many years later. Congress has the opportunity 
right now to make a difference for our veterans and for their future. 
Without proper diagnosis and care, their lives and livelihoods are 
affected forever. By enacting the VA Epilepsy Centers of Excellence Act 
of 2007, we will be putting into place a national network of Centers to 
address the affects of TBI and epilepsy for the war heroes of today who 
will be the citizens living in your towns tomorrow. 
  Thank you for this opportunity today. 
  
                             STUDIES REFERENCED: 

  Epilepsy after penetrating head injury. I. Clinical correlates: A 
report of the Vietnam Head Injury Study. Andres M. Salazar, Bahman 
Jabbari, Stephen C. Vance, Jordan Grafman, Dina Amin, and J.D. Dillon. 
Neurology 1985; 35;1406 Prognostic Factors in the Occurrence of 
Post-Traumatic Epilepsy after Penetration Head Injury Suffered During 
Military Service. Bizhan Aarabi, M.D., Musa Taghipour, M.D., Ali 
Haghnegahdar, M.D., Majidreza Farokhi, M.D., Lloyd Mobley, M.D., 
Division of Neurosurgery, University of Nebraska Medical Center, Omaha, 
Nebraska; Division of Neurosurgery, Shiraz University of Medical 
Sciences, Shiraz, Iran, Neurosurg Focus 8(1), 2000. Copywrite 2000 
American Association of Neurological Surgeons 

                                --------

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO 
  DR. BRIEN SMITH, M.D., MEDICAL DIRECTOR, COMPREHENSIVE EPILEPSY 
  PROGRAM, HENRY FORD HOSPITAL 

  1. Your prepared testimony noted that epilepsy is unlike most other 
medical conditions, in that despite known risk factors, a wait-and-see 
approach is used in lieu of aggressive preventive care. Recognizing 
that there is a large population of veterans who may be at risk for 
developing epilepsy, what types of preventive practices can be 
implemented? 
  Presently, there are no preventive practices from a medical 
perspective available. Aggressive preventative care would be ideal, if 
there was any data to suggest what that is. Completing controlled 
trials on acute Traumatic Brain Injury is very difficult and costly in 
the civilian population. Unfortunately, combat arenas, like Iraq, is 
one of the few scenarios where research trials could be performed to 
identify potentially profitable treatments. 
  A number of compounds have been tested either in animal models and a 
few in human civilian studies which were hoped to demonstrate 
neuroprotective or antiepileptogenic properties without disturbing the 
normal features of the healing process. No agents have been identified 
thus far which demonstrate positive results. In fact, a recently 
published study on the use of magnesium in humans with head trauma 
appeared to actually have a negative effect versus placebo, after 
animal studies had suggested potential neuroprotective properties. 

  Attempts are being made to optimize the care in the acute 
Post-Traumatic Period (first 2 weeks), but there has been no data to 
suggest that this has had any significant impact in reducing the 
subsequent development of epilepsy. 

  2. What role would the creation of epilepsy centers of excellence 
play in the development of preventative medicine and the early 
diagnosis of epilepsy? 
  Epilepsy Centers of Excellence would serve as a model to develop 
patient care practices designed to assist in recognizing the 
development of Post-Traumatic Epilepsy and rapidly initiate evaluation 
and treatment. All soldiers with a history of head trauma, and at risk 
for the development of epilepsy, would undergo baseline testing 
including EEG, MRI, and Neuropsychological testing. Vigilant outpatient 
monitoring followed by scheduled testing with a prolonged follow-up 
period would provide significant data to identify soldiers at highest 
risk to develop the condition and enable reduction of secondary 
morbidity from unrecognized seizures. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO 
  DR. BRIEN SMITH, MEDICAL DIRECTOR, COMPREHENSIVE EPILEPSY PROGRAM, 
  HENRY FORD HOSPITAL 

  Dr. Smith, in your testimony you spoke about a former patient, 
Mr. Bussell. He was injured in WWII, and began having seizures 16 years 
later, and yet he didn't enter your clinic and get proper care to treat 
his seizures until 1994. 
  Can you please share with us where he was in the interim and whether 
he sought medical care from the VA? 
  Mr. Bussell did seek care from the VA shortly after the onset of his 
seizures in 1960. He was informed that the seizures were unrelated to 
his previous head trauma, and that his problem was a separate issue. 
Due to the limited options offered to him, Mrs. Bussell felt she was 
running into a ``dead end'' with the VA and therefore pursued 
evaluations at outside centers. Mr. Bussell was evaluated at the 
University of Michigan for epilepsy surgery, but since he was 
considered a complicated extratemporal case, the surgical option was 
not offered, and he was entered into a number of experimental drug 
trials. After those attempts failed, he was subsequently seen in my 
clinic at Henry Ford Hospital where the surgical treatment option was 
offered. 
  Do you think veterans of this generation will meet the same fate as 
Mr. Bussell if we fail to develop a national program for epilepsy care? 
  Yes. The VA system is presently ill-prepared to handle the numbers of 
returning soldiers who are at risk of developing Post-Traumatic 
Epilepsy. Not only do they have only a limited number of centers that 
have the equipment to manage these patients, the specialty personnel to 
complete these evaluations, and provide cutting edge treatment is 
lacking. The VA has a very limited perspective on the problem of 
Post-Traumatic Epilepsy. When you review their 180 page Traumatic Brain 
Injury manual, there is only one-half of a page that addresses 
epilepsy, and none of the listed authors are considered epilepsy 
specialists. 
  Chairman AKAKA. Thank you very much, Doctor. 
  Captain WALKER? 
  
             STATEMENT OF CAPT. CONSTANCE A. WALKER, USN (RET.), 
               NATIONAL ALLIANCE ON MENTAL ILLNESS MEMBER, NAMI 
               VETERANS COUNCIL; PRESIDENT, NAMI SOUTHERN MARYLAND 
  
  Capt. WALKER. Good morning, Chairman Akaka and Members of the 
Committee. My name is Connie Walker. Thank you for your invitation to 
provide testimony as you consider this very important legislation 
related to mental health programs in the Department of Veterans 
Affairs. 
  This is a particularly important session for me, not only as a 
veteran and as a member of the National Alliance on Mental Illness, but 
as the parent of an Operation Iraqi Freedom 100 percent disabled 
veteran. Having said that, sir, I would ask the Committee's indulgence 
for two additional minutes, if I may. 
  My son asked if he could come today, but I said no. Mike is 
sixfoot-seven and very handsome and I was afraid that people would 
pay more attention to him than to what I have to say. 
He enlisted in the Army as a motor transport operator in June 
2001, Associateï¿½s Degree in hand, basketball trophies and varsity 
letters in the attic, and more impressed by a chance to see the 
world and a very large enlistment bonus than by the idea of two 
more years of college. He had a good service in the Army and 
particularly enjoyed his deployment to Germany. 
  In January 2003, his unit deployed to Northern Kuwait in support of 
the first phase of the war and our advance into Baghdad. They returned 
about 7 months later. I was deeply concerned with what I saw on that 
homecoming weekend. He would wake up screaming and was very subdued. 
The Army assured me he would be seen by a counselor at Fort Eustis, but 
in the coming months, his physical and mental decline became even more 
apparent. 
  In December 2003, at my insistence, after an aborted attempt by the 
Army to administratively separate him, my son received a full physical 
and mental evaluation. In January 2004, Michael was diagnosed with 
PTSD, major depression, and schizophrenia. He was hospitalized, and 
later that year medically retired. Today, he lives with my husband and 
I in rural Southern Maryland. After using every resource available to 
us where we live and coordinating with the VA whenever we can, we are 
encouraging him to accept residential mental health care at the VA 
Medical Center in Perry Point, Maryland. The issue is not that my son 
cannot be helped. 
  The issue is one of availability and quality of care where we live. I 
have been and remain my sonï¿½s primary advocate and have worked with 
military, VA, and civilian mental health care, insurance, and 
disability benefits systems. Navigating these waters is always a 
difficult job. At times, it is debilitating, even to someone with my 
skill sets: a 20-year career in recruitment, accession, retention, and 
retiree policy and program management; strong supporters within the VA, 
TRICARE, and other Federal and State agencies; and access to a local 
resource network that spans three Maryland counties. My experiences, my 
advocacy on behalf of OIF and OEF veterans and families in St. Mary's 
County and other parts of Maryland, North Carolina, Georgia, and 
California's rural areas, and connections to veteran advocates across 
the country have led me to this conclusion. 
  Mr. Chairman, it is impossible to overstate the stressors that rural 
and frontier family caregivers are bearing on a daily basis as they 
search for limited treatment and rehabilitative services, and work to 
support a loved one whose cognitive abilities have been severely and 
sometimes permanently impaired by the invisible injuries of PTSD, other 
mental health issues, or the aftermath of Traumatic Brain Injury. 
  From a mental health care perspective, a single bottom line looms 
over everything in mental health treatment and rehabilitation for our 
veterans in rural areas. The likelihood of obtaining effective services 
is slim to none for those who live beyond a reasonable commute from a 
VA medical center or do not have access to an appropriately and 
consistently staffed VA Community-Based Outpatient Clinic. 
  This is a painful realization for families of these veterans, 
especially in light of this truth about recovery: Early intervention 
and regular access to treatment and rehabilitation services are as 
vital to a disabled veteran's recovery from serious mental illness as 
they are to a physically injured veteran's recovery from serious 
physical injury. 
  Mr. Chairman, you asked me to limit my remarks to your mental health 
bill, S. 2162, the Mental Health Care Improvements Act. My formal 
statement submitted earlier this week also discusses the other 
legislation under your consideration. Your proposed mental health bill 
would establish new requirements in the VA for the treatment of PTSD 
and substance use disorder, with special procedures to address the 
treatment of veterans who suffer from co-occurring disorders. VA 
emphasis on concurrent treatment for veterans who have PTSD or other 
mental illness and are self-medicating with alcohol or drugs would be a 
welcome step forward in these veterans' journey to recovery. 
  That said, for OIF and OEF veterans who need these services in rural 
areas, I think the only practical avenue for VA care for this core of 
veterans would be through the CBOCs. The Substance Abuse and Mental 
Health Services Administration reports that rural substance abuse is a 
large and growing problem in America with insufficient resources in 
place to meet that challenge. So to reach rural veterans, rural CBOCs 
would need to be fully and consistently staffed, not staffed by 
rotating mental health professionals among multiple sites, in order to 
offer consistent treatment capabilities when these veterans need 
them--not on the day of the week that the physician happens to be 
there. I am afraid that even under these circumstances, veterans in 
need of mental health treatment who are self-medicating in our frontier 
areas are likely to be beyond reach. 
  To continue, the legislation would require a VA review of its 
residential mental health care facilities, including the domiciliaries. 
The deliverable would be a report on availability and quality of care 
at these sites for this Committee and the House Committee on Veterans 
Affairs. Mr. Chairman, this is an extremely important assessment of VA 
residential and long-term mental health care facilities and it cannot 
wait. 
  I was an Inspector General in my last Navy assignment. A legislative 
mandate is not necessary to initiate a fact-finding review of this 
nature. There are inspection and audit agencies that can be tasked to 
take this for action right now, for example, the VA's Office of 
Inspector General or the GAO. 
  Mr. Chairman, your legislation would require the VA to establish a 
pilot program in two VA networks for peer outreach and support, 
readjustment counseling, and other mental health services for OIF and 
OEF veterans in partnership with community mental health services and 
the Indian Health Service. Sir, this aspect of your legislation 
discusses a vital need for families like mine in rural America: 
increased access to mental health care programs and rehabilitation 
services for veterans who are coming home to places where VA resources 
are very limited or do not exist. 
  There are several issues of concern, not with your legislation's 
correct and critically important intent, but with the assumption of a 
capability of existing rural resources to achieve that goal, VA 
training notwithstanding. The overarching challenge is a national 
issue. There are too few mental health care specialists, programs, and 
services in rural areas to meet the needs of the existing population. 
Sixty percent of rural Americans live in federally designated mental 
health professional shortage areas. Sixty-five percent get their mental 
health care from their primary care doctor. In Southern Maryland, where 
I live, individuals seeking psychiatric care can wait up to 4 months 
for their first appointment. 
  Related concerns go to community mental health centers, where 
programs are funded primarily through grants from the Department of 
Health and Human Services. There are very few centers in rural areas, 
and sustained mental health workforce shortages have reached crisis 
levels in many areas of this country. Clinics most often operate at 
capacity, and many of their clients have lived with chronic mental 
illness for years. 
  My son received services through our countyï¿½s only community-based 
residential treatment program after his return to Southern Maryland. 
Mike has had an independent full life and although he wanted to come 
home, certainly, after his medical retirement--coming home to live with 
Mom was not something he was excited about doing...would it be for any 
young man or woman? We arranged for residential treatment at the only 
agency available and found the gap between slick marketing and reality 
to be more than disillusioning. 
  We know that 56% of OIF and OEF veterans utilizing VA health care are 
under 29 years old, just like my son. This demographic, these veterans' 
distinct psychiatric treatment and rehabilitation needs, and what they 
want and we all hope for, for their futures--will make the requirement 
for VA training of community mental health center clinicians, at a 
minimum, even more important. 
  Mr. Chairman, if this legislation will increase mental health 
staffing and resources in rural areas, then it can ensure access to 
care for OIF and OEF veterans who need it and it must be supported. My 
fear is that the current state of our country's rural mental health 
infrastructure will keep it from achieving its intent and more precious 
time will be lost, and that clock is ticking. 
  Mr. Chairman, Senior Ranking Member Burr, like you, I believe the 
solution is achievable and that a collaboration of care is what it will 
take. Local mental and physical health care providers must receive some 
VA training in mental and physical health issues for this generation of 
combat veterans so they know what to look for. A continuum of partnered 
care that keeps an assigned VA case manager informed on a regular 
basis, an approach that will take input from family caregivers into 
account and give them some training--
  Chairman AKAKA. Captain Walker, will you please summarize your 
statement? 
  Capt. WALKER. Sure. VA and Health and Human Services must actively 
partner and perhaps even combine resources for a treatment venue in 
rural areas that works for this population of veterans and their 
families. It cannot be business as usual, and in rural areas, right 
now, it is definitely business as usual. 
  Thank you for considering my views on this legislation, sir. 
  [The prepared statement of Capt. Walker follows:] 

         PREPARED STATEMENT OF CONSTANCE A. WALKER, CAPT, USN (RET.) 
           NATIONAL ALLIANCE ON MENTAL ILLNESS MEMBER, VETERANS' 
           COUNCIL, PRESIDENT, NAMI SOUTHERN MARYLAND 

  Chairman Akaka and Members of the Committee--
  As a member of the Veterans Council of the National Alliance on 
Mental Illness (NAMI), I appreciate your invitation to provide 
testimony for your consideration of several legislative proposals 
related to mental health programs in the Department of Veterans Affairs 
(VA). On behalf of NAMIï¿½s Executive Director, Mr. Michael Fitzpatrick, 
and our Veterans Council Chairman, Ms. Sally Miller, of Bozeman, 
Montana, please accept our thanks for this opportunity to speak with 
you today. 
  NAMI is the Nation's largest non-profit organization representing and 
advocating on behalf of persons living with chronic mental health 
challenges. Through our 1,200 chapters and affiliates in all 50 states, 
NAMI supports education, outreach, advocacy and biomedical research on 
behalf of persons with schizophrenia, bipolar disorder, major 
depression, severe anxiety disorders, Post-Traumatic Stress Disorder 
(PTSD), and other chronic mental illnesses that affect children and 
adults. 
  NAMI and its Veteran Members established the Veterans Council in 2004 
to assure close attention is paid to mental health issues in the VA and 
within each Veterans Integrated Service Network (VISN). We advocate for 
an improved VA continuum of care for veterans with severe mental 
illness. The council includes members from each of VAï¿½s 21 VISNs. These 
members serve as NAMI liaisons with their VISNs; provide outreach to 
national Veterans Service Organizations; increase Congressional 
awareness of the special circumstances and challenges of serious mental 
illness in the veteran population; and work closely with NAMI State and 
affiliate offices on issues affecting veterans and their families. 
Council membership includes veterans who live with serious mental 
illness, family members of this population of veterans, and NAMI 
supporters with an involvement and interest in the issues that affect 
veterans living with mental illness. The Councilï¿½s monthly meetings are 
conducted via teleconference and often feature guest speakers who 
provide updates on developments in treatment, research, program 
initiatives, and service delivery for veterans, active duty 
servicemembers, and family members with serious mental illness. We also 
use these opportunities to stay current on developments in Congress and 
the Executive Branch that have the potential to affect mental 
healthcare for veterans. 
  Mr. Chairman, as you indicated in my introduction, my name is 
Constance ``Connie'' Walker. I am a retired Navy Captain with over 22 
years of active duty service; a member of NAMIï¿½s Veterans Council; and, 
the President of a regional, rural NAMI affiliate in southern Maryland. 
My son, Michael, is a disabled veteran of Operation Iraqi Freedom 
(OIF). He enlisted in the Army as a Motor Transport Operator in June 
2001, associate's degree in hand, but Mike was more impressed by an 
enlistment bonus and a chance to see the world than the idea of two 
more years of college. 
  In January 2003, Mikeï¿½s unit deployed to northern Kuwait in support 
of the first phase of OIF and our advance into Baghdad. That deployment 
ended in July. In December of that year--at my insistence, after a 
season of observable physical and mental decline in him, and an aborted 
effort by the Army to administratively separate him--my son received a 
full mental and physical evaluation. In January 2004, Mike was 
diagnosed with PTSD, major depression, and schizophrenia; he was 
hospitalized, and medically retired later that year. Today my son lives 
with my husband and me in southern Maryland. 
  Throughout that period and since my sonï¿½s medical retirement, I have 
been his primary advocate in working with military, VA, and civilian 
mental healthcare, insurance, and disability benefit systems. 
Navigating these waters is always challenging and sometimes 
debilitating--even to someone like me, with over 20 years of experience 
in recruitment, accession, retention, and retiree policy and program 
management; having strong supporters within the VA, TRICARE, and other 
Federal and State agencies; and professional involvement in a local 
resource network that spans three Maryland counties. My family's 
experiences; my advocacy work on behalf of OIF and Operation Enduring 
Freedom (OEF) veterans and families in rural areas of Maryland, North 
Carolina, Georgia, and California; and, connections to veteran 
advocates across the country, have led me to this conclusion: 
  It is impossible to overstate the stressors that rural and frontier 
family caregivers are bearing on a daily basis as they search for 
limited treatment and rehabilitative services, and work to support a 
loved one whose cognitive abilities have been severely and sometimes 
permanently impaired by the invisible injuries of PTSD or other serious 
mental illness. 
  There is a looming reality over all discussions about recovery-based 
treatment and rehabilitation services for rural OIF and OEF veterans 
living with PTSD or other serious mental illness. The likelihood of 
obtaining those specialized services on a consistent basis is very 
small for veterans living in rural and frontier areas beyond a 
reasonable commute to a VA Medical Center (VAMC) or without access to 
an appropriately and consistently staffed VA Community Based Outpatient 
Clinic (CBOC). 
  This is a sobering fact, Mr. Chairman. Early intervention and regular 
access to appropriate treatment, rehabilitation, and support services 
are as vital to a disabled veteranï¿½s prospects for recovery from 
serious mental illness as they are for recovery from serious physical 
injury. 
  Mr. Chairman, with that background, I offer the following comments on 
the legislation before the Committee today, as requested in your 
invitation letter: 

                         S. 2162 MENTAL HEALTH BILL 

  Title I--PTSD and Substance Use Disorder 
  This bill would establish new VA requirements and re-emphasize 
existing VA programs for the treatment of PTSD and substance use 
disorder (SUD), with special procedures for VA to address the treatment 
of veterans who suffer from co-morbid association of these disorders. 
It would require VA to expand its offering of services for SUD, 
including counseling, outpatient care, prevention, aftercare, opiate 
substitution and other pharmaceutical treatments, detoxification and 
stabilization services, and other services the Secretary deems 
necessary, at every VAMC and CBOC. It would create a joint program of 
care for veterans with PTSD and a SUD, and authorize VA to spend $50 
million a year in FY08, FY09, and FY10 on this program. VA would also 
designate six ``National Centers of Excellence on Post-Traumatic Stress 
Disorder and Substance Use Disorder.'' 
  Following orthopedic problems, mental health is the second largest 
area of illness for which OIF and OEF veterans are seeking treatment at 
VA medical centers and clinics, and the demand for mental health 
services is increasing at a faster rate than orthopedic care. If this 
trend continues, we can expect to see mental health care at the top of 
the VA's treatment list in the future. Within the range of mental 
health issues that OIF and OEF veterans are experiencing, PTSD tops the 
list. PTSD is a special emphasis area for NAMI in its work to support 
veterans in the VA health care system. 
  The requirement in this legislation to emphasize concurrent treatment 
for veterans who have PTSD or other mental illness and a SUD is an 
important step forward in the treatment and recovery of veterans with 
PTSD or other mental illness who self-medicate with alcohol and/or 
drugs. Expanded VA efforts to treat co-occurring disorders would be 
welcome, and is long overdue. That said, for OIF and OEF veterans who 
need these services in rural and frontier areas, the only practical 
avenue to VA care for co-occurring disorders would be through VA's 
CBOCs. The Substance Abuse and Mental Health Services Administration 
(SAMHSA) reports that substance abuse is a large and growing problem in 
rural America. There would need to be a sense of urgency in ensuring 
CBOCs in rural areas have a fully staffed and consistent treatment 
capability for this population of veterans. Even under those 
circumstances, veterans who need mental health treatment and are 
self-medicating in America's frontier areas are likely to be beyond 
reach. 
  This legislation would also require a review of all VA residential 
mental health care facilities, including domiciliary facilities. The 
results of the review would produce a report to Senate and House 
Committees on Veterans' Affairs that addresses the availability of care 
and provides, for each one, an assessment of supervision and support; 
staff-to-patient ratio, assessment of rules and procedures for 
medication management; description of protocols for handling missed 
appointments, and recommendations for improvements to residents' care 
and the facilities themselves. 
  This is an issue of extreme significance but I am personally puzzled 
by the need for legislation to conduct this review. Unless there are 
legal constraints to doing so, it should be possible to avoid delays 
inherent to the legislative process by requesting GAO or any of the 
audit or inspection agencies available for tasking by Congress (to 
include the VA's Inspector General) to conduct this review and deliver 
the report. 

            TITLE II--MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS 

  This legislation would require the establishment of a 3-year pilot 
program in two VA networks to provide peer outreach, peer support, 
readjustment counseling and other mental health services to OIF and OEF 
veterans, particularly National Guard and Reserve veterans, who live in 
rural areas and are unable to routinely access comprehensive mental 
health services through the VA. These services would instead be 
provided through community mental health centers or facilities of the 
Indian Health Service participating in the pilot as VAï¿½s partners. 
Clinicians at these facilities would receive VA training to help them 
address mental health concerns unique to the experiences of OIF and OEF 
veterans. These facilities would be required to annually report the 
following information to the VA: number of veterans served; courses of 
treatment provided; and demographic information for services, 
diagnoses, and courses of that treatment. 
  Mr. Chairman, the goal of this legislation is vitally important: 
increasing access to mental healthcare programs and rehabilitation 
services for veterans returning to rural and frontier areas where VA 
resources are limited or do not exist. It is similar in its proposals 
to S.38, but downsized. In an effort to address this need using inhouse 
resources, the VA recently launched a program at selected test sites to 
provide Mental Health Intensive Case Management (MHICM) services in 
some rural areas, but this program is in its infancy. 
  If legislation can increase mental health resources for veterans and 
families who live in rural areas, it should be supported. However, 
there are concerns that cause NAMI to question whether legislation 
alone can achieve this goal. 
  The lack of availability of mental healthcare specialists, programs 
and services in rural areas is a national issue. Most rural areas do 
not have the mental health resources in place to meet the needs of the 
existing population. More than 60% of rural Americans live in mental 
health professional shortage areas. 65% percent get their mental health 
care from their primary care physicians. St. Mary's County, Maryland 
received its federal designation as a psychiatric services shortage 
area in 2005. Individuals seeking psychiatric care often wait 3 or 4 
months for their first appointment. 
  Community Mental Health Center programs are funded primarily through 
grants from the Department of Health and Human Services. There are very 
few centers in rural areas. Those there are tend to operate at 
capacity, and many of their clients have lived with chronic mental 
illness for years. These centers would be attempting to assimilate a 
very different client population in terms of OIF and OEF veterans' 
average age, psychiatric treatment, and rehabilitative needs. Given 
these considerations, the legislation's requirement for VA training of 
clinical staff takes on even more significance. 
  These considerations raise a question as to whether legislation alone 
will be able to create an acceptable solution for OIF and OEF veterans 
in rural areas, who need timely and regular access to recovery-based 
mental healthcare treatment and rehabilitative services. 

                                   S. 38 

  This legislation would establish a 3-year program of services for 
members of the immediate families of new veterans diagnosed with PTSD 
or other serious mental illness. Services would include education, 
support, counseling and other programs for families to increase their 
understanding of their veteranï¿½s illness, enabling them to more 
effectively support their veteranï¿½s journey to recovery. These programs 
would also improve the familyï¿½s coping skills and ability to more 
effectively manage the stressors that family caregivers deal with every 
day. VA would have to develop a program based on these 
requirements--but these families are in desperate need of help. There 
is an equally important subject this bill does not address: 
compensation for family caregivers. Their role, in advocating for a 
seriously disabled veterans' physical and mental healthcare and 
supporting their recoveries, is a fulltime job. My circumstances are 
unusual. I draw retired O-6 pay from the United States Navy and have a 
supportive spouse who is willing and able to work past retirement 
eligibility age. We can support my son. The vast majority of family 
caregivers supporting a seriously disabled veteranï¿½s recovery do not 
enjoy these luxuries. In many cases, family caregivers have had to quit 
their jobs to take on fulltime caregiving responsibilities--placing the 
family under even more stress as it struggles to deal with the loss of 
income. 

                                   S. 2142 

  This bill would require the Secretary of Veterans Affairs to 
reimburse veterans with service-connected disabilities for costs 
incurred as a result of emergency treatment in civilian hospitals, for 
the period of inpatient care needed before they can be transported to 
VA facilities. 
  It is a fact that a percentage of OIF and OEF veterans with PTSD or 
other mental illness, TBI, and other injuries not visible to the eye, 
go undiagnosed until symptoms become obvious. A VA facility is not 
always within commuting distance when the veteran with a service 
connected disability needs emergency inpatient care. NAMI supports 
legislation that broadens the entitlement of service-disabled veterans 
to emergency inpatient care covered by the VA, certainly until the 
veteran can be safely transported to a VA facility. Therefore, since 
this bill clarifies that VA responsibility, NAMI supports it. 
 
                           S. 2004 AND S. 2160 

  Mr. Chairman, these two bills do not deal with mental illness, so 
NAMI takes no position on them. 

                              CONCLUSION 

  The National Alliance on Mental Illness is committed to supporting VA 
efforts to improve and expand mental healthcare programs and services 
for veterans living with serious mental illness. Our members directly 
see the effects of what the national Veterans Service Organizations 
have reported through the Independent Budget for years: chronic 
under-funding of veteransï¿½ health care has eroded the VA's ability to 
quickly and effectively respond to present-day and projected 
requirements, even with the infusion of new funds it now is receiving. 
Forward motion has been stalled for 3 years on VA's ``National Mental 
Health Strategic Plan,'' to reform its mental health programs--a plan 
that NAMI helped develop and fully endorses. A Government 
Accountability Office (GAO) report released in September 2006 noted 
that the VA had failed to spend all of a promised $300 million in 2005 
that was allocated towards improved awareness of mental illness 
treatment services in the VA; improved access to mental health services 
for Veterans returning from Iraq and Afghanistan, as well as others 
diagnosed with serious mental illnessï¿½all important initiatives within 
the VA strategic plan. NAMI hopes the Committee will agree that 
oversight of VA's implementation of its National Mental Health 
Strategic Plan would be beneficial to ensuring its progress toward full 
implementation, to provide help to OIF-OEF veterans and all veterans 
who live with mental illness. 
  Chairman Akaka and Members of the Committee, thank you for your 
invitation for NAMI to offer testimony as you consider this 
legislation. I would be pleased to respond to any questions you may 
have. 
  Chairman AKAKA. Thank you very much, Captain. I really appreciate 
that. 
  Let me just ask one question and then I will pass it on to other 
Members. Ms. Ilem, in your testimony, you raised concerns about 
increasing contract care at VA. What safeguards do you feel are 
necessary to ensure that veterans get the best care available when they 
are treated for mental health issues or other conditions by outside 
care providers? 
  Ms. ILEM. Well, I think the provisions in the bill, in your bill, try 
to--attempt to make sure that there is cultural competence. If VA has 
to provide that care outside VA, I think that is critical. When they 
have to use contracted care, we hope that it would be more consistent 
with VAï¿½s care that those folks have access to, evidencebased 
treatments that VA had found effective in treating these very unique 
PTSD and readjustment issue problems, substance abuse issues, and that 
veterans are going to have the full benefit of good quality care. I 
mean, that is, I guess, our main issue with that. 
  We would like to see VA provide as much of that care as possible 
in-house, and hopefully through the Office of Rural Care that is just 
newly stood up that they have been charged to address these issues, and 
we are hoping that they can really get a handle on what the unmet need 
is out there and how VA can really help provide that care and not just 
contract it out with not having a good handle on who those veterans are 
and that they have access to VA evidence-based programs for the 
treatment. 
  Chairman AKAKA. Mr. Blake, you indicated that PVA remains concerned 
about the eligibility criteria that determines which veterans are 
eligible for reimbursements for certain emergency care. Can you please 
expand upon your concerns? 
  Mr. BLAKE. Well, Mr. Chairman, I think that my statement kind of 
speaks for itself. There are a couple of--I guess the 24-month 
requirement is something that we didnï¿½t see as being addressed by the 
legislation that we feel is a critical component to addressing the 
emergent care requirement. And again, our bottom-line point about 
allowing for emergent care for any veteran who is currently eligible 
for VA health care within the system to be reimbursed if they get that 
care outside of the VA or within the VA. 
  I mean, I don't know that I could expand on any more than that. I 
would certainly refer you to our section in the Independent Budget for 
fiscal year 2008, but most of that is also addressed by my statement, 
as well. 
  Chairman AKAKA. Thank you. I will yield now to Senator Burr. 
  Senator BURR. Mr. Chairman, thank you. 
  Captain Walker, thank you for that very personal testimony that I 
think sheds a lot of light on the challenge that Senator Akaka and I 
and VA deal with, and that is that, and I quote your numbers and they 
were very consistent with the numbers I found, that 60% of rural 
Americans live in an area where mental health professionals don't 
exist. So it implores me to turn to you, Mr. Blake, and you, Ms. Ilem, 
because I went back to read your testimony, Mr. Blake. Let me just read 
it. PVA opposes the provisions of this legislation that would authorize 
VA to contract with community mental health centers to meet the needs 
of veterans dealing with mental health. 
  I represent North Carolina. Sixty percent of North Carolina is rural. 
I think today in the private health care system, finding the 
specialists that we need to provide services to the entire population, 
much less the challenges it presents within the VA system to find how 
to reach some of the rural markets. 
  Let me give you an opportunity. Are you opposed to contracting under 
any condition, or are you opposed to contracting under some conditions? 
  Mr. BLAKE. Well, Senator Burr, I think our statement speaks for 
itself in that we believe that the authority exists within the VA to 
contract care, particularly in the rural setting, already. As we have 
testified on the broader rural health care issue, which we feel is 
probably maybe one of the leading issues that VHA is facing, our 
concern has always been that maybe the VA has not applied its fee basis 
authority in the appropriate manner anyway and it would also affect 
these individuals. 
  To qualify my statement that you read from a little bit further, our 
sense has always been that the VA can provide better care and more 
cost-effective care within its own system. That is why we voice our 
concerns about broader contract care with this in mind, being 
particularly the mental health aspect. 
  I think the point that Captain Walker made can't be lost, that it is 
not just a problem for the VA, it is a problem nationally. I mean, if 
the access and the professionals are not there, I can certainly see 
where this legislation gets the VA in the door, and we appreciate the 
provisions about training-- 
  Senator BURR. All this simply does is create some options where there 
are no options today, options that the VA in charge of delivering 
health care to veteransï¿½if, in fact, a veteran lives in an area that 
there is no VA services because, quite frankly, there are no mental 
health professionals, we are challenged. That may mean the only option 
for that veteran outside of driving an hour and a half, hoping that 
they are on their scheduled appointment, and we know the consistency of 
their visits and the access at difficult times is absolutely crucial, 
maybe they turn to some company that is specifically designed to cover 
rural areas. Would you object to that? 
  Mr. BLAKE. Absolutely not, Senator. In fact, I would suggest that 
the Spinal Cord Injury Service uses a similar method for individuals 
that we have, particularly PVA members who live in extremely rural 
areas, because they make those choices, as well. And they have fee 
basis as an availability. 
  Senator BURR. My attempt here is to find out exactly, when you say we 
oppose any effort, I mean, that is a pretty strong thing. 
  Ms. Ilem, let me turn to you. In your testimony, you said the VA 
should be given time to fully implement and deploy new programs and 
strategies that are not yet fully deployed, then we should reassess the 
situation and see about the possibility of contracting opportunities. 
How do I look at Captain Walker and her son and suggest that she wait 
until they complete an assessment of the deployment of new programs and 
strategies? Is that fair? 
  Ms. ILEM. Well, I think my point I was trying to make is that all of 
this money and effort has been put into, from Congress, making sure 
that VA has the opportunity to provide this care and the new law--
  Senator BURR. Should this Committee be focused on process or outcome? 
  Ms. ILEM. Well, certainly outcome, but it does take time for VA to 
get those services in place. But if VA doesnï¿½t have it right now when 
that veteran needs it, obviously they have the authority to provide 
that care on a contracted basis. But do you want them to provide that 
care or authorize that care through somebody who may not fully 
understand or have the cultural competence to provide PTSD or 
readjustment issue care? I mean, we want that veteran to have, you 
know, if they have to drive in to get it because that is the best care 
available, you know, what is in the best interest of that veteran? 
  Obviously, getting it close to their home is important, especially if 
it is a situation where they donï¿½t have good transportation to and from 
the medical center. But at the same time, we want to make sure there is 
the cultural competence out there on behalf of that provider providing 
that care. And if VA can't do it, and we would expect them to do it, if 
they do not have their services up and running for that veteran, that 
should be made available to them. 
  Senator BURR. How many veterans are you willing to let fall through 
the crack while VA completes their assessment of new programs-- 
  Ms. ILEM. We don't want any veterans to fall through the cracks. 
  Senator BURR. But they are. They are today. We wouldn't be doing this 
legislation. Captain Walker wouldnï¿½t be here testifying. And this is no 
reflection on the position of both of your groups or a reflection on 
the VA. 
  Dr. Smith, let me just turn to you because the vote has started and I 
know the Chairman has been very gracious, but I didn't see any other 
Members, so I thought I would take the opportunity. 
  [Laughter.] 
  Senator BURR. You clearly drew a distinction between Shockwaves and 
Direct Blows, not penetrations but blows. Can you sort it out for me? 
Is epilepsy, Post-Traumatic Epilepsy, more likely in Shockwave Injuries 
versus Direct Blow Injuries, or do we know? 
  Dr. SMITH. Senator, we donï¿½t know exactly the answer to that question 
right now. Most of the data that we have from in the past, for example, 
in Vietnam, you have missile injuries that penetrate the brain and 
create blood. Blood is something that is very irritative to the brain. 
But remember that a lot of head injuries that we see are closed head 
injuries where you have acceleration-deceleration injuries and it is a 
diffuse process where there can be the development of partial epilepsy 
which has nothing to do with penetration. 
  This is a whole new world we are looking at with these IEDs and the 
type of injury. In talking to a couple neurologists who have actually 
been there, when they talk about the type of injuries they are seeing, 
a bullet injury is directly in and can be directly out where these IEDs 
are smashing areas and there is debris in a number of areas that is 
creating a completely different picture that we are not used to seeing. 
  Senator BURR. Thank you for that, and there is a reason I went in the 
order that I did. You are dealing with it today, Captain. I know you 
guys have to take the position that you do. You bring a new element 
that we donï¿½t talk about enough. It is the servicemen and women today 
who are coming back with injuries that we haven't experienced, that if 
we are not focused on the technological progressions in prosthetics, if 
we are not focused on how we treat the mental health issues that arise 
from this current operation, if, in fact, we donï¿½t transition Traumatic 
Brain Injury from one of penetration to one of shockwaves and possibly 
some direct blows, then we have done an injustice to the personnel that 
we have asked to serve. 
  Part of our ability to address these is that we have to act quickly, 
and it doesnï¿½t mean that we always have all the information. It doesn't 
mean that we have all the programs out. Clearly, I think we could all 
find consensus that there are areas of the country that even in the 
private sector, it is very difficult to find the services that cover 
the scope that are needed and that it shouldnï¿½t be unusual for VA to 
have a problem there like the private sector does, and when we hit 
those, that we ought not wait for programs to be fully vetted, that we 
ought to contract with somebody if, in fact, there is somebody that is 
qualified to deliver that service. 
  Right now, the single most important thing we have to do is to drop 
the concerns we have with process. We will sort out process and focus 
on outcome, and that is how many of these men and women that go into 
the system for whatever need come out as quickly as they can, but with 
a life in front of them that is as productive as we can possibly make 
it and they can possibly enjoy. 
  I thank you for letting me ask you some very pointed questions. 
Again, I thank all of you for your testimony, and Mr. Chairman, I 
thank you for your indulgence. 
  Chairman AKAKA. Thank you very much, Senator Burr. 
  A vote has been called. I want to thank our panelists here. We have 
questions that we will submit for your responses. 
  I also want to thank Dr. Kussman, who has remained here to listen to 
the testimony of our second panel. I want you to know I appreciate 
that, Dr. Kussman. 
  Again, I appreciate all of you and your testimonies as well as your 
responses. The reason I am going to adjourn is that we have a series of 
votes, and instead of keeping you here waiting until we are done, I 
want you to know that we appreciate your coming. We have heard from you 
and this will, without question, help us in dealing with these issues 
in the Department of Veterans Affairs. This is all for the sake of 
trying to find the best ways of helping our veterans, and I thank you 
for contributing to that. 
  Captain Blake, I had questions about families and your family, as 
well, but we will hear from you on that in your responses. 
  I want to thank all of you again for appearing here and wish you well 
in all that you do. 
  This hearing is adjourned. 
  [Whereupon, at 11:12 a.m., the Committee was adjourned.] 
