[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
HEARING ON VA MENTAL HEALTH CARE STAFFING: ENSURING QUALITY AND
QUANTITY
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
TUESDAY, MAY 8, 2012
__________
Serial No. 112-59
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York
Helen W. Tolar, Staff Director and Chief Counsel
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
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C O N T E N T S
__________
May 8, 2012
Page
Hearing on VA Mental Health Care Staffing: Ensuring Quality and
Quantity....................................................... 1
OPENING STATEMENTS
Chairman Jeff Miller............................................. 1
Prepared Statement of Chairman Miller........................ 77
Hon. Corrine Brown, Acting Ranking Democratic Member............. 3
WITNESSES
The Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans
Affairs........................................................ 4
Accompanied by:
Hon. Robert A. Petzel, M.D., Under Secretary for Health,
Veterans Health Administration, U.S. Department of
Veterans Affairs
Robert L. Jesse, M.D., Ph.D., Principal Deputy Under
Secretary for Health, Veterans Health Administration,
U.S. Department of Veterans Affairs 78
Mary Schohn, Ph.D., Director, Office of Mental Health
Operations, Veterans Health Administration, U.S.
Department of Veterans Affairs
Antonette Zeiss, Ph.D., Chief Consultant, Office of Mental
Health Services, Veterans Health Administration, U.S.
Department of Veterans Affairs
Annie Spiczak, Assistant Deputy Under Secretary for Health
for Workforce Service, Veterans Health Administration,
U.S. Department of Veterans Affairs
John D. Daigh, Jr., M.D., Assistant Inspector General for
Healthcare Inspections, Office of the Inspector General, U.S.
Department of Veterans Affairs................................. 34
Prepared Statement of Dr. John D. Daigh, Jr., M.D............ 83
Linda A. Halliday, Assistant Inspector General for Audits and
Evaluations, Office of the Inspector General, U.S. Department
of Veterans Affairs............................................ 35
Nicole L. Sawyer, PsyD, Licensed Clinical Psychologist........... 44
Prepared Statement of Nicole L. Sawyer....................... 87
Diana Birkett Rakow, Executive Director of Public Policy, Group
Health Cooperative............................................. 46
Prepared Statement of Ms. Rakow.............................. 92
James Schuster, MD, MBA, Chief Medical Officer, Community Care
Behavioral Health Organization of University of Pittsburgh
Medical Center................................................. 48
Prepared Statement of Dr. Schuster, MD....................... 95
RADM Thomas Carrato, USPHS (Ret.), President, Health Net Federal
Services....................................................... 50
Prepared Statement of Mr. Carrato............................ 100
Joy Ilem, Deputy National Legislative Director, Disabled American
Veterans....................................................... 64
Prepared Statement of Ms. Ilem............................... 107
Alethea Predeoux, Associate Director of Health Legislation,
Paralyzed Veterans of America.................................. 65
Prepared Statement of Ms. Predeoux........................... 113
Ralph Ibson, National Policy Director, Wounded Warrior Project... 67
Prepared Statement of Mr. Ibson.............................. 116
STATEMENT FOR THE RECORD
Hon. Tim S. McClain, President, Humana Government................ 120
Thomas J. Berger, Ph.D., Executive Director, Veterans Health
Council, Vietnam Veterans of America........................... 123
HEARING ON VA MENTAL HEALTH CARE
STAFFING: ENSURING QUALITY
AND QUANTITY
----------
Tuesday, May 8, 2012
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, D.C.
The Committee met, pursuant to notice, at 10:38 a.m., in
Room 334, Cannon House Office Building, Hon. Jeff Miller
[Chairman of the Committee] presiding.
Present: Representatives Miller, Stearns, Lamborn,
Bilirakis, Roe, Stutzman, Johnson, Runyan, Buerkle, Huelskamp,
Turner, Brown, Reyes, Michaud, Braley, McNerney, Walz, Barrow,
and Carnahan.
OPENING STATEMENT OF CHAIRMAN JEFF MILLER
The Chairman. What I would like to do before we actually
start is I think the IG folks have stood down at this time. Mr.
Secretary, we are glad to have you, and go ahead and call this
hearing to order.
I want to welcome everybody to today's hearing. I apologize
for being tardy, but we are going to be talking about VA Mental
Health Care Staffing: Ensuring Quality and Quantity.
As I think most of the Committee knows, two weeks ago the
VA inspector general released a report reviewing veterans'
access to mental health care, something that we are all very
interested in as are all veterans and Americans across this
country.
And I have got to say that the findings in the report are
more than troubling. It is an understatement to call them
troubling.
One of the most disturbing things that the IG discovered is
that more than half of the veterans who seek mental health care
through the VA wait an average of 50 days, to receive a full
mental health evaluation.
Let me be real clear from the outset--A veteran who comes
to the VA for help should never, never under any circumstance
have to wait almost two months to receive the evaluation they
have asked for and begin the treatment they need.
And I do not believe anyone in this room thinks that there
is any excuse for that type of delay.
Given the gravity of the issues we will discuss this
morning, I invited Secretary Shinseki to participate in today's
hearing.
I was a little concerned, Mr. Secretary, based on a letter
from you last week that you may not be joining us this morning,
but I am very glad that you are here with us because I know
that this is important to you and the people who work at VA.
As you know, leadership and accountability begin at the
top, not with an under secretary, not with a deputy under
secretary, but with the secretary.
And these hearings are much more than opportunities for
this Committee to hear from the department. I think that it is
important for the department to hear from Members of this
Committee as well because we hear from our constituents on a
daily basis.
There is no one better positioned to represent the VA than
you. So, again, let me reiterate my thanks to you for being
here this morning.
Two days before the IG report was released, interestingly
enough, VA made a surprise announcement that VA was going to be
increasing their mental health staff by 1,900 people, adding
approximately 600 clinicians and 300 support staff to their
current roster of just over 20,000 mental health professionals.
Ensuring the VA is staffed adequately to fulfill the care
needs of our veterans and their families is a priority of mine
and each Member of this Committee.
So on its face, this is an encouraging step. However, I am
concerned by the timing and the implication of the
announcement.
The IG's report clearly illustrates that the VA does not
have meaningful or reliable data, to accurately measure a
veteran's access to care or facilities' mental health staffing
needs.
In fact, the IG states, and I quote, ``The complexity of
the computations and inaccuracies in some of the data limits
the usability of productivity information to fully assess
current capacity, determine optimal resource distribution,
evaluate productivity across the system, and establish mental
health staffing and productivity standards,'' end quote. Which
begs the question, if the VA does not even have a complete
picture of the problem, how confident can we be that access, in
fact, will be increased and care enhanced by really what could
be termed a knee-jerk reaction to what has been going on?
This is not the first time we have been here. There is a
long history of IG, government accountability office, and
stakeholder reports that have found serious deficiencies within
the VA mental health system of care including appointment
waiting times, scheduling processes and procedures, provider
performance measures, and data collection efforts.
There is an equally long history of congressional
oversight. Strides have been taken, but they are far, far from
enough.
I would like to give the department the benefit of the
doubt. I believe that we all have the best interest of our
veterans at heart, but I am afraid that VA's response in this
instance is yet another example of a Federal bureaucracy
providing a quick fix, cookie cutter solution to a very serious
multifaceted problem.
A true definition of access to care can be found in 1993
Institute of Medicine report which reads in part, ``The most
important consideration is whether patients have an opportunity
for a good outcome, especially in those instances in which
medical care can make a difference.''
The 1.3 million veterans who sought mental health care
through VA last year deserve better. The very least we owe our
veterans is a chance. VA can make a difference. VA must make a
difference.
And, again, Mr. Secretary, thank you for being here today.
And I yield to our Ranking Member, Ms. Brown, for an
opening statement.
[The prepared statement of Chairman Miller appears in the
Appendix)
OPENING STATEMENT OF HON. CORRINE BROWN,
ACTING RANKING DEMOCRATIC MEMBER
Ms. Brown. Thank you, Mr. Chairman, for holding this
hearing today on such an important issue.
I would like to thank all of you that are here today in
support of the veterans.
Since 2007, VA has seen a 35 percent increase in the number
of veterans receiving mental health services and a 41 percent
increase in mental health staff. While only one percent of
Americans have served in the war in Iraq and Afghanistan,
servicemembers represent 20 percent of suicides in the United
States.
The VA report that 52 percent of the returning veterans
from Operation Enduring Freedom, Iraqi Freedom, and New Dawn
who access VA health care do so for a mental health issue.
Oversight of VA mental health programs have long been a
focus for this Committee. Numerous hearings have been held,
funding has been increased, and legislation has been passed to
ensure that veterans of all era active duty servicemembers and
guards and reservists all have access to timely and quality
mental health care service wherever they choose to live.
While I agree that much has been done, I am discouraged
that we still hear stories of the struggles many veterans face
when trying to access VA mental health care services. Whether
it is a delay in care, denial of care, or that the care is not
available, frustration with the system may lead the veterans to
forego needed care altogether.
The inspector general's report was blunt and to the point.
The report found that the Veterans Health Administration does
not have a reliable and accurate method to determine whether
they are providing patients timely access to mental health
care.
I would like to hear how VA plans to move forward with the
recommendations obtained in the IG's report on the heel of this
report before the announcement from the department that 1,600
new mental health providers would be hired along with the
addition of 300 support staff.
Given that there have been some inaccuracies in the
information of the report over the last year, I am interested
in hearing from the VA today what methods and modeling VA has
used to arrive at the number and what and how long it is going
to take for the hiring timeline.
Finally, because there have been many improvements and
expansions in mental health services, I would like to recognize
the hard work and dedication of the VA employees who go to work
every day with the goal of making a positive difference in the
veterans' lives.
And, Mr. Secretary, I want to thank you for coming here
today. I want to thank you for your 38 years as a military
person, and as the Secretary for the Department of Veterans
Affairs.
I have been on this Committee for 20 years and I met with
many, many secretaries. And I can tell you many of them, they
come to this Committee, they talk a great talk, but they do not
walk the walk or, as the veterans say, roll the roll. You do.
We have a big task. And we are a very bipartisan Committee
and I am interested in working with you to make sure that we
improve the lives for all of the veterans.
Thank you, Mr. Chairman, and I yield back the balance of my
time.
The Chairman. Thank you very much, Ms. Brown.
I want to welcome again the panel to the table. We have
already recognized the secretary of VA, the honorable Eric
Shinseki.
Also, he is accompanied by Dr. Mary Schohn, the Director of
the Office of Mental Health Operations; Dr. Antonette Zeiss,
the chief consultant for Office of Mental Health Services;
Annie Spiczak, the assistant deputy under secretary for Health
Workforce Service; and also Dr. Jessee and Dr. Petzel.
Thank you for being here with us today.
Mr. Secretary, you are recognized. Thank you.
STATEMENT OF ERIC K. SHINSEKI, SECRETARY, U.S. DEPARTMENT OF
VETERANS AFFAIRS ACCOMPANIED BY MARY SCHOHN, DIRECTOR, OFFICE
OF MENTAL HEALTH OPERATIONS, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ANTONETTE M. ZEISS, OFFICE
OF MENTAL HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION,
CHIEF CONSULTANT, U.S. DEPARTMENT OF VETERANS AFFAIRS; ANNIE
SPICZAK, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR
WORKFORCE SERVICE, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ROBERT A. PETZEL; ROBERT L.
JESSEE
STATEMENT OF ERIC K. SHINSEKI
Secretary Shinseki. Thank you.
Mr. Chairman, Ranking Member Brown, distinguished Members
of the Committee, thank you for this opportunity to speak on
behalf both of veterans and their families but also the
employees of VA about this important issue of mental health.
Mr. Chairman, I ask the department's prepared written
statement that was previously submitted by Dr. Jessee be
included in the record.
The Chairman. Without objection.
[The prepared statement of Dr. Robert L. Jessee appears in
the Appendix]
Secretary Shinseki. Okay. Thank you.
Well, joining me today, as you have introduced them, are
the leaders and senior clinicians of the Veterans Health
Administration, who are the appropriate experts to provide
clinical staffing and policy information that you had requested
in your letter.
I want to be clear. Mental health and well-being of our
brave men and women who have served the Nation is the highest
priority for me, for this department, and for our Nation. We
are here to care for veterans' mental as well as physical
health and well-being.
Today's testimony takes me back a few decades, Mr.
Chairman, of my own experience coming back out of combat
situation. And I think you will appreciate why this has
priority for me and remembering some of the transitions I went
through.
I am here to speak to America's veterans and their families
as well and represent the dedicated employees of this
department and especially today to the 20,590 mental health
providers that are part of this discussion.
History shows that VA's requirements will continue to grow
for a decade or more after the operational missions as they
have in Iraq and next in Afghanistan come to an end.
And as veterans depart the military, we must ensure that
all of them have access to quality mental health care. I
believe we are all united in that pursuit. I believe the strong
actions taken under the President's leadership have illustrated
that clearly for the past four budgets.
And the last three years, VA has devoted more people,
programs, and resources towards mental health services to serve
the growing number of veterans seeking mental health care from
VA. Last year, VA provided specialty mental health services,
Mr. Chairman, as you pointed out, to 1.3 million veterans.
With the President's 2013 budget request, VA has increased
the mental health care budget by 39 percent since 2009 and if
we add to that the 2014 advanced appropriations request that is
currently being considered, that increases that factor to 45
percent.
Since 2007, VA has seen a 35 percent increase in the number
of veterans receiving mental health services, as the Ranking
Member pointed out, but at the same time 41 percent increase in
mental health staff to adjust to that.
And I think this describes a little bit of what we are
dealing with and that is in our process here, Mr. Chairman, you
resource us to a requirement and at best, those requirements,
because of the advanced appropriations request that gives us a
two-year budget, those requests are based on a prior year
number of folks who walk in the door. We try to extrapolate
that into some estimate of the future, but we are really
covering about four years as we look forward.
And what this really means is we are essentially in a react
cycle, that what walks in the door becomes the basis for
understanding what the requirements could be in the future
years.
And so if the trend line is smooth and uniform over time,
there is an opportunity in this system to react because it is
primarily reaction process.
Where we have spikes in that requirement, then we have
these occasional needs to address the staffing issue as we have
in this case.
Additionally, in 2010, I think we will all recall that the
department simplified its rules for veterans submitting PTSD
related disability claims which has greatly simplified access
to care and benefits and contributed to growth in the PTSD
mental health requirements.
So that was done in 2010. The claims have been submitted
and we are beginning to see a growth in PTSD mental health
requirements and, therefore, not unexpectedly, a requirement to
adjust our staffing.
VA's announcement on 19 April that we would add
approximately 1,600 mental health clinicians to include
psychiatrists, psychologists, mental health nurses, social
workers, as well as 300 support staff to our existing workforce
of 20,590 reflects both our commitment to mental health and
acknowledgment that changes in policy are having an impact.
And our efforts will likely not cease with the announcement
of 1,900 additional personnel being added to our workforce.
Future adjustments may be likely.
VA has a long history of being on the cutting edge of
mental health care whether through the use of vet centers, our
National Center for PTSD, our veterans' crisis line, or
integrating mental health into the primary care environment of
our health care facilities.
We will continue to review and monitor our facilities and
veterans' feedback so we can make other adjustments that are
needed and we will not hesitate to take action again. And I
appreciate the support of this Committee and the Congress over
the past years as you continue to provide us the resources we
need and the authorities we need to make this care available to
our veterans.
My invitation is let's continue to work together along with
our partners in the veteran service organizations focusing on
what is important, providing timely access to care and benefits
our veterans have earned.
And I look forward to working these issues with the
Committee and look forward as well to your questions. Thank
you, Mr. Chairman.
The Chairman. I apologize for the clock being on you, Mr.
Secretary. I ordinarily would not have done that. I just
noticed that it was on.
Did you have anything else you wanted to add? You kind of
sped up at the end and I do not want to take time away from you
in your testimony. Anything else you wanted to add?
Secretary Shinseki. No. I will let all the statements
stand. You have accepted our written statement and I am happy
to take questions.
The Chairman. Thank you. Thank you very much.
We will start a round of questions if we can. You talked
about the press release on April 19th. You have acknowledged
also that there are about, 1,500 mental health staffing
vacancies. It could be a bit more or less. And your testimony
today talks about maybe hiring more than 1,900.
So what I would like an answer to is, I know you are going
to try to fill the 1,500 vacancies that exist and you are going
to add an additional 1,900 plus staff. Is that correct? Then a
couple other things.
How quickly do you think VA can hire the additional staff?
Where are you going to put the additional staff? And how will
you be able to measure the impact that they will have on
improving care?
Secretary Shinseki. Mr. Chairman, let me just make an
opening statement here and then I am going to call on Ms. Annie
Spiczak who does the recruiting and retention personnel work
for us because you are asking to see what tools we have and
what our expectation here is.
We think that we will get most of that done in the next six
months, but some of these specialties are difficult to recruit
and I would, you know, be honest with you. I am not sure I can
pin a date when all of them will be in. But the vast majority
of the work will be done in the next six months. Some of this
may carry over into the second quarter of fiscal year 2013.
Let me call on Ms. Spiczak to talk about the process here.
Ms. Spiczak. Thank you, Secretary.
Sir, I would say that we have a four-fold strategy to
recruit and hire the mental health professionals that we need
in VHA.
The first part of that strategy is to have a very robust
marketing and advertising campaign to do that outreach to
mental health providers and professionals. That is by the use
of USA Jobs, using social media, getting all of those vacancy
announcements posted to specialty sites and job boards.
The second part of that is using our national recruiters.
We have 21 dedicated health care recruiters and they are very
involved with the VISNs and the medical center directors to
recruit those hard to fill positions, especially our
psychiatrists and our psychologists.
Thirdly, we are going to recruit from our active pipeline
of trainees and residents. VHA has a very robust training
program and they are an integral part to filling that pipeline
of our workforce.
And, fourthly, we are going to ensure that we have complete
involvement and support of VA leadership.
Secretary Shinseki. Mr. Chairman, I am going to call on Dr.
Petzel to just add some concluding points here.
But I would also point out that the national recruitment
program, the 21 high-quality recruiters that Ms. Spiczak
referred to all are veterans. Eighteen of them have extensive
experience in recruiting.
And for any new individual who joins the team, they go
through a training program and oversight, mentoring by some of
the old-timers. And so this is a pretty robust tool we are
talking about.
Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary.
Mr. Chairman, I just wanted to add briefly the VA trains,
has 1,000 psychiatric residency positions. We have over 730
internship positions for clinical psychologists just to mention
a couple of the professions.
We are the largest trainer of mental health professionals
in the country. And this group of trainees is the primary place
that we are probably going to be recruiting those individuals
to fill those 1,900 jobs.
And the last thing I would like to add is that the most
difficult to recruit group is psychiatrists, particularly in
rural or remote areas.
And we have recently sent a memo to the secretary which I
believe he has signed or is about to sign to change the pay
table for psychiatrists and to make available other incentives
so that we can compete more equitably with the private sector
and DoD in terms of recruiting psychiatrists.
The Chairman. Ms. Spiczak, how long does it take for VA to
fill a vacancy like the 1,500 that are open now for mental
health professionals? What is the average time that those
positions have remained vacant?
Ms. Spiczak. Sir, it takes anywhere from four to six. But
for some of our hard to fill positions, it can take up to a
year to fill those positions.
The Chairman. Have you ever been even close to a hundred
percent staffed at the full level with the 1,500 that you
currently have?
Ms. Spiczak. Sir, we will always have a turnover rate, a
vacancy rate, that we are always trying to close that gap, but
you have my commitment that we are going to work very hard to
close that.
The Chairman. At what level is the vacancy rate? Is it more
at the upper level or the lower tier? I hate to say lower tier,
but obviously the psychiatrist level downward, which is the
higher rate?
Ms. Spiczak. No, sir. Our turnover rate in fiscal year 2011
for our mental health professionals was 7.23 percent. And the
Bureau of Labor Statistics for the health care industry shows a
28 percent turnover rate.
The Chairman. The last question that I would like to ask in
this round is, how are we going to pay for the extra 1,900
mental health professionals?
Secretary Shinseki. For that question, I am going to call
on Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary.
Mr. Chairman, we have estimated that the cost in fiscal
year 2012 will be relatively small because it is going to take
some time to get these people on board. And we will use money
that we have available in 2012. We expect that this will not
exceed $29 million and maybe a bit less than $29 million.
In fiscal year 2013, we are going to separately identify
the funding for this particular initiative as part of each one
of the VISN's allocations and then the VISNs will receive a
hiring target based on this allocation. And we are going to
keep very close track of that hiring target.
Ms. Spiczak can give more detail about how we are going to
do that, but we are basically going to be daily looking at how
they are meeting that hiring target.
We will identify each one of these positions electronically
on USA Jobs by a special number so that we can track all of the
1,900 new people as well as all of the vacancies that exist
right now.
Secretary Shinseki. Mr. Chairman, just a data point.
Psychiatrists are the toughest to recruit. And I think under
this new model, we say it is about 57 that we are going to go
after in this group of 1,900. Of 57, 37 have already been
recruited. Seven are already serving. Thirty are being on-
boarded.
And so we are beginning to hone in on this most difficult
recruiting challenge and working it down. So there is some
evidence that we can recruit what we need here.
The Chairman. Before I turn it over to Ms. Brown, I also
want to say that I had the pleasure and the honor of
accompanying Ms. Buerkle to Syracuse, to visit the medical
center there. And I want to tell you that what I saw from their
mental health professionals was exactly what I think you want
to see around the country, the care and compassion they have
not only for the veteran but for the veteran's family as well,
and helping them to be able to assimilate and understand the
issues that they are confronted with.
And, you know, those ghosts, if you will, that the veteran
fights sometimes the family fights too. They have done what I
think is an outstanding job at that facility.
With that, Ms. Brown, you are recognized.
Ms. Brown. Mr. Chairman, I want to be the last on my side
because I have a real in-depth knowledge of this issue since I
have an educational specialist in counseling. And so I am
thinking about a different approach.
The Chairman. Very well. Mr. Reyes.
Mr. Reyes. Thank you, Mr. Chairman, and thank you, Madam
Ranking Member, for yielding.
And welcome, Mr. Secretary. We are looking forward to your
visit later on this month in El Paso.
And I guess my first question, does the VA do an ongoing
assessment? And the reason I am asking this question is because
since the 2005 BRAC, I will use my district as an example, we
gained the First Armored Division.
And as the downsizing of the army occurs down to 490,000,
we anticipate, and we are seeing already, a rapidly increasing
number of soldiers coming out of the army staying in the El
Paso region and, therefore, impacting our VA facility.
So my question is, is there an ongoing assessment to be
able to take care of areas like our district?
Secretary Shinseki. Congressman, this is a good point. And
this is a little bit of that resourcing to requirement that I
referred to. And the example I used was a decision to grant
PTSD, combat verified PTSD to anyone who had served in combat.
So for every generation from World War II to the current,
suddenly a new opportunity for them to receive care and the
numbers are beginning to reflect that.
Same issue here with the First Armored going to El Paso. We
are not part of that decision process.
Mr. Reyes. Right.
Secretary Shinseki. But we have worked very closely with
Department of Defense for the last three and a half years to
try to get better synchronization for us with understanding
where they are headed. And in many cases, they have shared with
us whatever they knew. Some of this First Armored going to El
Paso was probably a later breaking issue than we would have
been able to anticipate.
But, nonetheless, these are part of the changes that occur
in the requirements that then drive us to go back and review
our resourcing format. So, yes, I would expect that First
Armored soldiers would remain in El Paso and requirement for
veteran health care including mental health will go up and,
hence, a discussion about a future VA medical facility becomes
pertinent over time.
Mr. Reyes. Well, the assessment itself, is it ongoing or
how is that done by VA?
Secretary Shinseki. Well, heretofore it has been a sort of
acknowledge the requirement when people walk in the door
seeking help and that becomes a registration point of a
requirement for health care.
We have worked with the Defense Department to create the
single electronic health record so we would have a better
handoff, a warm handoff of individuals departing the military
who are coming to VA.
And we have worked at this with the attitude that everyone
who leaves the military ought to be enrolled in VA. And part of
the VOW Act was to create a transition assistance program and
we have been in discussions with DoD about how to structure
this.
For our purposes, during the transition period, we would
like to see individuals still in uniform have access to my
healthy vet, to e-benefit so that they are in our database
before the uniform comes off.
And as you know, we are working towards this integrated
electronic health record that will transfer automatically all
the information that they have built up in their military
service coming over to us.
And we are shooting to have integrated health record
probably initially, initial form of it ready in about two
years.
Mr. Reyes. And at what point or at what stage will
facilities like the one in my district get an idea of how many
additional personnel will be coming out of the new hirees?
Secretary Shinseki. Let me ask Dr. Petzel to provide that.
Dr. Petzel. Thank you, Mr. Secretary.
Congressman Reyes, we are right now discussing the
allocations with the VISNs. Dr. Schohn and her group actually
are doing that. And we expect that we will know within a couple
of weeks at probably the latest what it is going to specific.
Let me just go back to the question that you asked the
secretary and add one more thing. You talked about being able
to anticipate a surge or an increase in the number of people.
The foundation for how we determined the 1,900 people that
we felt we needed to distribute across the country is a
prototype of a staffing model. No one in this country has a
staffing model for mental health. We have developed what I want
to call a prototype because it has not been fully vetted.
But that model then can be applied to any population of
patients requiring mental health services to predict the kind
of both support personnel and mental health professionals that
are needed. This is going to be an ongoing assessment across
the Nation of our needs.
And we would hope to be more anticipatory now with this
model and less reactive than we have been in the past so that
in terms of returning veterans, we will be able to predict the
need and have the resources in place to be able to manage that.
Mr. Reyes. Great.
Thank you, Mr. Chairman.
The Chairman. Dr. Petzel, you are talking about the
allocation of resources and it begs the question--what type of
a workload analysis did you do prior to the announcement that
1,900 was the number? Could it be considerably more than 1,900,
could it be less, or was that just kind of a middle figure that
you worked with just to roll it out?
Dr. Petzel. Chairman Miller, that is an excellent question.
And Dr. Schohn can talk more detail about how this
prototypic model was developed, but it basically looks at the
population of patients requiring mental health services. And it
is able to say, as an example, across the country, we feel as
if we need about 5.3 mental health professionals for every
thousand patients that are presenting.
We began doing this, sir, back in November. This was not a
reaction to the IG. We began looking at what kind of staffing
increases we needed back in November. Dr. Schohn and her group
developed a prototype of this model, applied it, as well as
other information that we had and arrived at the number of
1,900.
It is being in a very detailed fashion tested in three
networks to see how predictive it actually is, but we think it
is going to allow us to do a better job of anticipating need in
the future and we think it appears to be quite reliable.
The Chairman. If, in fact, you did start back in November,
why wasn't this proposal in the President's budget submission
this year?
Dr. Petzel. We had not developed the model and we did not
know for sure until at least into January how this might work
and exactly the number of people that we would want to apply.
The Chairman. But I think even in January it would have
been able to have been included. I mean, two weeks after the IG
report comes out, it looks like a knee-jerk reaction. And I can
appreciate the fact that you may, in fact, have been working on
it.
But if you knew it was going to be an issue, I think it
would have been wise to have included it, especially a number
as large as 1,900, in the President's budget submission.
With that, Dr. Roe, you are recognized.
Mr. Roe. I thank the Chairman and I thank the secretary for
being here.
And I would like to introduce a guest before I start with
any questions. I would like to introduce a constituent of mine
from east Tennessee, Staff Sergeant Derrik Plank. Derrik is a
combat-wounded veteran who entered the army in 1995 right out
of high school and went on to serve three tours of duty in the
former Yugoslav Republic under General Shinseki, Bosnia, and
Iraq.
Derrik served with the Fourth Infantry Division in
Operation Iraqi Freedom. On May 5th, 2003, he suffered a
traumatic brain injury caused by shrapnel wounds when his tank
was attacked by an RPG. Derrik retired later that year.
As a reward for his bravery, Derrik was awarded the Bronze
Star for valor, the Purple Heart, four army commendation
medals, and a combat action badge.
He holds a master's degree in arts and education from East
Tennessee State University as well as a doctorate in education
from the University of Maryland.
He continues to be very active in the veterans community
and is a strong advocate on their behalf. As a part of this
support, Derrik recently wrote a lengthy dissertation on
suicide prevention and the proper treatment of mental health
injuries among veterans and servicemembers. And I would
certainly recommend that you read it.
As a veteran and doctor and co-founder of the invisible
wounds caucus, I recognize firsthand the need to address these
issues.
And I want to thank Derrik for his service to our country
and his efforts to continue supporting our veterans.
[Applause.]
Mr. Roe. I thank the Chairman.
And, Derrik, thank you for being here today.
And I do strongly encourage you to read this not from the
bureaucratic point of view but from the eyes of a veteran who
has been through the various treatments and sees the positives
and the minuses.
I think one of the things he brought up in his dissertation
that I read is, and it is a tough issue, Mr. Secretary, when a
soldier goes in, we have been very sensitive in this country
about culture, and it has been an issue as you have seen
recently and the photos that have been made. Our leadership
from someone like yourself has been very culturally sensitive.
The question is, is the VA being culturally sensitive when
it treats veterans?
Derrik's concern is when he goes in to see someone who is a
mental health provider who may be from a different culture, for
instance, Major Hassan is a perfect example of that, it is very
hard for these veterans to go and display these issues that
they have with someone that a few weeks or months or years ago,
even when these issues pop, that were the enemy. And it is a
real issue.
Is there any sensitivity on the VA's part--maybe Dr. Petzel
can answer this--in hiring individuals to treat these veterans
because it has been an issue for Vietnam era veterans and
certainly is an issue today for our Iraq and Afghanistan
veterans?
Secretary Shinseki. Congressman, I am going to call on Dr.
Petzel here to try to address the specifics of your question
which is a good one.
But I am also reminded that this is why this model we are
talking about is imperfect. I mean, it is the best we have
right now. It will get better as we finish the piloting. And
this is to get to the staffing issue.
What you are talking about is the special trust that
develops between a patient in the mental health arena and the
provider. And this is unlike the relationship in other
disciplines of medical delivery. Without that trust, not much
positive will come out of it.
And so I think here in the mental health side of medicine,
we are into the art of understanding what the right staffing
levels and capabilities are, whereas maybe in the other
disciplines in medicine, it is more the science where you can
measure and metric and get pretty accurate outcomes.
So when Dr. Petzel says he started with his staffing model
and began to adjust it in ways that would be helpful to mental
health, we are still learning how to do this because we have to
get to this answering what is the right number and what is the
right relationship we are trying to develop here.
And I would expect that there would be some concern like
you are describing that we would have to take on and deal with.
But we will do that as we see patients. And let me ask----
Mr. Roe. I think these issues make it almost impossible for
that veteran to get the quality care. It is not the quantity so
much but the quality.
Secretary Shinseki. Yeah.
Mr. Roe. In his case, it was very difficult.
Secretary Shinseki. Yeah.
Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary.
And, Dr. Roe, thank you.
You bring up an incredibly important issue and that is the
ability of not just in mental health but in medical care in
general the provider being able to empathize culturally with
the person that they are talking to. Do they understand where
they are coming from? Do they understand what the nature of the
experience is that they have had previously that have led them
to seek medical care?
And I am proud to say the VA has pioneered a program to
teach in medical schools and in other clinical education
settings about the military culture, about the issues
associated with combat, about the problems that may be faced by
somebody who has recently been discharged.
And I would venture to say that in almost every medical
school now in the country there is a section of education both
for medical students and for residents about dealing with
veterans and dealing with the issues of the military culture.
Mr. Roe. Dr. Petzel, I know Congressman Reyes and
Congressman Walz, myself, others have served. And how many of
these mental health individuals are veterans, because I think
it is--you know, when you put your pants on every day with
these guys and you go out in the tents and you go out with
them, you have a different view? I can tell you you just see
through a different set of lenses.
Dr. Petzel. The only figure I know, Congressman Roe, is at
our vet centers, the 300 vet centers that we have around the
country, 70 percent of those people working in those vet
centers are veterans.
Mr. Roe. What about the 37 psychiatrists that General
Shinseki has spoken of and dealing with those?
Dr. Petzel. I do not know, but we can certainly find out
and get back to you about that.
Mr. Roe. And it does not mean that you cannot provide good
care. I do not mean that at all. You certainly can. You do not
have to have had a heart attack to treat one. I understand
that. But certainly if you are treating combat stress, boy, an
ideal person is somebody like Derrik or someone who has been
there as General Shinseki has on many occasions. It is again a
different set of lenses that you look through.
Dr. Petzel. Just one more thing, Congressman, I would like
to add that I neglected to mention earlier. We have started
because of legislation that Congress passed, we have started
developing a peer counseling program and are in the process of
training 400 peer counselors that will work in our medical
centers. And these, of course, will all be veterans.
Mr. Roe. Okay. I yield back.
The Chairman. Mr. Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman.
Thank you, Mr. Secretary, and the panel for coming here
this morning on this very important topic, especially after the
IG came out with their report last month.
And I am very pleased to see the VA's response. In the
report and that I would like to quote, it says, and I quote,
``Unequivocally committed to providing veterans the best
possible care, the VHA would act rapidly on all findings that
may improve veterans' access to mental health care,'' end of
quote.
As the VA knows, the timeliness in providing that care is
extremely important when you are dealing with PTSD patients and
I really appreciate that.
My question is, do you believe that contracting to non-VA
facilities that have a proven track record in this regard would
be extremely important?
And the reason why I ask that question is looking at the
1,500 current positions that are vacant, looking at the 1,900
new staff that you are looking to be bringing on board, it is
going to take some time to get those on board. And,
unfortunately, some of our veterans I do not believe can wait
that long. So you have to look at other areas where contracting
has proven to be successful.
And I mention that because actually earlier this year,
Congressman Mike Thompson invited me out to California to visit
a program that they are currently offering out there in
California, pathway homes. And I had a great opportunity to
talk to a lot of the veterans that actually have gone through
that particular program and they had nothing but high praises
for the program.
And I also asked why did you not go to the VA and some of
them mentioned they just felt like they were a number in the VA
system. They did not feel that they were getting the
appropriate health care needs that they thought they might get.
So they went to this particular program which seems to be very
successful.
So I know contracting out has always been a concern among
some of the VSOs and the VA, but this program seemed to be a
proven program.
So is the VA going to be looking towards contracting out to
help relieve some of the burdens that is currently there in
this area?
Secretary Shinseki. I am going to call on Dr. Petzel for
that, Congressman.
Dr. Petzel. Thank you, Mr. Secretary and Congressman
Michaud.
We have several mechanisms for reaching out beyond the VA
to provide care and we do use them. One of them is fee basis as
I think you are familiar, non-VA care where we actually allow
people to be seen by private practitioners. And they then bill
us and we pay for the service.
And the other is contracting. And we do have in mental
health as well as in other parts of our health care system, we
do have contracts on the outside, often in places that are
quite remote or rural where we do not have a provider.
If you look at our system of community-based outpatient
clinics, we have over 800 of them and we provide mental health
services in virtually all of them. And many of them, that is
done by contract. We have a contract with mental health
providers in the community and that is the way we deliver
services in that clinic.
So it is an excellent idea. It is an excellent suggestion.
We do do it. And in some remote areas, I think we are going to
have to be doing it more than we do now.
Mr. Michaud. In the interim, until you get all the new
employees that you plan on hiring, I would assume that you
probably would need to take care to do more of it at least
initially for programs that have worked. And that is a concern
that I have is the lag between when you get these new employees
on.
You mentioned the CBOCs and the VA system. Are there
current plans now to upgrade, you know, the business plan for
these different areas to look at the increase of new employees?
How far along is that process?
Dr. Petzel. I am not sure I understand, Congressman
Michaud, the question. In terms of the facilities, yes, we are
updating their business plans to reflect the new people----
Mr. Michaud. New model.
Dr. Petzel. --that are coming on board. Exactly. And you
make an excellent suggestion about fee and contract. And we do
have other things that they can do in the interim, locum
tenens, and shifting some resources within the medical center.
But fee and the possibility of contracting should also be a
part of that. Absolutely agree with you.
Mr. Michaud. And my last question is, looking at the
additional 1,900 new staffing, is that to take care of the
current needs that are currently out there today and have you
taken into consideration over the next five years that there is
going to be about a million soldiers back in--will be into the
VA system, a huge increase? So does that 1,900 address the one
million that will be coming into the VA?
Secretary Shinseki. Congressman, the 1,900 addresses what
we know are today's needs. And we have said, as I said in my
opening statement, we are comfortable with this, but this
requirement could likely grow and, hence, the importance of our
relationship with DoD and being able to see what the future
brings.
The one million figure I have used and others have used, as
we talk to DoD, they indicate that that is not going to be as
big a spike as at one time was predicted. That reality is it is
going to be a much smoother transition out. It will still be an
increase, but this will be something that we think with this
model that they have created and we are piloting, we will begin
to anticipate a little better than we have which has been
primarily reaction.
Mr. Michaud. Thank you.
The Chairman. Mr. Stutzman.
Mr. Stutzman. Thank you, Mr. Chairman, and thank you for
having this hearing today.
I want to thank Secretary Shinseki for being here. It is
good to see you and thank you for your service and all that you
work to accomplish at the VA. This is obviously a very
important issue.
And I represent northeast Indiana where we are going to be
having a new outpatient mental health care facility that is
being built there. And with the IG's report that has just come
out, you know, this is obviously concerning.
And I am curious why these issues which have been raised
numerously have not been resolved. I know the VA has convened a
working group to attempt to address these problems in the IG
report.
My question is is, what is going to be different about this
particular group? What is going to be different about your
approach this time in tackling these problems so that, you
know, I can make sure that the veterans back home are confident
of the services that they receive?
Secretary Shinseki. Let me call on Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary, Congressman Stutzman.
I will do just a little bit of history about measuring wait
times which is, I think, what this is about. There are three
different ways to do this. One of them is to look for the third
next available appointment. That is called a capacity measure
because it measures your capacity. It does not give us
information about how long any individual would have waited.
And we at one time used that to predict our capacity for seeing
patients in the clinic setting.
But the two other ways of measuring this are desired date
which is you ask someone, a provider or a patient when do you
want to be seen. They say a date and then that becomes the mark
and you see how close to that date you can actually get the
appointment. It is called desired date.
The other is creating date. It means that there is no
interest in what the desire of the patient or the clinician is.
It is the day that that appointment is asked for. It becomes
the create date, relatively inflexible, but very easy to
measure and very easy to do.
We have used desired date since about 2007, 2008 and
trained everybody about how to do desired date, et cetera. It
is clear both from our look and from the IG's look that there
are difficulties for new patients with desired date.
So the first change we are making is that new patients are
going to be tracked based on create date so we can be
absolutely certain of that particular date. It requires no
judgment on a scheduling clerk's part. It is the date that that
appointment is asked for. And I am quite certain that is the
conclusion the work group is going to come to.
The second thing that we have to address then, and that is
only 17 percent of our appointments, our new patients,
relatively small amount. You have to remember that people
access our system in a lot of different ways. They come into
the emergency room. They call the crisis hotline. They are in a
primary care clinic and they are treated for mental health
there or they are referred out.
Very few people actually walk in or call in and say I want
an appointment in mental health, so we have to address how we
are going to measure appointment times with that other 83
percent of the patients and that is the primary job with this
work group.
We need to. Absolutely agree with the IG. We need to be
able to tell our veteran patients, our employees, and you how
long people are waiting to get times. And we are not able to
provide the data to be accurately doing that right now.
We will work with the IG after we come to a decision about
what we want to do to be sure they understand and agree about
the way we want to do this so when someone comes to audit this,
we will not have the confusion and the issues that we had with
this audit.
Mr. Stutzman. Okay. I know my time is short here. But in
the next panel, we will hear from a private sector provider who
states that they are able to increase patient access and
satisfaction by trying to fill open appointment slots with
patients waiting for appointments.
Does the VA have a similar system in place? If not, or yes,
no?
Dr. Petzel. I would ask Dr. Schohn to respond to that.
Ms. Schohn. Yes. Actually, at local sites, certainly people
keep lists to get people in sooner. That is part of the sort of
routine standard of practice.
Mr. Stutzman. Okay. All right. Thank you, Mr. Chairman. I
will yield back.
The Chairman. Mr. McNerney.
Mr. McNerney. Thank you, Mr. Chairman.
Thank you, Mr. Secretary, for coming today and your
testimony.
There is no doubt in my mind about your commitment to this
issue. There is no doubt in my mind about it and the dedication
of your staff. I am sure that psychiatrists could make more
money in the private sector, so working for the VA shows a
certain amount of dedication. I appreciate that.
My first question is really following up on an earlier
question. Dr. Petzel, I just want to be really clear in your
answer about this. Do you believe that the VA should assume
responsibility for treatments when the patient is referred to
outside agencies by the VA for PTSD or TBI treatments?
Dr. Petzel. Well, Congressman McNerney, yes, we are
responsible. When we refer somebody out, the patient is still
our responsibility. We have a responsibility to see that that
is high-quality care, that it is done in a timely fashion, yes.
Mr. McNerney. So the VA is assuming responsibility for
payments to these outside agencies?
Dr. Petzel. If we refer somebody to an outside
organization, yes, we are responsible for the payments.
Mr. McNerney. Okay. Thank you.
Secretary Shinseki, Chairman Miller, and this is a follow-
up on Mr. Stutzman's question actually, mentioned that the IG
report gives a two-month waiting period for some veterans
seeking mental health assistance.
What was your reaction to that? It sounds like from Dr.
Petzel's testimony that the standard for judging that two
months is a little bit mushy, but I would just like to hear
what your response is to that.
Secretary Shinseki. Congressman, I am not sure I would have
concurred in the IG's report exactly the way the department
did. And the reason I say that is like all of you, I am trying
to figure out what the issues are and how to apply our
resources and energy.
And so we have this large health care system in which if
you enter a vet center, you are into mental readjustment
counseling and if required, you get referred into the mental
health system.
As Dr. Petzel has indicated, there are 300 of these vet
centers out there. There are 800 plus community-based
outpatient clinics in which you can enter the mental health
system through contact with a primary care provider.
And that grows when you add our telehealth links, that
people in remote or even not so remote community-based
outpatient clinics can be linked in to psychiatrists,
psychologists that is at a distant station. So there is a level
of robustness here that I understand exists.
There are 152 medical centers and you can enter the system
by going to the mental health clinic and the medical center or
you can go enter the system through the primary care arena in
that same hospital because we have integrated mental health
care in with primary care providers or you can enter it through
the emergency room after hours if you need care. There is an
opportunity to get connected to a mental health provider and
then referral.
So a fairly complex system and we have added to that with
the homeless initiative that we have put in place. It is a
robust system in which entry into mental health care is
numerous.
I welcome the insights from the IG. I also welcome their
help in helping us create a model that will solve this
scheduling issue that occurs in a variety of ways. And it is
not just at the scheduling desk in a mental health clinic. It
is one entry point.
And I do not know that we fully understand and can measure
right now the robust aspects of what we do in mental health.
And my guess is we are doing good work here. We are just not
able to document it.
Mr. McNerney. Thank you.
Dr. Petzel, could you give me a little insight into the
nature of the model that has been developing, the staffing
model? Is it an Excel spreadsheet or how does it work? What are
some of the details?
Dr. Petzel. Congressman, I would like to turn that over to
Dr. Schohn whose group actually developed that model.
Mary, could you help.
Ms. Schohn. Sure.
We developed the staffing model using the same kind of
methodology that VHA previously used in developing a method to
look for our staffing model for primary care. And that included
looking in the literature to look and see what is out there,
what has been published.
There is very limited literature on outpatient mental
health staffing models, a little bit more literature on
inpatient, but we were really focused on outpatient.
We also connected with other health care systems, so we are
aware that DoD is actually piloting a staffing methodology and
we got details from them and ran it by our subject matter
experts.
It was promising, but we have a variety of different kinds
of services than DoD offers to its constituents, so we were
unable to effectively adopt that system.
We also talked to Kaiser Permanente to see, in fact, what
kind of model they had and they currently do not have a model
of the kind that we are looking for.
We were unable to get any information from other systems,
so we looked to our own data and we looked at the utilization
standards, staffing models and so on to look at the numbers.
We also had looked at what are the predictors of staffing
within VA. So we ran a model that looked at, you know, what
predicts. It includes things like, not surprisingly, the number
of patients served, the kinds of services, so including
residential services, inpatient services, as well as some
characteristics of facilities where patients are at, so things
like, is it a teaching hospital, are all predictors.
We put that together and we looked at our data and
identified that as kind of a starting point for us, 5.3
independent clinicians per 1,000 veterans looked like the place
to start in terms of looking at does this effectively do what
we want to do in terms of improving access as well as providing
veteran and provider satisfaction.
Mr. McNerney. Thank you, Mr. Chairman. I yield back.
The Chairman. Mr. Johnson.
Mr. Johnson. Thank you, Mr. Chairman.
And, again, Mr. Secretary, it is good to see you here
today.
I am going to start off with a little bit of a difficult
question. You know, year after year in annual budget
submissions and annual performance reports, quarterly reports,
congressional testimony, and in countless press releases and
statements, the VA has consistently touted the 14-day standard
as the number one measure of mental health care access.
In a five-month investigation, however, the IG found that
measure to have no real value and to be essentially
meaningless.
Mr. Secretary, how is it possible that that is not bubbling
up to your level? How is it possible that you do not know that
and who is responsible for misleading Congress and the public
on this metric and how will they be held accountable?
Secretary Shinseki. Congressman, I do not think anyone has
misled Congress here. Dr. Petzel described three methods of
identifying in the scheduling arena capacity, desired date,
create date.
They have in the mental health arena been using desired
date now since 2007 and my understanding was this goes back to
when we had a previous discussion like this.
I am not sure how the results were achieved, but it just
seems to me that desired date and create date in the report are
brought together in a way. It is hard for me to determine
whether there was a pure assessment of whether desired date was
being executed properly, whether staff were properly trained
and following the instructions. That would allow us to focus on
corrective actions.
Right now part of my discussion with Dr. Petzel is that we
have got to sit down with the IG and make sure we come up with
a clear standard here so that when we audit in the future,
there is not this confusion about which date we are using and
that we get a cleaner outcome and understanding.
I am not able to address the specifics here, but I would
assure the congressman there is no misleading of Congress.
Mr. Johnson. I can certainly agree that there is no
intention to do so, but I think we all agree here that the
objective here is to make sure that those veterans that request
mental health counseling get it as soon as absolutely possible.
Secretary Shinseki. I would just like to assure you so we
do not confuse the two terms, access is being able to get
treatment. Scheduling is the timeliness of this. Both are
important. But I want to assure you that veterans who and even
active component individuals who come to us for mental health
care do have access.
We are going to go to work on the scheduling issue to make
sure that timeliness standards are clear and that we can
measure whether we are achieving them.
Mr. Johnson. Okay. Thank you.
Dr. Sawyer who we will hear from on the next panel
mentioned in her written testimony an issue of space for
clinicians at some VA mental health facilities.
What is your plan to make sure that the 1,900 new
clinicians and support staff will have adequate space to do
their jobs?
Secretary Shinseki. Let me call on Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary.
Congressman Johnson, the two relatively rapid ways we have
for dealing with space issues are the nonrecurring maintenance
and repair money and the minor construction money.
We do have already in the pipeline projects in both those
areas dealing with ambulatory mental health as well as other
ambulatory space.
In addition to that, we can give priority right now because
they fall into one of the five special categories, we can give
priority to move nonrecurring maintenance and repair money
projects that deal with mental health up. And we are going to
do everything that we possibly can to see that the projects
that need to be done to create this space is done.
I cannot argue with the statement that there is going to be
or there are going to be space issues at some places. We are
going to address those as quickly as we possibly can.
Mr. Johnson. Okay. One final question. Do your performance
measures only apply to OIF and OEF veterans or any veterans?
Secretary Shinseki. Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary and Congressman
Johnson.
No, they do not. We have a long list, and I want to just
briefly mention them, of performance measures that look at all
categories of veterans.
Now, the timeliness is just one performance measure. There
are many other things that we look at. Are patients timely
referred if they are at risk for suicide? And we track that.
Are patients getting the eight sessions of individual
psychotherapy within eight weeks if it is prescribed and if it
is needed? Are high-risk patients being referred to the high-
risk patient case management in a timely fashion? Are we
following up post discharge? Everybody is supposed to be
contacted after discharge from a mental health facility within
seven days of the discharge. Are all new patients being
screened for depression, alcohol misuse, and in the case of
OEF/OIF particularly PTSD?
So, no. The performance measures apply to every single one
of our mental health patients.
Mr. Johnson. Okay. Thank you.
Mr. Chairman, I yield back.
The Chairman. Ms. Brown is going to go ahead and ask her
questions, Mr. Walz, if that is okay with you.
Ms. Brown.
Ms. Brown. Thank you, Mr. Chairman.
Recently I participated in a workshop with Secretary
Donovan and the Mayor of Jacksonville and the issue was
veterans, just veterans and veterans' mental health.
And we were discussing how we can combat this working with
our partners, not just the VA, but how can we work with other
stakeholders.
And recently I visited the VA facility in Los Angeles. And
the reason why I mention that I had an educational specialist
in counseling is because I think everything should be group and
counseling and working in that group setting.
I was surprised the number of veterans talked about how
they prefer or in addition like the online and accessing the
system.
Can you tell us how you plan on expanding the system to
include that aspect of, you know, video conferences and other
aspects?
Secretary Shinseki. Let me call on Dr. Petzel. We are doing
many of these things now, Congresswoman.
Ms. Brown. You are, but I was surprised that they liked it.
Secretary Shinseki. That is a new generation.
Ms. Brown. Yes, it is.
Secretary Shinseki. They are folks that are very
comfortable with the technology and they do not mind that
little gap distance----
Ms. Brown. That is right.
Secretary Shinseki. --between themselves and the provider.
Dr. Petzel. Thank you, Mr. Secretary.
Congresswoman Brown, you put your finger on what I think is
probably the most important future development in not just
mental health services delivery but in medical care delivery in
general and that is tele-mental health and telehealth.
The VA is a pioneer in tele-mental health. We had over
150,000 people using tele-mental health facility services this
last year. It is particularly important in rural and remote
areas.
Just as an example, we have a telehealth PTSD treatment
program on the Rosebud Indian reservation in South Dakota. It
has been in existence for almost ten years now. And it provides
PTSD treatment for Native American veterans living in Rosebud
and Pine Ridge reservations being followed by a psychiatrist in
Denver at the University of Colorado.
So we absolutely agree with you. This is a fundamentally
important thing. We are pushing the development of tele-mental
health particularly as rapidly as we possibly can.
One more example of that. I dedicated or helped dedicate a
new mental health building at the Pittsburgh VA Medical Center,
a state-of-the-art inpatient and outpatient facility. They have
19 cubicles for mental health providers to be providing tele-
mental health at remote areas in Pennsylvania.
Ms. Brown. Thank you, and that is very helpful.
But one of the reasons why I mentioned the meeting with
Secretary Donovan was that we talked about the array of things
that needs to go to help veterans like the housing, like the
casework, making sure we have a caseworker there in the homes
that we are working with. And we have many stakeholders and
partners that is already doing it and want to partner with us.
Seems like we in Congress in many areas, we always talk
about--I do not like the word even--outsourcing or, you know,
that is a negative to me, but in this area, it seemed like it
makes some sense to partner with people that have the same
level of expertise as long as we have the oversight and making
sure because the problem is so deep.
Secretary Shinseki. Congresswoman, good points. We do not
rely on just our internal capabilities. I think Dr. Petzel has
referred to fee basis contracting. Telehealth, telemedicine,
you know, I think we are doing the right things in investing in
the technology for the years ahead. I personally do not think
we are investing enough. If this is the breakthrough in medical
delivery in the future years that is going to create, reduce
the tyranny of distance and get veterans, patients in need of
help in contact with health care providers I think this is it.
If it is, I think we could be doing more here in investments.
But we are moving quite smartly. $360-some-odd-million this
year investing in telehealth connectivity.
Let me call on Dr. Petzel for anything else he adds here.
But especially in the area of mental health we talk about it as
though it was all one kind of issue.
Ms. Brown. Yes.
Secretary Shinseki. And it is all individual. And we also
find out that you almost have to tune to the individual patient
the care that is going to make a difference. And so we want to
have as many options as are available and that we can afford to
be sure that we have something that will work.
As you know we have five polytrauma centers. The most
recent one opened in San Antonio. I happened to visit the one
in Richmond and while they were giving me a tour I
encountered--with a veteran briefing at each station. At one
station I encountered a female person who in this polytrauma
center was, spoke to me and there was no speech problems that I
could see. Had all appendages. And I said, ``This is a
polytrauma center. Are you a member of the staff?'' She says,
``No, I am a patient here. I am one of those comatose patients
who came in here some time ago and this place brought me back
to consciousness and brought me back to the ability to speak,
and walk, and do all the things I did before.''
We are doing some terrific things here. And when I ask
people, ``What is opening the door?'' You know, there is really
no good answer. Because when you push the envelope you do not
necessarily know how to seal the lid on things. You just keep
going. So this young lady is a promotable master sergeant in
the United States Air Force. She is going to leave Richmond
here sometime this summer, according to plan, and she will go
back and be promoted on active duty.
So we need as many tools as we can get, and that is what
you are talking about here.
Ms. Brown. Yes, sir.
Secretary Shinseki. And we will look to incorporate as many
as we can and balance that in a way that is both efficient and
cost effective.
Ms. Brown. Thank you again for your service, sir.
The Chairman. Ms. Buerkle?
Ms. Buerkle. Thank you, Mr. Chairman. And thank you,
Secretary, for being here, and to all of you for your service
to this Nation and to our veterans. I think that is the place
we all start at, how can we make sure we are doing the right
thing for our veterans?
I am chair of the Subcommittee on Health and many of you
have been here and testified before the Committee. In December,
on December 2nd, we had a hearing in the Subcommittee regarding
suicide and the grave concern that we have at the rate of
suicide. And of course, that plays into what we are talking
about here today. There is not really the luxury of time, and
that was part of that conversation, and it is again the part of
this day's conversation. We do not have the luxury of time. We
do not have the luxury of sitting down and trying to come up
with plans and think tanks. We really need to act
expeditiously.
In that hearing Dr. Jan Kemp spoke and she testified on
behalf of the National Mental Health Suicide Prevention at the
Veterans Health Administration. And she talked to us about the
VA has significantly expanded its suicide prevention program
since 2005, when it initiated the Mental Health Strategic Plan
and Mental Health Initiative funding. So that has been in
place. There is an awareness of Post Traumatic Stress. There
has been an awareness. Why now is, it, I get the impression
this morning that now the IG's report came out so now there is
increased awareness. This is nothing new. This is, she assured
us in that hearing that the proper steps were being taken. And
my concern is that there is a lack of coordination. That many
good things are happening within the VA, and as the Chairman
pointed out in Syracuse we have an excellent facility, always
ready to meet the needs of the VA. But I am concerned about a
lack of coordination. We have heard that in other hearings,
that one hand does not know what the other hand is doing. And
ultimately those who get hurt are the veterans. So if you could
comment on that?
Secretary Shinseki. Congresswoman, I could not agree with
you more. Better coordination is needed. We think we are doing
good work but there is more to be done. And I think the issue
here is trying to come up with a good scheduling tool that will
allow us to incorporate all of the opportunity that is
available in the VA system and do what you are suggesting. And
better coordination will enable us to have faster access to the
right quality of care that veterans need.
We need a tool to do this. Right now we are operating one
that is 20 years old?
Dr. Petzel. Oh at least, yes.
Secretary Shinseki. And it has been useful but it has I
think, you know, it has outlived its usefulness. We need to
move on and we have taken steps to do that, come up with a new
tool. Let me call on Dr. Petzel here.
Dr. Petzel. Thank you, Mr. Secretary. Congresswoman
Buerkle, you bring up, as the Secretary pointed out, an
excellent point. A couple of things I would like to mention.
First of all, the assessment of staffing goes back a long time.
This was not a reaction to an IG report. We began looking at
this long before the IG was even out in the field. We
appreciate the fact that they substantiated what we feel is the
case, and that is that we needed to have more staffing and
particularly in certain parts of the country.
In terms of the integration and coordination, let me tell
you how we try to accomplish this. We have set up within the
last two years a unit in our operating organization. There is a
group of people that operate the medical care systems. And up
until two years ago when I got here there was no clinical
presence there. It was basically an administrative operation.
What we have done is taken clinical people from other parts of
the central office organization and put them into operations.
Dr. Schohn is the person who that is responsible centrally for
the operation of the mental health system out in the field. She
has a lead in each network. She has a council in each network
composed of the leads from each one of the medical centers. And
this is the way we intend to create a uniformity of
distribution of care to assure that the evaluation of care is
being done in a comprehensive, thorough way. So I think that we
are going to have a much better grip on the integration of our
health care deliver system.
But I do want to point out that this system is without
question the best integrated mental health care delivery system
in this country. Nobody has the breadth and the depth of
services available that we do.
Ms. Buerkle. Thank you, Dr. Petzel. I just, if I could, I
would like to make comment of my colleague from Florida about
the concern that, I do not believe that the VA can do it alone.
We need to partner. We recently had a symposium in Syracuse
about communities partnering. And I would please ask the VA and
the way you think it is going to take the VSOs, it is going to
take the private sector, it is going to take communities, it is
going to take the clergy and churches to work together to make
sure that the veterans have what they need and what they
deserve. And we have got to stop thinking in terms of silos. We
as communities, we as a country must reach out and provide what
it is our veterans need. I thank you all very much.
Secretary Shinseki. Congresswoman, I could not agree with
you more. And then if you were to look at what we have tried to
do in the homeless effort, the thing I think I am proudest of
is we have connected from our level, the national level, down
through the network directors, down through our medical
centers, and out into the communities, touching all of the
providers and nonprofit organizations that work with the
homeless to create this collaboration that you are talking
about. And it has begun to show results. So I could not agree
with you more.
Mr. Bilirakis. The gentleman from Minnesota, my good friend
Mr. Walz. You are recognized.
Mr. Walz. Well thank you, Mr. Chairman. And Mr. Secretary,
thank you and your staff for being here today. This room with
you being at the point of it understands care of our warriors
is our top priority, whatever it takes. And I have said it many
times, I will continue to say it. I am your staunchest
supporter and I can be your harshest critic as we ask. And so
when the IG reports come out we value their input to this. But
I want to, I want to make several things clear. I want to thank
the Chairman for holding this. I would like to ask him, and
hopefully right now let us schedule the follow-up for this
because you will want us to see what happens in six months and
things down the line. But the Chairman is not here, but I would
make mention. I was going to ask him. I think his comments in
his opening statement that this is an example of government
bureaucracy gone wrong, if only it were that simple. We could
handle that, I think, even though a tough one there.
This issue is far broader than that. This issue of mental
health parity and mental health care is absolutely fundamental,
one of the issues this country needs to face. And less than two
weeks ago Senator Domenici, former Senator Domenici had an op
ed in the Washington Post where he stated, ``mental health
insurance plans still refuse to cover lifesaving mental health
treatment. Others create discriminatory barriers to care, such
as imposing stricter prior authorization requirements for
mental health care. And sadly, underscored in a recent report
by Assistant Secretary for Planning and Evaluation at Health
and Human Services levels of care for evidence based behavioral
treatment such as residential psychiatric services are being
eliminated because of uncertainty of what is required.''
This is an issue of mental health parity and much broader.
Senator Domenici spent a career on this, Senator Wellstone did
so also. So I take this, that we do have to come together. It
was echoed by Ms. Buerkle. It was echoed here. And I think you
have talked about leading this, that this is a collaborative
effort. This is our opportunity to create the model. There is
no private sector model to go grab to fix the problem on this.
Mayo Clinic's CEO met with me last week about trying to see if
I can help foster collaboration on telehealth with the VA
because we know that that is Mayo's model that they are moving
to with the lessons that were learned.
So this is a much broader issue. This is an issue where we
are going to have to, as Ms. Buerkle said, work together to
find solutions because volume numbers do not matter, good
intentions do not matter, outcomes matter. And we as a Nation
are going to have to address this. So I am certainly not going
to be an apologist for if there is care not being delivered
appropriate, timely, and effective to our veterans. That is
where I will be that harsh critic. But I think we need to look
at this in the macro sense of what you are saying, how we are
going to get there. How we talk about those use of resources.
And I want to be clear, the past is prologue on these. When
these conflicts started, we were told it would be weeks not
months. And if I recall there were a couple of voices at least
telling us to look longer, that there would be issues here. So
we as a Congress have a responsibility to get this. It is not
as easy as just saying that the entire system failed and if you
just farmed it out it would work its way right. I would lay in
front of this Committee if the IG did a mental health care
inspection of any major health care facility or institution in
this country you would come up with results that would not get
to this. So we have to figure this out.
So I guess my question is, of listening to you and hearing
you lay this out and where things are going, how do we
accelerate the ability to move this forward? How do we recreate
this model that you have heard all of my colleagues talk about
to try and get to that place? Are we moving in the right
direction? I know Dr. Petzel talked about it, talked about
those measures. The public is going to pick up on when care was
not delivered immediately, when the scheduling was an issue,
when anything else came. But how do we build that together? And
I will, the Chairman is back so he can defend himself as I was
going after that. But please, Secretary?
Secretary Shinseki. Congressman, I would tell you as I said
in my opening statement, based on what I know of what we have
put our youngsters through for the last ten years, and based on
my own recollection of what coming home from combat is like,
this has my highest priority. And I am going to drive this
hard. You know, we set a priority on homelessness and we got
that ball moving. And we will bring this one along as well.
Mr. Walz. Do you think we are getting there? And I think, I
hear what Ms. Buerkle is saying because my constituents are
telling me that too. They want more options. They want more
choices. We are probably providing more than anything. This is
going to come down to a question that is a fair question for us
as both the watchdogs of the care of our veterans as well as
the tax dollars, I too wonder if you have the resources. I do
not know where you are going to put all these people, those
1,500. I am concerned. Do you have what you need to do the job?
Is this a matter of now implementation and follow through?
Secretary Shinseki. Right now that is the assessment that
is underway, Congressman. And as soon as I have an answer if I
am in need of assistance we will come and talk.
Mr. Walz. Well, I thank you. I yield back, Mr. Chairman.
The Chairman. Thank you. Mr. Bilirakis, you are now
recognized.
Mr. Bilirakis. Thank you, Mr. Chairman. Thank you, General.
I appreciate your service and I think you are doing a great job
as our Secretary. I really appreciate it very much on behalf of
our veterans. How will the 1,900 new VA mental health employees
be allocated amongst facilities?
Secretary Shinseki. Let me call on Dr. Petzel.
Dr. Petzel. Thank you, Mr. Secretary. Congressman
Bilirakis, we have a tentative distribution to the networks. We
are now negotiating with discussing with the networks the
actual distribution to each one of the facilities. And I had
mentioned earlier in testimony that we hope to know the
allocations to individual medical centers within about a couple
of weeks.
Mr. Bilirakis. Okay, thank you very much. I want to follow
up on Ms. Brown's testimony and questions with regard to
telemedicine. I have spoken to many in my district, both health
care providers and veterans, and have learned that stigma and
individual will are significant barriers for servicemembers and
veterans to seek out mental health services. Can you elaborate?
You mentioned briefly on the telehealth services in your
testimony and you answered Ms. Brown's questions. The
availability is very important. How are veterans informed that
such services are available to them? How can they gain the
access? In your opinion, will this reduce the stigma associated
with mental health services, because that is important. And
also, how effective are these services?
Secretary Shinseki. Dr. Petzel?
Dr. Petzel. Congressman Bilirakis, you make an excellent
point about stigma. And the VA is involved in a nationwide
campaign to help reduce the stigma that is associated with
seeking care for mental health. Two of the things that we are
doing I think are significant. One is that we are providing
mental health services now in the primary care clinics. So that
a patient does not have to go into a special clinic that has
got a sign saying ``Mental Health'' on the top of the door and
be identified as somebody going into a mental health clinic.
They get this care as a part of their primary care. Which I
think is very reassuring, if you will, to those patients.
Number two----
Mr. Bilirakis. Do they choose these types of services?
Dr. Petzel. We provide it, we offer it----
Mr. Bilirakis. --voluntarily to do the telemedicine as
opposed to the face to face appointments?
Dr. Petzel. There is some choice associated. I just want to
mention, telemedicine is the same way.
Mr. Bilirakis. Yes.
Dr. Petzel. It is done in the clinic and it is not
associated with walking into a particular mental health clinic.
In some cases there is a choice. When it is available, it is
offered. I can tell you that. Most people pick up on it, but
not everybody.
Mr. Bilirakis. Thank you very much. Again, you know, we do
not really want this to be utilized in lieu of face to face.
But if we can have the telehealth appointments I think that is
very, very important that they get the care they need
immediately rather than waiting. Do you want to comment on
that?
Dr. Petzel. Oh, I absolutely agree with you. I will just
give you, my personal opinion is that in terms of mental health
ten years from now 40 percent or 50 percent of the encounters
that you see in mental health are going to be done by a
telemental health, I think. Not, I do not mean just in this
system, but I mean across the country. And I think when you,
when you talk about general consultations here is what I think
is going to happen. You are going to have a primary care doctor
who is going to see a patient, and he is going to say, ``You
need a cardiology consult.'' They are going to dial up on their
webcams the cardiologist and that consultation is going to
begin right then, whether it is 200 miles away or two floors
away. It is definitely the wave of the future.
Mr. Bilirakis. Have VA looked into partnering with private
telemedicine mental health providers? You are doing that
currently. I believe there is a pilot program. But do you plan
to expand that?
Dr. Petzel. Well Congressman I am not aware that we are
piloting, we have a pilot going or any interactions going with
other telemental health providers.
Mr. Bilirakis. Maybe the Department of Defense?
Dr. Petzel. With Defense, yes.
Mr. Bilirakis. Okay.
Dr. Petzel. And the PTSD telemental health program I
mentioned with you before is actually with the University of
Colorado, a non-VA provider. So there are some examples of
that. And we would certainly encourage doing that where we can.
Mr. Bilirakis. Okay, very good. Thank you very much. I
yield back, Mr. Chairman.
The Chairman. Mr. Carnahan?
Mr. Carnahan. Thank you, Mr. Chairman. And to our Ranking
Member for holding this today. And for Mr. Secretary and your
team for being here, and thank you for the work you do that
oftentimes is difficult and sometimes may seem thankless. So I
want to start with a thank you. And I want to really talk
about, we have covered a lot of the issues that came out in the
report today. But I really wanted to talk about two particular
veterans and their stories and what, how that fits with the
reforms that you are trying to make.
I saw a young new generation veteran in the last few weeks
when I was back home in St. Louis. He knew he had mental
issues. He had gone to the VA. He wanted to get well. And
doctors there prescribed him medicine, but he could not get
into see counselors. He was not getting that follow up, human
interaction that he needed. And so he had to go elsewhere, out
of his own pocket. Again, just out of his own willingness to
get what he needed. But whether it was capacity, or delays, or
whatever he was not, you know, the VA was not serving that
veteran. And so my first question about this veteran is how is
this additional capacity that you have planned you think going
to help with those kind of delays for that veteran and veterans
like him?
Secretary Shinseki. Let me call on Dr. Petzel and then I
will close.
Dr. Petzel. Thank you, Mr. Secretary and Congressman
Carnahan. First of all, we would like to find out about that
particular individual veteran so we can contact him and get him
or her into the right kind of care with the VA. The issue that
the increased staffing primarily is directed at addressing is
this next level. As you pointed out, this patient came in, was
seen, and began some treatment. And I am assuming from what you
say that his treating physician felt he needed individual
therapy and that was not available, at least in a timely
fashion. And these people are intended to address that specific
issue. So that we do have those services available in a timely
fashion. So there is not an excessive wait. So that patients
when they need to be seen can and will be seen.
Mr. Carnahan. Mr. Secretary?
Secretary Shinseki. I would just add part of this is also
this scheduling issue that we are wrestling with. And so we
have increased the staffing to shore up what we think are
requirements. We also need to see where the capacity is that is
not being used and make sure that we are maximizing all of what
is out there, even as we bring on the 1,900.
I just mention I think that mental health is a large issue
for us and this country. CDC, and it is, you know, one of those
issues that is difficult to talk about. CDC has released ten-
year studies that show suicide amongst Americans, the top ten
causes of death in this country, suicide figures very
prominently in it. So it is an issue out there. And then when
you subject youngsters to the stress of combat repeatedly, we
have work to do here. Between ages 15 and 24 suicides, 15 and
25 suicides are number three cause of death amongst Americans.
Mr. Carnahan. Thank you, Mr. Secretary. That really is an
important segue into the other issue I wanted to raise. Another
issue, time is so important in how we address these issues. On
the front end when treatment is going on, but the other time
factor that we encountered, we had a Vietnam veteran that
served on my local veterans advisory Committee. Had been a
great advocate for veterans mental health for years, took his
own life. And, you know, he is somebody that again just was not
getting what he needed. And some veterans I think we are
missing because of this time factor of having to get into the
system within five years from discharge or release. And that we
also need to look at that because, again, for the doctors here
we do not always catch that in that initial five-year period.
And I would like to ask your comment about that. And I have
also worked with several other members on legislation that
would remove that five-year limit so again we are not missing
those kind of veterans. I would like your comment about that?
Secretary Shinseki. Well obviously we are having a
discussion here. I think I agree with, you know, the idea here
that sometimes PTSD shows up later than this five-year policy.
I do not have enough data here to be able to say that it is a,
how broadly this happens. But I do know that PTSD and perhaps
other mental health issues do not follow the usual clock. That
they may show up later, but I just do not know how broad a, you
know, an issue that is. And I am happy to try to do some
research, and provide you a better answer.
Mr. Carnahan. Yeah, if you all have additional information.
Any others that want to, can address that issue in particular?
Secretary Shinseki. Dr. Jessee?
Dr. Jessee. So we have mentioned outreach a few times here.
And I just would like to take a second to talk to the extent
that we are doing that. We, you know, public campaigns are all
well and good but sometimes people who need help do not know
they need help, and they have to be brought along. We are
working very closely with our chaplains, for instance, with the
Guard chaplains. But most, even more so they are working with
lay chaplains to teach them about the very subtle signs that
their returned hero is struggling. And in many rural areas that
is the only mental health provider really, are the churches.
We do that in order that they know how to get people
referred into our system. The Vet Center was a brilliant
program established several years ago just to bridge a trust
gap but to provide readjustment counseling. Because in many
cases that is what people really need. But they are very well
trained to identify the higher risk people and get them into
the system.
And the one other thing I just want to be very plain about
is mental health issues, like heart attacks, so I am a
cardiologist, I can always refer it back to that, you know the
first thing you have got to do is make sure people are safe.
And I think we do that very well. We see people very quickly.
We have staffed up our emergency departments with very strict
criteria about the mental health capabilities in the EDs
because that is where people, that is the door to the hospital
that is open 24/7. And we have to make safe and secure. And the
one thing in the IG report is this first 24--hour evaluation
and we do that well. So the safety piece I think is front and
foremost. But outreach also means bringing people in. And as
you say often it may take a lot longer time for them to come to
grips with the fact that they have got a problem. The more we
can work with them coming home the better we will be at that.
Mr. Carnahan. Well again, thank you. And thank you, Mr.
Chairman. And I look forward to working with you all on that
issue of that five-year limiting period to see really what the
magnitude of that issue is in terms of who we are missing.
Thank you.
The Chairman. Mr. Turner?
Mr. Turner. Thank you, Mr. Chairman. Thank you, Mr.
Secretary. Many mental health problems are accelerated and
exacerbated through drug and alcohol abuse. Are you making use
of any of the NGOs, particularly AA and NA, incorporated into
these programs to kind of address the problem of drug and
alcohol abuse?
Secretary Shinseki. There is certainly some tangentiation
here between some of the mental health issues and also, you
know, self-medication if you will. Let me call on the experts
to be able to address this.
Ms. Schohn. In our drug and alcohol programs referral and
use of AA and NA or other self-help groups for issues is often
a critical component of it. So the VA recognizes that it is not
just the VA itself that really has to be working to address
these issues but that we do need to partner with community
resources, particularly for times when a veteran is not in
treatment and when he goes home and needs resources in the
community. So it is a critical component of the care. And I
will turn to Dr. Zeiss to add more.
Ms. Zeiss. Or one additional thought. We do work very
closely with the Office of the National Drug Control Policy.
And they have actually stressed that VA's substance use care is
a model in terms of how it is integrated with mental health
care and how we partner with nongovernment agencies, but also
provide that integration with care in VA. And we certainly work
with them, the ONDCP, on their yearly national policies and
strategic goals. So we definitely are trying to partner on this
issue as on others.
Secretary Shinseki. Congressman, if I would. I am the non-
clinician at this table. My other concern is do we overmedicate
and create some of the problems? I do not know the answer to
that, but I get paid to ask the questions and get assured that
we have good controls and good balance so we are not creating
on our own the kinds of issues that you are referring to here.
Mr. Turner. All right. Thank you, Mr. Secretary. I yield
back.
The Chairman. One quick comment. I would hope that
organizations that have a faith-based component are not
squeezed out of the process. The fear that I have, and not just
at VA but also within DoD and other Federal agencies, is that
we do not allow these organizations to participate because they
do have that component. I do not think at all that is anybody's
intent at that table, but just to comment.
Secretary Shinseki. Fair enough. I will go take a look at
it, Mr. Chairman.
The Chairman. Mr. Stearns?
Mr. Stearns. Mr. Chairman, thank you very much. And Mr.
Secretary, thank you very much for serving and for all you are
doing under some difficult situations, obviously. I have got
before me some audits of the VA Health Administration
outpatient waiting times. And I have got another one dealing
with outpatient scheduling procedures. And when you look at
those I guess you wonder, you announced on April 19 of this
year that you are going to hire 1,900 new mental health staff,
is that correct?
Secretary Shinseki. That is correct.
Mr. Stearns. And I guess the question is based upon these
audits of the VA Health Administration how can you assure, I
guess, to the Committee that these new employees, the 1,900 new
employees, and perhaps even the current employees, are going to
receive the proper training considering I guess these audits
have indicated otherwise? And this goes back to 2003. So from
2003, 2004, 2005, 2006, 2007, on up they are saying that they
have not got the training. So I guess the question is the
Committee just wants to have an understanding that the new
1,900 are going to get the proper training? Is that legitimate,
Dr. Petzel?
Dr. Petzel. I will make an opening comment and then I think
I will turn to the two mental health experts. There will be a
period of orientation for anybody that is new to the VA,
whether it is a licensed counselor, a pastoral counselor, a
psychologist, a psychiatric social worker, a nurse mental
health clinician, or a psychiatrist, they will all have an
orientation to VA. An orientation to our approach to the
treatment of the various kinds of disorders that we might see
in our patients. So with that I would ask briefly just describe
what happen?
Mr. Stearns. Maybe the question is for your experts, are
they aware of these audits, and what the audits have said about
outpatient waiting times and outpatient scheduling procedures?
How----
Dr. Petzel. Let me ask Congressman Stearns, are you, is
that the audit that addresses the scheduling clerks?
Mr. Stearns. Yes, that is one of them. Yeah.
Dr. Petzel. The scheduling clerks, sir, do undergo annual
training and annual certification to demonstrate that they
understand the scheduling procedures. But as we have said
earlier we have a task force that is looking at the way we do
scheduling in mental health as well as in every other area to
try and simplify and clarify the scheduling task so that we can
do a better job of saying how long someone is waiting to get an
appointment, how long it takes for them to get an appointment.
We agree with the IG in a general sense in terms of the
recommendation, and that is that we have to find a better way
of measuring the scheduling time. So yes.
Mr. Stearns. Okay. You know, when I looked at some of the
definitions here I think the VA has claimed about a 95 percent
success rate in seeing veterans within 14 days. However, I
guess a IG report this year indicated that the VA has been
measuring when they see the veteran to conclusion not when and
how long from their request, which averages about a 50 days
wait. Does that seem logical? Is that a fair explanation? That
the IG report does not agree with your 95 percent success rate
in seeing veterans within 14 days?
Dr. Petzel. That----
Mr. Stearns. Do you disagree with the IG?
Dr. Petzel. That, Congressman, is an appropriate
conclusion, that they did not agree with our 95 percent. That
is correct.
Mr. Stearns. So do you agree with what they said, that it
is an average of 50 days wait? Do you agree with what they say?
Dr. Petzel. There is some discussion with the IG,
Congressman, about the way they measured versus the way that we
measured. And while we----
Mr. Stearns. Do you think they are wrong?
Dr. Petzel. Sir, while we agree with their recommendation
that we need to have a better system of scheduling so that we
can measure the wait times, do not necessarily agree with the
fact that only 49 percent of the people were seen in a
particular period of time.
Mr. Stearns. Okay. You mentioned earlier that the model
used to measure wait times came from the previous model from
the VA. What in the previous model has kept and what was
changed or improved? I guess maybe a better understand of what,
have you changed the model? Or have you used the model complete
from the previous ways you have done this for the wait time?
Dr. Petzel. Congressman Stearns, in----
Mr. Stearns. It seems that the IG and you are having a
little trouble understanding these procedures. So I am just
trying to understand what model you are using.
Dr. Petzel. The, Congressman we changed our method of
measuring wait times to desired date. I explained this earlier
in the hearing.
Mr. Stearns. Okay.
Dr. Petzel. Desired date back in 2007.
Mr. Stearns. Yeah.
Dr. Petzel. And there is another way to do this called
create date.
Mr. Stearns. Yes.
Dr. Petzel. And the discussion with the IG is around the
appropriateness of using desired date or create date. And our
intention is after our task force comes to an agreement about
what we need to do in the future to work with the IG so that we
agree about the way to measure waiting times.
Mr. Stearns. Okay. Mr. Chairman, it looks like we have got
the difference between desire date and a create date. Is that
not what you are saying? That there is a difference between you
and the IG in those areas? Is that----
Secretary Shinseki. There is a third measure called
capacity, I believe.
Mr. Stearns. Okay. So between those, the capacity date, the
create date, and the desired date, that is differentiation, the
IG is not completely in agreement with you? Is that a fair
statement or am I missing something?
Dr. Petzel. I think that is a fair statement, correct.
Mr. Stearns. Okay. Thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Stearns. Ms. Brown, closing
comments?
Ms. Brown. Thank you. Thank you, Mr. Chairman, and thank
you for holding this meeting. And thank you Mr. Secretary for
coming and bringing all of your people that is involved in the
area of mental health. There are just a couple of points that I
want to make. I want to first of all thank the President and
the First Lady for their initiative including the entire
family. And I hope as we develop mental health programs that we
realize that it is not just the person in the military but it
is the entire family that is involved, and making sure that we
include it and make it inclusive of the entire family, the
sessions, the programs, as we move forward. Because that
person, that spouse, or that mother, whoever is with that
person, knows that that person needs assistance even if that
person that needs the assistance do not know it. So let us make
sure we have some way to evaluate and include the family.
Secondly, we need to make sure we are evaluating that
provider. Because the person that had a complete breakdown at
Fort Hood was someone that was working for the government and
was working in the area of mental health. So we need to have
some checks and balances working with that person, obviously
under stress, you know, doing the counseling, doing the
advising. And so we need to make sure we include that.
And I want to once again thank all of the professional
people that we have working with us. And just mention that the
Chairman asked me to have a round table kind of hearing next
Monday, May 14 and 15 down in Orlando about the Orlando
facilities and meeting with the contractors and the VA to
discuss how we can be online and changing the subject, but
making sure that my hospital is one that will come in for our
veterans that we have been waiting on for 25 years efficient,
cost effective, and ready to operate as soon as it opens up,
Mr. Secretary.
Secretary Shinseki. I hear you, Congresswoman.
Ms. Brown. Thank you, Mr. Secretary. And with that I will
yield back the balance of my time.
The Chairman. I think the lingering question in today's
hearing from the department's perspective is if you have a
vacancy rate of 1,500 individuals, and you are talking about
hiring an additional 1,900, 3,400 new hires, how in the world
are you going to accomplish that in a timely fashion in order
to provide mental health care to the veterans who need it
today? I do not know if you want to take that for the record,
or if you want to respond. I do not think anybody at this
Committee believes that you can quickly hire 3,400 plus people.
Secretary Shinseki. Fair enough. And I would like to take
that for the record. But Mr. Chairman, if you think that we can
achieve a zero turbulence turnover rate, you know, it is not
going to happen. We will always have a working set of numbers
because we do not require people to give us warning two years
out that they are going to make a change decision, you know, in
their lives. Sometimes we get it in about 30 days.
The Chairman. But even if you use the rate, though, that
Ms. Spiczak quoted earlier of 7.5 percent, or even double it.
Say 15 percent, even if you have a 15 percent vacancy rate you
are talking about a tremendous lift. Not that the veterans do
not need those people out there, but the department has been
unable to fill 1,500 slots. Now you are putting 1,900 plus on
top. And if you would I look forward to your----
Secretary Shinseki. Fair enough. Let me provide that for
the record. But I would say most large organizations, 7 percent
turnover is not unexpected.
The Chairman. But I would say that you have got higher than
7 percent at this point. If I would, also, before you leave,
Mr. Secretary, I want to ask that you work to provide the
Committee with a couple of things that we have requested. And I
would go ahead and outline them for you. On 29 November of 2011
we requested information on VA's SES bonus review. And after
repeated follow ups with the Congressional Affairs Office I
still await an answer for that.
On the 19th of April of this year we asked for information
regarding VA facility activations. To date after again repeated
inquiries there have been no information provided to us.
And then VA provided the Committee a delivery date of today
for the Committee's post-hearing questions in connection with
the February, the February budget hearing. And just a reminder,
we continue to await those responses. I have got a couple other
outstanding requests that the Committee staff will get to
yours. But I ask a renewed effort from VA and a timely response
to our Committee requests. I know that you are responding to
our requests, as well as the Senate as well. But I would ask
that you look into these and the others that we provide. And I
thank you for providing the Committee your personal testimony
today, Mr. Secretary. I appreciate you being here. And with
that the first panel is excused. Thank you.
Secretary Shinseki. Thank you, Mr. Chairman, and the
Committee for your courtesies and generosity. Thanks.
The Chairman. I will go ahead and call the second panel
forward if we could. I apologize for the confusion. But joining
us as the new second panel, because we did separate them from
Secretary Shinseki's panel, Dr. John Daigh, the Assistant
Inspector General for Healthcare Inspections; and Linda
Halliday, the Assistant Inspector General for Audits and
Evaluations. Thank you both for agreeing to speak with the
Committee this morning. And you are recognized for your opening
comments.
STATEMENTS OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR
GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR
GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND LINDA A.
HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR AUDITS AND
EVALUATIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT
OF VETERANS AFFAIRS
STATEMENT OF JOHN D. DAIGH, JR.
Dr. Daigh. Thank you, Mr. Chairman, Ranking Member, members
of the Committee. It is an honor to be able to testify before
you here today. I and my staff from the Office of Healthcare
Inspections address current clinical issues in VA on a daily
basis and I do believe that the leadership and employees at VA
strive hard to provide the highest quality medical care
possible. I also do believe that VA provides veterans with high
quality medical care, to include mental health care.
The report that we published focused on access to care
standards, which I think need a great deal of work as our
report outlined. VA, though, however, is a leader in quality of
care standards and has done a great deal of work in that area.
Listening to the comments made earlier, I would like to
make a couple of comments. The first would be I think that the
IG has worked for a long time, over five or six years at least,
to get VA to develop what I would call staffing standards in
order to be able to answer the question of how many people do
you need to do any one particular job? Be it nurse staffing
standards, or medical specialist staffing standards. So I think
that VA needs to focus on its business practices in order to
have the relevant data available to address the need and timing
of hiring 1,900 people as they have indicated that they plan to
do.
I would also be remiss if I did not indicate that there
have been several software projects which have not been
successfully concluded over the last period of years. One would
be the scheduling effort, which was not successful several
years ago and which I think VA does need a better scheduling
platform. And the other two would be the Core FLS platform and
Flight, both of which were financial systems which would allow
the gentlemen in the first panel to have I think more accurate
data on productivity and related issues that would allow them
to make a better business case for the changes they think are
required.
With that I will end my testimony and invite Ms. Halliday
to comment.
[The prepared statement of John D. Daigh, Jr. appears in
the Appendix]
STATEMENT OF LINDA A. HALLIDAY
Ms. Halliday. Chairman Miller and members of the Committee,
thank you for the opportunity to discuss the results of our
recent report on veterans access to mental health services at
VA facilities. We conducted the review at the request of the
Senate and House Veterans' Affairs Committee and the VA
Secretary. Today I will discuss our efforts to determine how
accurately the VHA records wait times for mental health
services for both new and established patient appointments. I
am accompanied by Mr. Larry Reinkemeyer, our Director of our
Kansas City Office of Audits.
Our review found that inaccuracies in some of the data
sources and inconsistent scheduling practices clearly
diminishes the usability of information needed to fully assess
current capacity, resource distribution, and productivity
across the system. In VA's fiscal year 2011 performance and
accountability report VHA reported 95 percent of first time
patients received a full mental health evaluation within 14
days. However, we concluded that the 14-day reported measure
has no real value as an access to care measure because VHA
measured how long it took to conduct the mental health
evaluation, not how long the patient waited for the evaluation.
Using the same data that VHA used to calculate 95 percent
success rate shown in the PAR report, we calculated the number
of days between the first time patient's initial contact in
mental health and completion of their evaluation. We projected
VHA provided only 49 percent, or approximately 184,000 of the
evaluations, within 14 days of either the veteran's request or
a referral from mental health care. On average it took VHA
about 50 days to provide the remaining patients their full
evaluation.
Once VHA provides the patient with their evaluation VHA
then schedules the patient for an appointment to begin
treatment. In fiscal year 2011 we determined that VHA completed
approximately 168,000, or 64 percent, new patient appointments
for treatment within 14 days of their desired date. Thus,
approximately 94,000 or 36 percent appointments nationwide
exceeded 14 days. In comparison VHA's data showed that 95
percent received timely care.
We also projected that VHA completed approximately 8.8
million, or 88 percent, of the follow up appointments for
treatment within 14 days of the desired date. Thus,
approximately 1.2 million, or 12 percent appointments, exceeded
14 days nationwide. In comparison, VHA reported 98 percent
received timely care for treatment. We based our analysis on
dates documented in VHA's own medical records. However, we have
concerns regarding the integrity of the date information
because providers told us they use the desired date of care
based on their schedule availability. This is in direct
conflict with the VHA directive. VHA should not use that, the
date the patient requests.
I want to point out that we reported concerns with VHA's
calculated wait time data in earlier audits of outpatient
scheduling procedures in 2005, again outpatient wait times in
2007. During both audits we found schedulers were entering
incorrect desired dates. And our current review shows these
practices continue. For new patients the schedulers frequently
stated they used the next available appointment slot as their
desired appointment date for new patients. This practice
greatly distorts the actual waiting time for patients. To
illustrate, VHA's data showed 81 percent, or approximately
211,000 new patients, received their appointments on the
desired date of care. We found veterans could have still waited
two to three months for an appointment and VHA's data would
show a zero wait time.
Based on discussions with medical center staff and our
review of the data, we contend it is not plausible to have that
many appointments scheduled on that exact day the patient
desired. In conclusion, VHA needs a reliable set of performance
measures and consistent scheduling practices to accurately
determine whether they are providing patients timely access to
mental health services. And they need to ensure the desired
date of care is defined by the patient without regard to
schedule capacity. That would be true as to whether they use
the create date or the desired date of care.
Mr. Chairman, I would be happy to answer any questions.
The Chairman. Thank you very much for your report and your
testimony. You have talked about the string of IG reports
finding serious deficiencies and inaccuracies within the
appointment scheduling and the performance measures that VA
uses. Since you have begun your investigations and found fault
with their scheduling processes and procedures, I think the
Committee would like to know has it gotten better. Or has it
gotten worse? Because we have spent hundreds of millions of
dollars in the process. What have you seen?
Ms. Halliday. We went to four sites as part of this review.
At three of the four sites, we found schedulers were not
following VHA's own directives. That is a pretty compelling
number, 75 percent. I cannot say it is getting better. I think
that we were surprised at the delta that we saw between the 95
percent that VHA had said they had provided timely care for
veterans and the 49 percent that we saw for the new patients,
and then again, the difference with the follow on appointments.
So I cannot say it is really getting better.
The Chairman. You may or may not be able to answer this
question. But is it better for the veteran to accept a
scheduling date that fits an open slot at VA? Or is it better
for the veteran to get the care and the appointment when they
need the care?
Ms. Halliday. I am going to let David Daigh respond.
Dr. Daigh. I think we would all agree it is better to get
the care when they need to get the care.
The Chairman. And is it your testimony just a second ago
that that is actually not what you found they were doing? That
they were actually filling open slots, but not necessarily when
the veteran needed the care?
Ms. Halliday. That is correct.
The Chairman. Thank you. Ms. Brown?
Ms. Brown. I guess I am concerned. Are you saying that the
veterans, because they indicated, I guess you heard the
testimony with the number of, did you test any of their
stakeholders or partners that they was working with? Or you
just did the VA?
Ms. Halliday. We looked at the VA information to examine
whether there was data integrity behind it. So we concentrated
on the 10 million appointments for new patients and established
patients. And those appointments, because they include follow
up, really represented about 1.3 million unique veterans
needing care.
Ms. Brown. And your findings, would you expand on that a
little bit? Because you said you went to four facilities.
Ms. Halliday. We looked at scheduling procedures four
facilities. What was the time it took to evaluate new patients
getting care after the point of the first triage. We did feel
VA did a good job when a patient made their first contact,
saying they needed mental health services and there is a
triage. And then from there they conduct a mental health
evaluation. Based on what VA was reporting you would say that
the majority of evaluations were accomplished in 14 days or
less. We did not see that. And we also saw a very high number
of patients that waited zero wait days. And it was basically
because of the way the schedulers were inputting the
information. What we are saying there, is that we did not think
that information was plausible.
Ms. Brown. Okay. And what are some of the recommendations
that you all made?
Ms. Halliday. We offered three recommendations in the
report. To ensure a full mental health measurement is
calculated from the veteran's initial contact with the clinic
or the veteran's referral from mental health, we want VA to put
in place an access to care measure that measured the time a
veteran waits for that care.
Ms. Brown. On that point, what was mentioned earlier was
that the veterans do not always come directly to the VA. They
may be coming through an emergency room, or some other
resource. Were you able to measure that? In other words,
basically they are not walking into the VA and saying, ``I need
mental health services.'' Or calling. They are getting referred
through other means. So did we compared that wait time?
Ms. Halliday. No. We compared the point of when the veteran
makes the contact, or there was a referral from a mental health
provider that the veteran needed care. We do recognize that
veterans seek care and come through different avenues in VA.
But I think that our information, as I said before, was based
on 10 million appointments nationwide and 1.3 million unique
veterans seeking care. So it is a pretty good representation of
what is happening in VA at this point.
Ms. Brown. And you gave one recommendation. What were the
other two?
Ms. Halliday. The second was to reevaluate the mental
health performance measures that could more accurately reflect
the patient experience. As both Dr. Daigh and myself have said,
VA needs a new set of performance metrics to measure to really
know how long veterans are waiting for appointments. And then
the third was to conduct a staffing analysis to determine if
vacancies represent a systemic issue impeding VHA's ability to
meet timeliness goals and if so to implement corrective action
plans. This had been discussed well in advance of our report
with the senior people in VHA. So, you know, it seemed logical
to move forward on that. We believe based on what we heard at
the sites that the vacancies for psychiatrists and mental
health professionals were impeding the ability to provide all
the services needed.
Ms. Brown. I guess my last comments, but I guess you all
did not do any evaluation on it, because I personally do not
necessarily think that all of the services have to be in VA. VA
could work with some of the other stakeholders. People in our
community are providing mental health services every single
day. They are just not getting reimbursements for it. And is
there any way that we can measure the quality of some of these
providers? Because the problem is that I do not necessarily
think that we need to hire millions of psychiatrists because
they do not even exist. But there are many levels of mental
health professionals that could work in partnership with the VA
and the VA making sure we have a certain standard of service,
and working in conjunction with other stakeholders. I guess
this is the only time I have ever supported outsourcing to some
degree. Whew!
Dr. Daigh. Ms. Brown, I think I would agree very much with
you. If you take a look at the number of psychiatrists VA has
on board, between last year and this year it actually went
down. Over the last years, last four years, when they got a
bonus of money they increased it by 600. So I think it will be
difficult for them to hire new psychiatrists at any significant
level.
Ms. Brown. But you see, I do not necessarily think
psychiatrists that, you are at a different level.
Dr. Daigh. Right.
Ms. Brown. I do not necessarily think everybody needs a
psychiatrist.
Dr. Daigh. Right, I----
Ms. Brown. --they need, you know, it is the whole list of
different kinds of services people need. When I said, when I
went out to LA and saw the telemedicine, I was surprised that
the veterans really like it. I would not like it at all. But
they was very pleased with the services. But they are a
different generation. I am old school. And the new school like
the telehealth.
Dr. Daigh. And we did a report a couple of years ago on
access to mental health care in Montana. And in Montana VA had
actually used the community mental health centers and linked up
with them. And we showed where that made a dramatic impact on
their access to usually not psychiatrist but the staff at the
community mental health center. We found there thought that
substance abuse treatment, however, was difficult to hire at
that level. And so I think we would agree very strongly that
there are not the resources for VA to hire as, or I am doubtful
that they will be able to hire them as they say they will. And
we think there are sources that they should look at within the
community of non-VA providers.
Another source of providers would be how their own
employees spend their time. So VA has several missions. One
mission is patient care. One mission is research. One mission
is training. There are several others. A physician can allocate
their time between several different missions. So if the
priority mission, which it is not currently stated as the
priority mission, were patient care then one might align their
time more with the primary mission. The FTE data are often FTE
allocated to patient care, not the total on the employment
roll.
The second area they might look at is VA has wonderful
arrangements with academic medical centers.
Ms. Brown. Yes.
Dr. Daigh. All of whom have significant psychiatric staff.
So there might be some room to, you know, to get some benefit
there. And then the third would be outsourcing as you described
with community mental health centers and other areas like that
that I think would be useful.
Ms. Brown. Or working with the universities. I mean, we
partner with them in many different areas. But I will yield
back my time and maybe I can get additional time to ask
additional questions.
The Chairman. Mr. Stearns?
Mr. Stearns. Thank you, Mr. Chairman. You heard earlier
that the VA was talking about the three ways they define this
waiting time. The capacity date, the desired date, and the
create date. When you did your report in which you said, ``our
analysis projected that the VA provided only 49 percent, or
approximately 184,000, of their evaluations within 14 days. On
average for the remaining patients it took the VA about 50 days
to provide them with their full evaluations.'' Were you using
the create date as a model? Would that be a fair statement? Or
is, are you using a different definition than the VA is using?
Ms. Halliday. At the time we did the review we looked at
the desired date. VHA's policy says the desired date should not
be the date of clinic availability, it should be the date the
patient requests or has a medical referral. The create date was
used years ago and there were problems with that at that time.
VA is now proposing to bring the create date back and use it
again to rely on as a performance metric. I think if they
clearly define it and put the right scheduling procedures in
place to ensure it is at the point the veteran contacts and
requests care, or gets the referral from a provider, it will
improve the system.
Mr. Stearns. So you, what I just read from your report was
based upon when the veterans desired to be taken care of? And
you said it actually was 50 days, whereas the VA is projecting
14 days. And I guess they are using that 14 days, so they must
be using the capacity date or another type of thing. Is that
true?
Ms. Halliday. We looked at the desired date of care.
Mr. Stearns. Yeah. You know, if you went out to the private
sector and you said, ``Okay, let us look at the capacity
date.'' The capacity date is when the company could deliver the
product, or when they could deliver the resources for the
patient. Well, the patient is not really interested in whether
you have the capacity. They just want to get it taken care of.
So the whole idea of a capacity date seems to be a source of
confusion because no one is interested when, what capacity, I
mean, if you do not have the capacity then the date could be a
hundred, ten years. I mean, if you do not have the capacity,
that is not what we should be striving for. And as far as the
create date, it seems to me that is more accurate. The desired
date is what the customer wants, I understand that. But also
the create date is based upon the physician recommended and
also I guess based upon what the patient has recommended? I am
having a little trouble understanding between the create date
and the desired date. Go ahead.
Dr. Daigh. Sir, the measurements are between two dates. So
we have a time, how long it takes for something to occur.
Mr. Stearns. Right.
Dr. Daigh. So if you call in and say, ``I would like an
appointment.'' That would be the create date.
Mr. Stearns. Okay.
Dr. Daigh. You called in and the scheduler stamps that you
called in on that date.
Mr. Stearns. You called in today, you will get an
appointment in two days.
Dr. Daigh. Right. So if you desired an appointment in two
days, then that date would be two days.
Mr. Stearns. Mm-hmm.
Dr. Daigh. But if the next available appointment was in a
week then that date would be seven days.
Mr. Stearns. And that would be the desired date?
Dr. Daigh. That would be, well the desired date would be
whatever you tell the scheduler.
Mr. Stearns. Okay.
Dr. Daigh. And then the actual date that the appointment
was made on would be the next available appointment date.
Mr. Stearns. Yeah. It just seems to me that if you are
trying to make the customer happy, which is the veteran, and we
have, we have given the Veterans Administration more money
every year, sometimes as much as 18 percent a year, it seems
like you should come up with one date and that should be the
date that basically when the customer wants to be taken care
of, if the customer is the one we are trying to satisfy. We
should not be talking about when the VA has the capacity
because that is all nebulous. It could be a long time.
Dr. Daigh. One of the considerations, sir, is the cost of
getting data. So the scheduling systems are designed to create
certain data streams accurately. And if you create a metric
that the scheduling system will not easily give you a reliable
data stream for, for example the difference between, ``I want
to be seen on this day,'' and the appointment was actually made
on that date, then it creates business rule problems for the
actual schedulers. And in that it then makes the data set VA is
using unreliable. So I am only saying, sir, that in the mix
people need to look at what they are asking for.
Mr. Stearns. Well I think the bottom line is you said it
takes 50 days to provide this roughly 200,000 veterans with
their full evaluation. That is what you are saying. And that is
not good. And that should be changed. And I think that is, no
matter what we are talking about, a capacity, a desired, or a
create date, the bottom line is veterans, almost 200,000, are
not getting serviced. And the Veterans Administration can use
whatever terminology and definitions they want, but by golly
these guys and gals are not getting taken care of and that is
why we are here today. So thank you.
Ms. Halliday. We agree.
The Chairman. Mr. Walz?
Mr. Walz. Thank you, Mr. Chairman. And thank you both for
your work. And I think that, again, if there is one veteran not
being served on time that is one too many. Following up on what
Mr. Stearns was saying, is there a private sector comparison?
Not just to widgets, but to people with mental health issues? I
brought up earlier that I think this is a broader issue of
mental health parity and access to care. One of the things that
is hard to measure is if you are denied insurance coverage for
this your wait time is forever. There is no denying of care in
the VA system. Everyone, and PTSD has been there. So with that
being said, and not to, because I still think the wait time is
too long and I want to figure out how that scheduling nexus
with that, do you have data to show how the private sector is
doing this on mental health scheduling?
Dr. Daigh. So yes, sir, we have some. We went out and
talked to three of the larger entities that provide
comprehensive mental health care. And talked to them about
their metrics. The first point they made was that they have
seen an increase in demand of 15 percent to 20 percent over the
last couple of years as VA has, they say probably from the
economic downturn. And then they have a variety of metrics,
both in terms of timeliness within which you get your
appointment. So they would say for a new patient appointment,
you call in being day one. You get your appointment, that being
day two. That time span ought to be about 14 days for a new
patient appointment. And then for follow up appointments people
often use capacity measures. For example, for PTSD it is
desirable you get a certain set of appointments in a certain
set of time. For oncology, for cancer therapy, it might be
desirable----
Mr. Walz. And those are based on best practices inside----
Dr. Daigh. Right. So you might then say, ``How many
appointments, did these patients with these disorders get in
the last 65 days?'' So there are a variety of measures, usually
driven directly off the appointment scheduling system, that are
as close to reality and cost effective as it is to get the data
and use it, that people use to try to manage their capacity
being the number of patients that they can see.
Mr. Walz. Does anybody have anywhere close to the capacity
of the VA?
Dr. Daigh. I do not think so, no.
Mr. Walz. I mean, I am just wondering if there comes a
diminishing return or if this is a program that should be
exponentially be able to grow, to assume that. So if you have
ten patients you should be able to schedule them the same way
if you have 10,000 or 10 million.
Dr. Daigh. Well the scheduling is all a very local issue.
So if you are in charge of a clinic, your job is to manage a
clinic, then you have to come in in the morning and see what no
shows you have in your schedule, and how you can juggle the
people you have to meet the demand that you have. So every
physician's office deals with this problem, whether it is an
institution----
Mr. Walz. That is right. And your assessment was, though,
it is not uniform. That there were some of these places were
not as good at it as others. And if you rose, or pulled the
standard up on some of these you would start to see
improvements?
Dr. Daigh. I think if VA would improve some of its business
practices, and had a scheduling system that allowed it to
leverage the data in a scheduling system accurately, I think
they could manage their patient workload, or capacity, much
better than they are currently doing.
Mr. Walz. Very good. I yield back, Mr. Chairman.
The Chairman. Thank you very much, Mr. Walz. You know, I
think the thing that we are seeing is a very clear picture of
VA hiding and manipulating numbers, for whatever reason. Of
waiting times, of appointments, of statistics. Look, we all
want the veteran to be seen when they need to be seen. We do
not want them to be medicated with only drugs. We want them to
get better. Thank you to the IG again for bringing these issues
to the table. I hope somebody at VA is listening. Because if
you are not, you are the only ones that do not hear the message
that is being delivered by any number of people, including the
IG. And I am sure the next round of witnesses will be bringing
similar information to the table for us as well.
I would ask Ms. Brown if she would waive her next round of
questions, only because we have a series of votes coming at the
bottom of the hour. And I would like to try, if we can, to get
to all of the witnesses that have very patiently waited. But if
you have a question that you need to ask I would go ahead and
yield to you at this time.
Ms. Brown. No, sir. But as they change maybe I could have
30 seconds to say that I would just kind of disagree with the
Chairman that they are trying to manipulate the numbers. Maybe
we are reading them differently. And maybe we can get some
clarity on how we are spelling out what the VA is saying and
how we can better clarify.
But basically, we all want the same thing. We want the
veterans to get service. And there are many ways that we need
to define that. And it is not just, like I said, and what was
said earlier, they are coming to us from the emergency room,
they are coming to us in many different ways. And we need to
make sure that we are utilizing the taxpayers' dollars and
providing the service in the best efficient way. And I am
interested in working with our stakeholders and partners. There
are many universities that work very closely with the VA in the
mental health area. How, you know, I would like some
explanation of how this is working. University of Florida in
Gainesville and Shands in Jacksonville work very strongly with
the VA and they work in partnership. Did we capture that in any
way? And how can we better serve the veterans?
You know it is a lot of, we have got a responsibility. It
is not just the VA. It is all of us working together. And so
Mr. Chairman, you know, I am not disagreeing with you. It is
just that it is not us against them. It is, you know, one team,
one fight. That is the Army's motto. And we are all in this
fight together.
The Chairman. I thank you very much for your comments. And
I would say, though, that if you are the one that is designing
the metric it is very easy to decide a positive outcome based
on that metric. And so I have got to say that everybody else
understands and hopefully VA will pick up on that. With that I
would say thank you very much for your testimony and I would
like to call the next panel forward.
Ms. Brown. Mr. Chairman, I do know that you all agree that
we do not need to give them no more work, though. In other
areas, like housing or labor.
The Chairman. I thank you very much to the next panel.
Thank you for bearing with us while we separated the first two
panels.
We are joined now by Nicole Sawyer, licensed clinical
psychologist and former local evidence-based psychotherapy
coordinator for the Manchester VA Medical Center; Diana Rakow,
the executive director of Public Policy for Group Health
Cooperative; Dr. James Schuster, the chief medical officer for
Community Care Behavioral Health Organizations; and Thomas
Carrato, retired rear admiral for the United States Public
Health Service, now the president of Health Net Federal
Services.
Thank you very much, and, Ms. Sawyer, you are recognized to
proceed with your testimony.
STATEMENTS OF NICOLE L. SAWYER, LICENSED CLINICAL PSYCHOLOGIST;
DIANA BIRKETT RAKOW, EXECUTIVE DIRECTOR OF PUBLIC POLICY GROUP
HEALTH COOPERATIVE; JAMES SCHUSTER, CHIEF MEDICAL OFFICER,
COMMUNITY CARE BEHAVIORAL HEALTH ORGANIZATION OF UNIVERSITY OF
PITTSBURGH MEDICAL CENTER; THOMAS CARRATO, PRESIDENT, HEALTH
NET FEDERAL SERVICES
STATEMENT OF NICOLE L. SAWYER
Dr. Sawyer. Thank you.
Members of the Committee, thank you for inviting me to
participate in this important discussion. I am a licensed
clinical psychologist. My primary focus is the treatment of
trauma with both veterans and civilians.
I have worked in a number of clinical settings. However, my
testimony today will be focused on my work at the VA medical
center from which I recently resigned.
My goal today is to share with you some of the impact that
VA culture and common practices have on our veterans as well as
the impact it has on the ability of our skilled clinicians to
provide effective mental health treatment.
Let us consider the fact that many of the men and women who
seek mental health care at VA medical centers have been faced
with decisions and taken action on matters far exceeding the
imaginations of most.
But the decision to seek mental health treatment is for
many of them an admission of failure, an inability to hack it.
This decision feels humiliating and shameful. Many of them have
spent years trying to hide these invisible wounds. They have
avoided feelings and memories. They have pushed loved ones away
and many of them have contemplated taking their own lives.
Some of them fear the part of themselves that was so
capable of those deeds over there. Some vow to never let anyone
know what they have seen, who they have hurt, or how it felt to
do it.
Choosing treatment takes a series of gut-wrenching
decisions. Admitting the need for help is the first one, making
the telephone call is the second, showing up for the
appointment is the third, but the fourth is the heaviest of
all, actually speaking the pain.
Endless research and certainly my experience informs me
that the closer together these three decisions occur, the more
likely the veteran will commit to treatment. This is not rocket
science. The more rapid the decision making process, the less
likely any of us are to let our doubts and fears get in the
way.
But VA health care facilities as was demonstrated in the
recent OIG report leave a majority of veterans waiting more
than 50 days to begin treatment.
In my experience, nearly 70 percent of the work of combat
trauma treatment is in telling the trauma. Acknowledging the
pain, the regret, the guilt, the shame that are associated with
their experiences marks the beginning on the road to recovery,
but it is not the beginning of treatment.
Treatment begins with trust. But trust for the combat
veteran does not come easy. Trust is the belief that they will
not be judged; that their feelings will be validated and
accepted no matter what they are, and that despite having told
these things to another person that he, the veteran, remains in
control of that information.
These are people who have done things, they have seen
things, they have felt things that would be considered
horrendous and evil if they happened at home.
For many of these men and women, trust in another person is
a myth. Now, do not get me wrong. A soldier knows trust. He
knows what it is to believe that the man next to him cares as
much about his life as he does.
But to trust in a person who does not share those
experiences is an incredible risk. Most VA clinicians
understand this. They respect the pain. They are well-trained
and they are dedicated. While most do not know the pain
themselves, they do know what it takes to connect with their
veterans and they understand the importance of trust.
But trust takes time. I appreciate the secretary's stated
appreciation for this in his testimony, but time is not what
most VA clinicians have when it comes to treating their
veterans. Psychotherapy is a process, not a prescription. It is
work that takes time.
For some of us, our strategies for coping and understanding
the world and our experiences lead us astray and we find
ourselves drifting or trapped in patterns that are harmful and
destructive. Psychotherapy is intended to steer us back on
track, but it requires the patient to trust in the process, and
in the clinician to be successful. The VA fails to value the
importance of trust.
Trauma treatment demands a session every week or every
other week. Too much time between sessions allows suffering to
linger too long after wounds have been opened up. And that
suffering can lead to retraumatization, strengthening of those
negative patterns, and loss of trust.
Effective treatment requires a full evaluation of needs and
appointments should be scheduled as often as the veteran needs
them. But both of these vital factors of effective care were
noted to be chronic nationwide failures by the OIG report.
We let down our veterans and we set our clinicians up for
failure. But the hidden tragedy in this whole thing is that
many of the veterans failed by the system blame themselves.
Like most people, they do know what effective mental health
care is supposed to look like, they assume that they have
failed to get better and they are too far gone to be helped.
As I mentioned, VA sets its clinicians up for failure too.
Staffing is an obvious weakness in VA mental health care and
last month's announcement of 1,900 additional staff is a
welcome attempt at improving the situation.
But how do we know 1,900 is enough? The VA lacks any
expectation for clinical productivity. There is no way to
identify a clinician's caseload as full and, therefore, it is
impossible to know if the flow of veterans into the service
exceeds the capacity of its providers.
Developing a model for clinician caseload must be a
priority for VA. Community mental health clinics and other
mental health facilities have defined expectations for their
clinicians. With a defined caseload, a clinician can make the
time necessary to write session notes, do treatment plans,
consult with other providers, and return patient phone calls.
All of these tasks are demanded by the ethics that govern
all of mental health professions and, yet, in my experience,
they are seen as luxuries at the VA.
At my former VA medical center, clinicians could easily
have hundreds of veterans assigned to them for care and that
number grew daily as new veterans walked through the door.
Clinicians are virtually gagged under these circumstances.
They cannot do their jobs. They will not rip open those trauma
wounds only to let them fester untreated for weeks or even
months until that next appointment. Clinicians are set up for
failure and the veterans lose.
The VA struggles to fill the 1,500 vacancies already out
there and now there will be 1,900 more positions to fill. But
this problem has an additional concern. Where are we going to
put all these new folks? Many VA facilities across the Nation
simply do not have the space for more clinicians.
Where I worked, some clinicians dragged carts around the
hallways because they did not have an office. This is not
simply inconvenient. It is unprofessional and demeaning for the
clinicians and has a significant impact on the veterans.
Safety in their space and predictability in their
environment are important to many veterans struggling with
PTSD. Attending therapy sessions in whatever office is
available each time they arrive can be very distressing and
lead to dropping out of treatment.
The VA has professionals with advanced degrees, passion,
and the expertise to help our veterans, but often these highly-
trained clinicians must set aside their own clinical judgment
in response to requirements dictated by central office,
performance measures, and other mandates.
Unfortunately, I have heard this story echoed across the
Nation. It is not unique to just one or two facilities.
I want to thank you again for the opportunity to share my
experience and perspective. I hope that if there is anything I
communicated here it is that quality, effective care cannot be
sacrificed for quantity.
When it comes to mental health and most anything else
really, care that is not quality driven is not only useless,
but it can be harmful to those who receive it.
Thank you. I am happy to answer any questions you may have
and I have many thoughts to share in my response to the
secretary and his panel if it interests the Committee. Thank
you.
[The prepared statement of Nicole L. Sawyer appears in the
Appendix]
The Chairman. Thank you very much, Dr. Sawyer.
Ms. Rakow.
STATEMENT OF DIANA BIRKETT RAKOW
Ms. Rakow. Good afternoon, Chairman Miller, Ranking Member
Brown, and Members of the Committee.
I am Diana Birkett Rakow, Executive Director of Public
Policy at Group Health Cooperative, an integrated health care
coverage and delivery system based in Seattle, Washington.
Thank you for inviting me to be here this morning to
discuss Group Health's experience managing mental health
appointments for our members.
I appreciate your leadership on health care issues
affecting our Nation's veterans and want to thank you for
inviting me to discuss Group Health's experience managing
behavioral health appointments.
Treating patients with behavioral health needs is a
difficult challenge for any organization. At Group Health, we
have created systems to ensure that our members have access to
timely high-quality care.
Our success stems from our belief in patient-centered care
and coverage. This philosophy is at the heart of a model of
care we apply to mental health services as well as every other
type of care we provide.
In simple terms, our model links aspects of health care:
insurance, clinical care, information systems, and more in a
tightly integrated system that facilitates a close relationship
and collaboration between informed, engaged patients and
multidisciplinary care teams.
Group Health members seek and receive mental health care
through primary care as well as specialty behavioral health
services and we provide many different routes into care,
individual appointments, phone and group visits, and e-mail
access to your health care provider and care team.
Our models enable us to provide high-quality care since we
were founded in 1947, but it is the more recent implementation
of Lean that has enabled us to achieve break-through results.
As you may know, Lean is a management philosophy developed
by Toyota. Applying the Lean to health care is based on
understanding patients' needs, develop systems and processes
around them, and tracking results in order to continually
improve patient health.
For patients with behavioral health issues, we look at a
number of specific measures and goals. For example, an
electronic medical record automatically measures how long it
takes from the time a patient calls for an appointment to the
time they are seen by a health care provider.
We set goals for timeliness based specifically on the
urgency of a patient's needs as recommended by the National
Committee on Quality Assurance.
We monitor access to follow-up appointments and track key
indicators of capacity and productivity. For example, we track
the percentage of patients seen three times within six weeks
and patient satisfaction with their appointment frequency.
We also know that simply tracking these measures is not
sufficient. We must make the information visible and use it to
ensure that we are serving our patients well.
This is where Lean really helps. Last year, our behavioral
health staff looked at appointment patterns and identified a
high number of appointments that went unfilled, cancelled or
skipped. Using this information, they developed a process
called packaged intake, scheduling three appointments at once
when a patient first calls to come in.
We also started doing group visits to maximize the use of
our existing capacity for patients who would benefit from a
group setting.
And a certain number of available appointments are held
back to ensure that urgent and emergent needs are always met.
Now clinic staff meet every morning to assess what appointments
are still available and to reach out to waiting patients to see
if they can come in sooner.
This set of strategies has enabled us to meet and exceed
the targets that we set for timely access to care. And we saw a
statistically significant increase in patient satisfaction with
their access.
This is just one example of how Lean gives us the
discipline to focus on our patients' needs and to address
problems as they arise. These tools have enabled us to
significantly improve how we serve our patients with behavioral
health care needs over the last few years.
But it is important to acknowledge that this is an ongoing
process. Our system is built around a culture of continuous
improvement. Putting the patients' needs first and recognizing
that as their needs change, so, too, must our approaches to
meeting them.
Thank you again for the opportunity to share our experience
and I look forward to your questions.
[The prepared statement of Diana Birkett Rakow appears in
the Appendix]
The Chairman. Thank you very much.
Dr. Schuster.
STATEMENT OF DR. JAMES SCHUSTER
Dr. Schuster. Thank you, and thanks for inviting me here
today to talk about this important topic.
My name is Dr. James Schuster. I am the Chief Medical
Officer for Community Care Behavioral Health Organization and a
psychiatrist. And I agree with Congresswoman Brown. Not
everybody needs a psychiatrist.
Community Care is a not-for-profit 501(c)(3) behavioral
health managed care company and one of several payer insurance
companies affiliated with UPMC, the University of Pittsburgh
Medical Center, which is a large, integrated payer provider
system based in Pittsburgh.
Community Care provides managed care behavioral health
services to more than 650,000 Medicaid eligible persons in 36
counties in Pennsylvania and also manages behavioral health
services based in facilities in 16 counties in New York.
It also serves both commercial and Medicare members through
care coordination agreements with UPMC Health Plan.
Our data indicates that in any given year, 23 percent of
the members in our Pennsylvania Medicaid plans are active
consumers of behavioral health care. In light of this, little
is more important to us than assuring that the membership has
timely and adequate access to services.
However, ensuring access is anything but simple. I will try
to touch on several high points here in my allotted time.
Ensuring that members with behavioral health needs have
timely and adequate access begins by first deciding what is
timely and what is adequate. In practice, these terms can mean
different things in different circumstances.
As has been discussed here for individuals with psychiatric
emergencies, timely might mean right now. As such, our access
standards require immediate appointments in emergency
situations. In other circumstances where more routine care is
appropriate, we allow up to a week initially between the
initial contact and the initial appointment.
Establishing these access standards has required a
dedicated effort on the part of Community Care. We work in
collaboration with a wide range of stakeholders including
accrediting bodies like the National Council on Quality
Assurance and the Pennsylvania Department of Public Welfare. We
also work with local government entities, advocacy groups, and
families.
Among the most important collaborators, though, who help us
establish access standards are the members themselves. We
collect input through member surveys and through meetings with
member advisory Committees who report directly to the board of
directors.
We receive additional information through monitoring of
member complaints around access and through site visits to
provider services.
Defining the access standards would have somewhat limited
value if we did not communicate them clearly to our staff, the
providers in our network, our members and the community at
large. We work to make sure that everyone is aware of what the
access standards are and how they are measured.
The true value to Community Care in terms of collecting
data around access has been its usefulness in devising
necessary changes and interventions.
Over the years, we have created a wide range of changes
related to the data. These include traditional types of
intervention such as increasing numbers of subspecialists when
those fall short of access requirements.
But they have also included more systemic changes such as
increased funding, dedicated community-based services, and an
expanded range of services such as mobile crisis service units,
hospital diversion programs, psychiatric rehabilitation, and
certified peer specialist programs.
These more systemic changes have probably had some of the
most substantial impact on access to services broadly.
Access feedback has also prompted us to implement newer
types of service delivery including tele-psychiatry. We
currently support approximately 20 tele-psychiatry units in
rural parts of Pennsylvania using secure forms of video
transmission.
We have also worked with providers to create new clinical
strategies to deliver care such as supporting shared decision-
making strategies and physician-based services.
All of these services have created new ways to access care,
as they are alternative to traditional inpatient and outpatient
models.
We have also increased access to the broad and
comprehensive range of community-based services. During the
past decade, funding for community-based services in the
Medicaid programs that we work with in Pennsylvania has risen
from about 50 percent to about 80 percent of the total dollars
spent on care.
In conclusion, what I would ask that the Committee take
from my comments today is that improving and maintaining access
to behavioral health services is, of course, critical, but it
requires typically a broad set of efforts and collaborations
among many stakeholders including the patients and members
themselves.
We have learned much through our efforts over the past 15
years and are certainly happy to answer any questions that the
Committee has today or in the future.
Thank you.
[The prepared statement of Dr. James Schuster appears in
the Appendix]
The Chairman. Thank you very much, Doctor.
Admiral.
STATEMENT OF THOMAS CARRATO
Rear Admiral Carrato. Thank you, and thanks for the
invitation to appear before the Committee.
Health Net is proud to be one of the longest-serving health
care solution partners for the Department of Defense and
Department of Veterans Affairs. Health Net currently serves as
the TRICARE contractor in the TRICARE north region supporting
three million DoD beneficiaries.
We also deliver behavioral health and wellness services to
military servicemembers and their families through the military
family life counseling program, a worldwide program which
provides short-term problem-solving situational counseling.
Health Net also works with VA in support of veterans'
physical and behavioral health care needs through community-
based outpatient clinics and the rural mental health program in
select rural counties in VISNs 19 and 20.
Appreciate the opportunity to offer our thoughts on
addressing the growing and urgent need for veteran access to
mental health services.
Untreated mental illness impacts overall health and
reintegration into the community.
Chairman Miller, as you stated in a recent news release,
these are wounds that cannot wait.
We appreciate VA's efforts to enhance capacity to address
this growing need and respect its leadership in developing and
deploying evidence-based treatment protocols and comprehensive
clinical practice guidelines.
Moreover, we appreciate the fact that VA understands
veterans' needs better than anyone else. But addressing the
dramatic increase in the demand for VA mental health services
is challenging. Clearly the demand has stretched VA's capacity.
Based on current services we provide to both VA and DoD, we
believe there are ready approaches to address this urgent need
quickly and effectively. These proven solutions for addressing
both short-term and ongoing access issues can be performed
without sacrificing clinical excellence which is a priority for
the VA.
Health Net has collaborated with VA and DoD in delivering a
full continuum of high-quality, flexible, and accessible
solutions which augment existing capacity and capability.
These programs are very flexible in meeting demand from
supporting the surge of returning servicemembers to reaching
out to veterans living in remote geographic areas.
Our counselors have been carefully screened and then
receive extensive training on military culture and relevant
military and veteran issues. This training easily could be
augmented with additional VA specific training.
Our rural mental health providers are trained on VA
benefits and on addressing specific veteran issues.
For the military family life counseling program, we have a
network of over 5,200 licensed counselors who are fully
trained, highly experienced, and ready to deploy.
This network has drawn from a Health Net pool of over
50,000 qualified professionals which is further supported by
over 22,000 behavioral health providers in the TRICARE provider
network.
We believe a path forward for VA should be based upon
existing proven programs using available clinical resources.
Such an approach could effectively supplement VA's capacity
without sacrificing clinical excellence.
Short-term actions might include deployment of clinical
resources to alleviate short-term demand requirements at VA
medical centers or community-based outpatient clinics using
enhanced telephonic and Web-based counseling to provide
veterans with easy access to ongoing support, and finally
augmenting VA's capacity with an existing network of community-
based mental health providers.
We commend the VA for promptly responding to the OIG report
on access to mental health care. We also commend this Committee
for its strong leadership over this critical issue for our
Nation's veterans.
I look forward to your questions. Thank you.
[The prepared statement of Thomas Carrato appears in the
Appendix]
The Chairman. Thank you very much, Admiral.
I have a question to pose to you that does not have
anything to do with your testimony. You heard the bells ring
just a minute ago; we are in our first series of votes. We have
a little over two minutes to get to the floor.
So I would like to ask, if it would be amenable to you, if
we could recess until about 2:30, come back to give us an
opportunity to ask our questions and not feel rushed. We have
one other panel after this. I think 2:30 would give you an
opportunity also to take a break maybe and do some things.
Would that be okay with the panel?
With that, the Committee stands in recess until 2:30.
[Whereupon, at 1:36 p.m., the Committee recessed, to
reconvene at 2:30 p.m., the same day.]
The Chairman. Thank you, everybody, for returning. I
appreciate your indulgence to allow us to go over and have a
series of votes and I had a quick speech that I had to make.
Fortunately, it was here on the Hill.
I would like to begin the round of questioning first. In
the department's written testimony, it states that no industry
standards for accurate mental health staffing ratios exists. So
my first question is, is this a true statement and, if so, how
does your organization determine mental health staffing ratios?
Is there such a thing as an industry standard out there? And if
there is no standard, I understand that, too.
Ms. Rakow, you are recognized.
Ms. Rakow. Thank you, Mr. Chairman. We don't actually have
a set standard that we use for our staffing ratios. I can't
speak to whether or not there is one out there. So we use other
measures of capacity and productivity, such as the number of
slots that providers have still available to take on new cases.
We use relative value units, which is a common measure of
productivity in the health care industry to measure capacity,
as well as productivity, and then use that as demand increases
to translate whether or not we need to increase our supply.
Dr. Schuster. Yes. But I think, generally, I would echo
what Ms. Rakow said. There are standards in terms of access
times, which we had talked about, but I think--and access
availability in terms of how far someone might have to go to
reach a practitioner. But I think the kind of productivity and
staffing standards are probably more-- idiosyncratic is too
strong a word, but there is not one common standard that is
used universally.
Dr. Sawyer. I just want to point out I think that having a
staffing model is part of the problem. I think that we need to
take a look at the actual productivity that a clinician can
achieve while providing effective mental health treatment. The
expectation right now is completely irrelevant. It is just as
many people as you can cram into your schedule a day is your
expected productivity.
However, in other facilities, community mental health,
other mental health facilities, there is a certain expectation
of a clinician. For example, a former mental health center I
worked at there were 22 hours of therapy per week were expected
for your 36 hour work week.
Now, those 22 hours could be made up of many different
things. It could be made up of group therapy. It could be made
up of individual therapy. You may be running a 90 minute
session with someone, given whatever sort of methodology you
were using. But those 22 hours were dedicated to psychotherapy
of some form if you were a full time clinician. Now, the rest
of the hours of the week were spent writing up notes, you know,
providing consultation, all of the things that are important to
providing effective care.
Now, that allowed a case load to be developed so, if you
are effectively seeing your people in 22 hours per week of
therapy, then that can be extrapolated into how many veterans
you could actually have on your case load and treat them in a
manner that is clinically relevant.
So approximately, in my experience with the community
health, a full time clinician could carry about 40 people on
their case load and treat them effectively with 22 hours of
therapy per week because some people only need an every other
week appointment. Some people need once a week. Some people are
coming in for monthly check-ins.
So the intensity of the treatment that you are providing is
disbursed among your case load when you have about 40 people.
And that allows room for you to manage incoming, so you are
taking on new patients periodically when you are discharging
others because they are getting well. So a system that actually
has a case load and a productivity expectation for their
clinicians allows a flow to take place because people are able
to get better. Care is actually effectively provided.
Dr. Schuster. If I could just add one other comment, which
is what's optimal numbers per site might vary depending to some
degree on the range of services that are available for a
particular site. So, for example, if there is only outpatient
services available, you might need more outpatient clinicians
than if you have a broader range of services, case management,
peer services, day hospital, etc. So it probably makes sense or
it might make sense to look at each kind of level system in
terms of what is available and how they can serve the
population they are responsible for.
Dr. Sawyer. Certainly.
The Chairman. And if we can, let's go here because VA has
said that they have been in consultation with other health care
systems to, in fact, create a prototype staffing model for
general mental health at outpatient care. Are any of you aware
of this? Have they reached out to you or the folks that you
represent? And if they have not, do you think it would work and
would you be willing to work with VA to help them resolve this
issue?
Ms. Rakow. We would be glad to work with them. I was
speaking to Dr. Petzel at the break and we would welcome
members of the VA or members of the Committee and your staff to
come visit Group Health and see what we do, if we can offer any
lessons.
The Chairman. Dr. Sawyer, what do you think? I thought I
heard you say you did not think that a staffing model would
work.
Dr. Sawyer. Well, I guess my fear with a staffing model is
this very global approach to, as Dr. Schuster pointed out, a
very facility specific issue. So depending on a range of
services that a facility is providing is what their case loads
of their clinicians need to look like.
So I get a little bit nervous when we start talking about
this sort of global definition of what a staff should look
like. It starts to make me think of mandates sort of trickling
down onto the ground level and then we are all trying to figure
out how to meet these demands.
So in terms of a staffing model, I feel like we need to
look more at a case load model for clinicians. What do we
expect our clinicians to be doing every day and how can we
design that so that they are actually able to provide effective
treatment.
Dr. Schuster. And I found that, staffing models,
particularly in behavioral health, it is, as the panelists have
said, it is so dependant on the type of provider for
psychiatry, for social work, for psychologists, whether it is
acute inpatient, day treatment. So you do come up with staffing
guidelines that can be used as a starting point to determine
availability and accessibility, but it is a very complex
undertaking.
Dr. Sawyer. Well, and you bring up an excellent point, as
well. I am sorry. If I could continue to comment.
On the VA's statement that they have come up with this
number of 5.3 mental health professionals per 1,000 veterans,
what does that mean? 5.3 mental health professionals per 1,000
veterans, if that's 5.3 psychologists, that means I am
responsible for 200 veterans? That is absurd. I can't provide
adequate care to 200 veterans at a time.
If you are a psychiatrist that is providing only 15 minute
appointments, which no psychiatrist actually is, but if you are
only providing 15 minute med checks, maybe you could manage a
case load of 200 people. But a social worker, a psychologist,
people who are providing psychotherapy, which runs in 50 minute
increments at least, sometimes as much as 90, can't manage 200
people.
The Chairman. Mr. Walz.
MR. Walz. Thank you, Chairman. Thank you all for being
here. I really appreciate it and I tell you this not because I
think you care, but it is a little bit of background. I
represent the Mayo Clinic area and, as we got into this whole
health care debate of looking at accountable care
organizations, patient centered care, medical home models, it
is kind of the air we breathe. And I still go back to this
issue as much more systemic in the delivery of the mental
health services in this country.
Would you agree that that is looking at that? I hear you
speaking that way, that partnering together. The VA is a
wonderful opportunity for us to learn on the private sector
side, too. How to deliver mental health care in some complex
situations. But I'm trying to figure out what you can teach
them, too, about going down the line.
So I am going to go to Ms. Rakow first. I found some
interesting things on GHC. They did a great commonwealth study
on you that we were looking at in my office that I think--I
think this sums up where VA is at and where you guys can maybe
provide some help.
It says, ``In recent years, however, GHC pushed to improve
its competitiveness in the marketplace. It began to see the
unintended consequence of a production oriented approach to
primary patient care. Swollen patient model is reaching as high
as 3,000 patients for a physician, increasing specialty care
referrals, rising costs, costs of hospital care, emergency
care, and signs of burnout in the workforce. Like other large
health organizations, GHC was finding it difficult to recruit
primary care physicians and struggling to improve performance
by engaging patients in their own care.''
But here is the good news on this. This is what your vice
president said. ``We were on a platform that was
unsustainable.'' In response to these challenges in 2007, GHC
began a pilot project to define and test a medical home model
of primary care delivery in its Bellevue Seattle suburbs there
and went through and listed some of these things.
Have you been there long enough, Ms. Rakow, to see this as
it changed because, as we have talked about health care and
health care delivery, the debate up here became that it was
like any other commodity to be delivered. It was a supply and
demand issue and all that and it would just work itself out in
the marketplace. The problem with that is, especially with
mental health care, it is not quite that simple.
And so what I am trying to figure out here is could the VA
employ some of the things that you did, you think, to reduce
these wait times and to get better outcomes on patients and
their care?
Ms. Rakow. Thanks for the question. I would hope so. I
think when we actually started looking at access to behavioral
health services in 2001, we had a wait time of, on average,
often 50 days. So we have come a long way. And, similarly in
primary care, we piloted the medical home model a few years
ago. It proved workable and so we rolled it out to all of our
clinics.
But it is really a multi-faceted strategy. On the one hand,
we tried to maximize the use of our capacity with things like
virtual consults with specialty providers from primary care,
which we do with behavioral health services, as well, phone and
group visits, email access to your doctor. We also at the same
time are continuously working to improve. So with some of the
tools and measures that we use, we do track supply and demand,
but we also, at the same time, track quality and clinical
effectiveness and we empower front line staff to actually be
very involved in that tracking process, to visually report
results in the clinic, to huddle every day and look at results.
Mr. Walz. Those outcomes are what matter, what I am trying
to get at.
Dr. Sawyer, I am going to end. I have my last two minutes
to leave to you this issue of value care versus volume care. It
is a problem we have in Medicare delivery, obviously, and it is
what is the biggest cost driver in health care is. How do we
get to that value based care?
Now, I am thinking two questions to you is why would a
psychologist choose to work in VA? Why would a young
psychologist coming out just with their doctorate now and they
are ready to go, why would they choose to work in VA? And could
you just briefly explain what a typical day as a VA
psychiatrist looks like for a psychologist?
Dr. Sawyer. Sure. Thank you. So part one of that I guess is
why a psychologist would come to work for the VA. I think that
right now we have a tremendous opportunity with mental health
professionals coming directly out of school, graduate programs,
because the VA right now is an opportunity for them to serve
their brothers and sisters that have gone off to war. I mean,
we are talking about a generation of graduate students coming
out of school who have watched their cohort go off to war and
come back in a lot of pain. This is an opportunity for them and
we need to seize it. This is something that we can really grab
on to to help encourage psychologists to want to come to work
at the VA.
The VA is not the place where they are going to make the
biggest amount of money. It is going to be a lot of work. They
can get a pretty good benefit package, but it is the feel good
that comes with working at the VA that really motivates a lot
of mental health professionals.
Mr. Walz. Was your motivation tampered a little bit with
some of the requirements that kept you in a box, that didn't
allow you to practice your profession maybe?
Dr. Sawyer. Absolutely. I mean, one of the most difficult
things about working at a VA in its current system is that you
are coming into this system as a professional; You feel very
good about the training that you have taken on. You feel very
good about your expertise.
And then you get there and you are told, oh, no, no, no,
that is not how we do it here. This is how we are going to
practice. These are the treatments you are going to provide.
This is how often you are going to see your veteran. This is
what you are going to say to them about those treatments. I
mean, it comes right down to how you actually practice.
Mr. Walz. Is it your experience when you network across
there? Because I try to get out to as many of my facilities as
is possible and I know it is a gross generalization to say they
are all the same, but you probably network closely with other
professionals.
Dr. Sawyer. Yes. In my job as the evidence based
psychotherapy coordinator, we had contact on a monthly basis
with our local VISN, as well as nationally. And this is common
across the board. It is the greatest frustration of
psychologists and social workers, as well, who are providing
psychotherapy is that their clinical judgment is tossed out the
window. You know, we are--everything is being dictated to us by
the performance measures that the administration----
Mr. Walz. Do you think that is a natural response, though,
to cost benefits and where you are being funded? I say that as
a professional educator where I said, wow, 51 kids in this
class? I am not sure that is the best model for us to do this,
but you are going to have to deliver. Do you think that happens
in a lot of professions where you have to balance between what
the cost is or is this one of those I have always made the case
of whatever it takes to get it right, we need to do?
Dr. Sawyer. Well, I think the biggest problem with taking
the clinical judgment away, not only is it certainly
interfering with the retention of these professionals, but it
also means that there is this very cookie cutter approach that
starts to happen for veterans. And mental health cannot be
cookie cutter. I mean, I can't even imagine another medical
issue that can be less cookie cutter than mental health. But
the VA is trying very hard to create this structure around
health care to provide it to these veterans and that is a major
turnoff to the professionals that are supposed to be sort of
disseminating this care.
Mr. Walz. Is it your judgment that that is simply to meet
the demand, that there is just that many people?
Dr. Sawyer. Absolutely.
Mr. Walz. Okay.
Dr. Sawyer. Absolutely.
Mr. Walz. Thank you.
The Chairman. Ms. Brown, questions?
Ms. Brown. I think my question is for Dr. Schuster. You
have a medical degree. Ms. Sawyer have a educational degree.
Both are very important, but a medical degree I guess is the
top as far as treatment is concerned. I would imagine a person
coming to you would have severe, severe problems as opposed to
going to a, let's say, a social worker with clinical training,
you know, in mental health.
It seems as if we want--we talk about psychiatrists or
psychologists, which is a vast difference, but I know that we
are providing care and need to provide care in many different
ways. I think if you are talking about a professional coming
out of school with no experience, that is a problem dealing
with people with severe trauma, you know.
So can you share with me because I am pushing and I am
going to talk to the next group that we need to have different
tiers as far as providing care for veterans. I mean, when I see
the soup line wrap around the kitchen and who is there are
veterans, then we are not providing them the basic services
that they need. And so we need a combination of working with
our stakeholders in different levels and working with the
professionals in a different level. And to integrate. I see the
VA playing a major part, but I don't see them going out and
hiring no 3,000 psychiatrists because that is not what we need.
Dr. Schuster. Right. I mean, I think that the literature
suggests that having a combined team of professionals available
to treat groups of people is the most effective model, so you
probably don't want just psychiatrists or just psychologists or
just social workers but, really, a team of folks so that people
can get what they need. And if people need to be seen by
multiple professionals, then that is available to them, as well
as I think other community based services.
You know, again, there are models for intensive treatment
services that can be provided actually out in the community,
including peer support services and case management and
thinking about a broad spectrum of services is probably the
most effective way to go. And I know we have talked some here
about looking at different private models of delivering care,
but I think it probably is also useful to have some feedback or
think about models that are used in publicly funded systems to
local mental health center systems and other systems because
part of the VA population is probably more like that than might
be seen in a commercial or a private setting. Some are probably
more typical of what you might--folks who get their services in
publicly oriented settings.
Ms. Brown. Okay. Ms. Sawyer, do you want to respond to
that?
Dr. Sawyer. I couldn't agree more. I mean, I think that
the--there are many veterans that come through the VA that
could be very well served in a community health setting. I
think that the VA could be very good at doing a few very
difficult things and then also being willing to partner with
outside community and private providers.
The difficulty with that is that the VA right now requires-
-first of all, it dictates how many sessions a veteran can have
when it fees out to someone. So it may say, you know, we will
fee you out to this psychotherapist in the community, this
psychologist, and she is going to work with you, but we are
going to give you eight sessions.
Now, that psychologist on the other side wants nothing to
do with that situation. If you are going to put the liability
of this person's mental health care in my hands, I want to be
in control of how that treatment is provided. This is--I am the
one providing it.
So the VA is saying to them, well, we are only going to
give you eight sessions. I don't know, I haven't even met this
person yet, whether or not I am going to be able to do anything
for them in eight sessions.
Ms. Brown. I understand what you are saying, eight
sessions, but we are dictating the--we are dictating the costs
and it is a limited amount that we are willing to pay.
Dr. Sawyer. Mm-hm.
Ms. Brown. So it is a catch. The VA can't--it is a very
frustrating for the VA because they can't satisfy because of
our demands and, of course, the user end. So if eight is not
the appropriate number, how do we control the costs? Because
the people up here, that is all they are interested in.
Dr. Sawyer. Mm-hm.
Ms. Brown. You know, that is all they are interested in.
Costs.
Dr. Sawyer. I certainly understand what you are saying. I
mean, there is definitely a catch there where we can't just let
things run wild on that side. But I think that trying to find a
balance with that so that we actually are respecting the
clinicians that we are trying to fee these folks out to, while
also being mindful of the costs that will come to the facility,
there has to be a balance. We can't just choose one. And I
think that is what is happening right now.
Ms. Brown. All right, Mr. Chairman. I am sure I will get a
chance to follow up.
The Chairman. I don't know. After that last comment, you
may not get a chance. I would say that this Committee and the
House has, in fact, offered up everything that the VA has asked
for, I mean, to the point that we have got 1,500 empty
positions right now that we can't get filled and they are
asking for 1,900 more. And if that is what they need, this
Congress is going to give it to them. But, again, I don't see
how we do 3,500 positions in a timely fashion to a veteran who
needs help today.
Now, Dr. Sawyer, you have said in your opening statement
that you have some comments regarding the secretary's comments
and you would be willing to provide them to this Committee if
we would like to hear them. Now, we would and I would like to
ask you to please expand on it.
Dr. Sawyer. Okay. Well, I think what struck me the most at
one point in the secretary's statement was something that he
said that represented clearly the problem that we face on the
ground. The VA is not providing good care right now. We are
trying our hardest. As providers on the ground, we are working
as hard as we can, but we are simply not able to do the work.
And he identified it as being we are providing good care. We
are just not measuring it very well. That is what happens on
the ground level. That is the message that we're getting from
our administrators within our facility.
When they miss a performance measure or when for some
reason, their VISN or central office comes down on a facility
for not doing something well, how that translates to the
clinicians who are busting their butts every day to try to see
as many veterans as possible is you are not working hard
enough. You are clearly not tracking your work load well
enough. We need you to start keeping better track of how you
are doing this, this, and this.
So when I heard that from the secretary, it was--we I
guess, as clinicians, used to think it was a facility thing.
And then, when it came directly from him, it was very
disheartening to hear that. It is not that we are not measuring
our work well. It is that we are actually not providing the
work. There isn't anything to measure. We are not doing the
work that we need to do.
And part of that is because the clinicians are so overrun.
They are completely incapable of providing the services that
they are trained to do of 200 veterans per clinician, which is
probably about average for some facilities and clinicians right
now. Now that is going to be the expectation. We can't work
with that now. So asking us to say, well, that is going to be
your new norm is ridiculous. There is certainly no way that we
can provide effective care in that way.
I guess some other thoughts that came up were comments
regarding, you know, trainees, that there are a lot of
facilities that have training programs, that I think they
mentioned having many post-docs and interns and one of the
biggest training organizations. I'm wondering, what I would
have liked to have asked the secretary, is what are his
thoughts on why we are not keeping those folks in our system.
What is happening,
Ms. Brown. Chairman?
Ms. Brown. Excuse me. Mr. Chairman, I am not comfortable
with this line of questioning. I don't mind the panel making
whatever comments they want to about the testimony, but to say
that we are responding directly to the secretary, I think that
is inappropriate. The secretary is entitled to his comments and
the panel is entitled to theirs. But to say that we are
responding directly to the secretary, I think that is
inappropriate.
The secretary has a broad experience and takes a broad view
of the VA mission. You are talking about where you work and the
environment you worked in, which is limited. So if we are
talking about the entire system, you don't know what is going
on in the entire system. You only know what goes on in your
area that you were working in or the environment you worked.
You have not talked to everybody in VA.
So I don't want to be put on the spot that I feel like I
need to defend the secretary, but I do not want the panel
saying we are going to comment or critique the comments of the
secretary. That is inappropriate.
I have been on this Committee for 20 years. I guess I am
the only one with institutional memory, but I never heard a
panelist discuss what a secretary said and I don't think that
is appropriate.
The Chairman. Thank you, Ms. Brown, for your comments. Dr.
Sawyer, please continue.
Dr. Sawyer. Well, with all due respect, Congresswoman
Brown, I actually do have a lot of contact with professionals
across the Nation and within my system. And I am certainly not
going to in any way imply that every facility is a disaster.
That is certainly not the case. There are many facilities out
there doing fantastic work. But there are a large number of----
Ms. Brown. No. That is not appropriate. That I was not
speaking to the panelists. I was speaking to you. And she needs
to talk directly to you----
The Chairman. All right.
Ms. Brown. --and not----
The Chairman. All right.
Ms. Brown. Not through----
The Chairman. Ms. Brown, she is trying to talk to you. If
you want her to go through me, that is fine, but she is trying
to answer my questions. And you asked me a question. She is
trying to answer your question. She is not a member of
Congress. She is a doctor and she is trying----
Ms. Brown. She a educational doctor. She is not a medical
doctor. So make sure you get the comments from the medical
doctor, also. She is a educational. She doesn't have a medical
degree and it is a difference between the two.
The Chairman. I will let all my education friends know that
you don't consider a Ph.D. a higher degree, which is what you
just did.
Ms. Brown. That is correct, sir.
The Chairman. Please continue. I really want to hear what
you have to say and I think it is very appropriate for you to
comment about the secretary's comments. Please continue.
Dr. Sawyer. Thank you, Chairman Miller. I guess the last--
the last thing that came to mind with one of the secretary's
comments was that we need to maximize the staff that we have.
And I think that is certainly reasonable to look at it this
way, but our staff are currently maxed out. I mean, I don't
think anyone here was denying the fact that the staff in our VA
facilities have been working extremely hard to meet the demand.
And so there really is nothing left to maximize at this point.
We need more staff and we need a more efficient way of using
our staff. It is not about maximization. It is about
efficiency.
The Chairman. Thank you very much. I thought you were
leaving.
Ms. Brown, you are now recognized.
Ms. Brown. Mr. Schuster, can you give us some----
The Chairman. Excuse me. It would be Dr. Schuster.
Ms. Brown. M.D.? Yes, sir.
Your comments on how we should move forward as far as I
understand the work load is tremendous. And I also understand
we don't need to hire 3,000 Ph.D.s or E.D.D.s. We need a
combination and a team. What are some of the recommendations
that you can give us that we can move forward with and not
criticize or critique the secretary in this Committee. As I
said before, it is one team, one fight, and we are all fighting
for the veterans.
Dr. Schuster. Yes. I am not an expert on the VA per se, so
I can't respond directly to that. But I am happy to provide
some feedback in terms of strategy.
Ms. Brown. So no one in this--no one up here is an expert
on the VA and no one out there is an expert on the VA because
there are many, many aspects of the VA.
Dr. Schuster. Some strategies that we--that the company I
work for has had experience with in terms of trying to address
access, one is certainly looking at numbers of professionals.
So it is certainly an important item to look at.
A second item that we would look at are access measures in
terms of how long it takes people to receive appointments. We
have also looked at and tried to get input from families and
patients, as well as the people providing the care about what
types of services seem like might be missing to help address
people's needs because sometimes people access care through
outpatient services, but sometimes their more urgent needs and
sometimes there are other needs that direct therapy or even
medications might not address.
And then I think the one other thing that we have found
helpful is, in addition to looking at some of the quality
measures we talked about this morning, like time to
appointment, we have also tried to look at some other measures,
like time to follow up, and this was in the GAO report, time to
follow up after a hospital stay, readmission rates, complaints
about access, whether or not there are any concerns from the
community about access to services.
So we have tried to--the GAO report talks about a dashboard
around the outpatient services and we have tried to put
together a series of items that really look like a dashboard,
but address some items beyond the outpatient services, as well,
that we call our provider benchmarking process. So we look at
lots of quality indicators, including complaints and access to
services.
So we found it helpful to certainly look at the items
address here as part of to look at some other quality issues,
as well, that might either affect this or be affected by it.
Ms. Brown. I visited a program in the Tampa-St. Pete area
that they work with the veterans. And one of the things that
they did was they had some kind of horse therapy. That was, you
know, the service organization working with the VA, but it
proved to be very beneficial to the veterans.
So it's all kinds of therapists and all kinds of levels of
services that you can provide. Like I said, we have the
University of Florida in Jacksonville, but you also have them
working with the VA and that is the urban model.
And how can we emphasize and support the different services
because community health or the health department, they work
with providing services. I do not see the VA going out and
hiring 3,000 professionals. How can we better put together the
teams that we need to provide immediate services? I guess that
is the question. And we would just kind of overlook the other
person. Would you like to respond, sir?
Dr. Schuster. Yes, ma'am.
Ms. Brown. Yes, sir.
Rear Admiral Carrato. As you pointed out, the demand for
behavioral health services is just increasing across the DoD
and VA. And I would like to commend the VA for their work in
developing clinical practice guidelines. And the issue is that
the demand is just exceeding the resources. So to your point,
we do need to involve the private sector, and community
solutions.
And I just had three recommendations that I would make and,
you know, I would like to caveat of them because one thing we
don't like to hear is, you know, this is the way we do it here
and you ought to do it and everything will get better. But just
some lessons learned from the Defense Department. Again, the
same folks wearing the uniform. When they take the uniform off,
that demand continues to grow. We developed jointly with DoD
the military family life counseling program.
Ms. Brown. And you said you handle TRICARE also, don't you?
Rear Admiral Carrato. TRICARE and----
Ms. Brown. Which is the family?
Rear Admiral Carrato. The military family life counseling
program is sponsored by the under secretary for Personnel and
Readiness. And to your point with the supply issue with
psychiatry, this is based on using primarily licensed masters
prepared social workers.
Now, there still is a supply issue, so we developed a
rotational model where we are able to respond specifically to
short term demands like the VA is facing now. So we can rotate
social workers, psychologists around the world for 30, 60, 90,
120 day assignments on a rotational basis and we bring folks
back, you know, into the states or back home into their active
practice. The benefit is we can use professionals who are in
active practice.
This isn't a staffing model because I know, as one of the
panelists pointed out, when someone works up the courage to
raise their hand and say I need behavioral health services, to
go in to somebody who has no idea what you have gone through
can just turn you away. So our folks get extensive training on
military, culture, customs. They understand what it means to be
deployed multiple times. And so a rotational model similar to
the military family life counseling program could be effective.
The second suggestion I have, and, again, I know the VA is
a pioneer in this area, but it is to use technologies, web
enabled, Skype enabled counseling, telephonic counseling, to
reach out to veterans and some harder to reach veterans. And
this has proven to be effective.
And, finally, again, the point of augmenting the VA, there
are, in the TRICARE program, the taxpayer has paid us to
develop a network. They have paid Humana to develop a network.
We have over 22,000 behavioral health providers in our network
and there may be an opportunity for that network to be used to
augment the VA.
So those are the suggestions I would have to address the
immediate and the ongoing issues that the VA is facing.
Ms. Brown. One last comment. We are working real hard to
get the Department of Defense to work kind of seamlessly with
the VA. And what recommendations do you have that how we can
work closer together because I don't know why we lose someone
when, you know, and there is that period between when they are
out and they don't think they need services. And then when we
get to them, it is almost too late sometimes.
Rear Admiral Carrato. You know, I think it is just the
ongoing communication. I know when I was still on active duty
and was at DoD, I worked very closely with colleagues at the VA
and I just encourage--would encourage ongoing communication
around these common issues because, as you said, one team, one
fight.
Ms. Brown. Thank you. And thank you, Mr. Chairman. I yield
back the balance of my time.
The Chairman. Dr. Schuster, how long did it take Community
Care to develop and implement the timeliness benchmarks that
you use? And, also, how often do you reevaluate those
benchmarks?
Dr. Schuster. Some of the benchmarks that we used we have
used almost from the beginning. They were dictated by the State
of Pennsylvania as part of its Medicaid program. Other
benchmarks we developed and the company really started its work
with the Medicaid program approximately 15 years ago in
Pennsylvania. Other benchmarks we adopted from NCQA, which is a
company that accredits insurance companies, and we have had
that accreditation for about ten years. So we adopted some of
those additional standards between then.
And then we have really done evolving standards around
access and trying to assess adequate access to care really on
an ongoing basis in the different regions that we work in. We
work very closely with the counties, with each county that we
work within, and with the providers and the advocacy groups, of
family and patient advocacy groups in that area.
So we have ongoing discussions, really, all the time to try
to assess, if people feel like their needs are being met or, if
not, what do we need to do to address it.
The Chairman. Admiral, same question. Do you, if you would,
benchmarks, time to look at reevaluating programs.
Rear Admiral Carrato. You know, pretty much agree with what
Dr. Schuster said. It starts with establishing access
standards, availability standards, and just monitoring closely.
But as we have talked about before, in the behavioral health
area, we are still--we are still learning.
The Chairman. Mr. Walz, any other questions?
Mr. Walz. No. I'm good, Mr. Chairman.
The Chairman. Ms. Brown, anything?
Ms. Brown. Just one last thing. I want to be clear, so when
I read it.
I am not saying that a person with a educational degree is
less qualified than one with a medical degree. I am saying we
need all of those health care providers. I want to be clear. I
think we need all of them, including the social worker and the
community resource person and the family and the veteran. So it
is a team effort and I want to be clear I am not putting down
any profession. I think they are all very important as we
develop this model that we are trying to address this problem.
It is one team, one fight, even though it is the, I mean, we
are working with all of the branches. Thank you.
The Chairman. Thank you very much. Thank you for your
indulgence. You may be getting questions from the full
Committee. For the record, we would ask for a timely response,
if you would in getting those back. Thank you for being with us
today. You are dismissed.
The Chairman. Thank you much for hanging with us for so
long. The final panel today at the witness table is Joy Ilem,
the Deputy National Legislative Director for the Disabled
American Veterans, Alethea Predeoux, the Associate Director for
Health Legislation for the Paralyzed Veterans of American, and
Ralph Ibson, the National Policy Director for the Wounded
Warrior Project. We thank you so much for being here. And, Ms.
Ilem, you are recognized for five minutes.
STATEMENTS OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR
FOR THE DISABLED AMERICAN VETERANS; ALETHEA PREDEOUX, ASSOCIATE
DIRECTOR OF HEALTH LEGISLATION, PARALYZED VETERANS OF AMERICA;
RALPH IBSON, WOUNDED WARRIOR PROJECT, SENIOR FELLOW FOR POLICY
STATEMENT OF JOY ILEM
Ms. Ilem. Thank you, Mr. Chairman, and members of the
Committee. We appreciate the opportunity to offer our views on
the problems confronting the VA in meeting the critical mental
health needs of our Nation's veterans. For over a decade, the
media has covered readjustment challenges that new veterans
face upon returning home. Likewise, the House and Senate
Veterans' Affairs Committees have held numerous hearings on VA
mental health services, and GAO and VA's inspector general have
evaluated and examined a number of related issues.
Typically, coverage focuses on veterans who have fallen
through the cracks, taken their own lives, or gaps in VA and
DoD mental health care. It is rare to see a positive report
about VA mental health programs.
Nevertheless, over the past five years, VA has made
remarkable progress in establishing a stronger foundation for
mental health services. VA has worked hard to institute the
principles of recovery and a national policy to ensure
consistency and availability of mental health services
throughout its 1,400 sites of care. State of the art
approaches, evidence based treatments, and new technologies
have been deployed.
All of this progress has occurred during a time of steadily
increasing work loads and rising demand, culminating in the
current situation VA is experiencing as it struggles to provide
quality mental health care in a timely manner.
Despite significant improvements in care, the current
environment makes it difficult to shift perception to the gains
VA actually has made. The recent IG report and informal survey
by the Senate Veterans' Affairs Committee continue to point out
lingering and troubling findings. According to the IG, VA is
only meeting its 14 day access goal for completing a full
mental health evaluation and treatment plan for about half of
the new patients it sees.
Based on these findings, VA reported it has developed a
comprehensive action plan to enhance mental health services. It
is conducting an external focus group to better understand the
issues raised by front line providers, as well as conducting
site visits to each of its medical centers to evaluate all
mental health programs.
While VA has applied these actions, many contributing
problems exist. For example, after more than a decade, VA's
office of information and technology has still not completed
development of a state of the art scheduling system that can
effectively manage appointment scheduling or provide accurate
tracking and reporting. Likewise, despite the addition of
thousands of new mental health staff since 2002, demand for
services by tens of thousands of new veterans has strained the
system. VA recently announced it needs to hire 1,900 additional
mental health staff, but experts have pointed out that
increased staff alone will not fix the existing problems. We
agree.
So the question is what could and should be done at this
critical juncture. Unfortunately, the problems in VA's mental
health program are multiple, system based, longstanding, and
complex in some cases and cannot be resolved by any single
action. However, as VA moves forward, we urge a focus on
correcting the root of its problems to find real solutions, not
just applying temporary measures for a quick fix.
We believe one of the barriers that prevents VA from being
more effective in many of its programs is human resources
policy and management practices surrounding them. Clinical
leaders across the VA system have told VA for years the
recruitment of new professionals is a lengthy and frustrating
problem that contributes to VA's current issues. We urge the
Committee to carefully examine VA and OPM appointment
authorities and statute and regulation to learn how they are
being applied and determine whether new legislation might offer
some resolution.
VA must develop reliable data systems, fix the flaws in its
appointment scheduling system, develop a usable staffing model
that allows providers to address veterans with their physical,
mental, and social health and do all of this in a patient
centered manner. We make a number of other specific
recommendations in our formal statement to the Committee and
VA, as well.
In closing, we appreciate VA's progress in developing an
improved mental health system of care and the Committee's
continued funding commitment to VA mental health and its
oversight efforts. DAV recognizes this progress and support,
but it is eclipsed and obscured by the problems we are
discussing here today and happening at the worst possible
moment when expectations are the highest.
We believe, collectively, the recommendations we are
making, along with VA's own planning measures and Congress'
continued oversight, can help to begin to resolve these issues.
And we urge VA to solidify its plan, and act expeditiously.
Mr. Chairman, that concludes my statement. I am happy to
answer any questions.
[The prepared statement of Joy Ilem appears in the
Appendix]
The Chairman. Thank you very much.
Ms. Predeoux, you are recognized.
STATEMENT OF ALETHEA PREDEOUX
Ms. Predeoux. Chairman Miller, Ranking Member Brown, and
Members of the Committee, thank you for allowing Paralyzed
Veterans of America to testify today on one of the most
important health care issues facing America's veterans and the
health care system of the Department of Veterans Affairs. PVA
believes that when veterans have timely access to quality
mental health care services they in turn have the opportunity
to establish productive personal and professional lives.
In recent years the VA has made tremendous strides in the
quality of care and variety of services provided to veterans in
the area of mental health. Although these improvements were
much needed and have helped many veterans, PVA believes that
issues of access and mental health care within the VA continue
to exist and more must be done to make certain that all
veterans receive mental health care that is timely and
effective.
The VA's Office of Inspector General report, entitled,
``Veterans Health Administration: Review of Veterans' Access to
Mental Health Care,'' identified many weaknesses within VA's
Department of Mental Health that if improved upon will allow VA
to continue in its progression of providing high quality mental
health services to veterans. Overall, the report concluded that
VHA's mental health performance data is not accurate or
reliable and VHA measures do not fully reflect critical
dimensions of mental health care access.
The report provided recommendations that PVA believes will
help VA better identify and address the issues of access to VA
mental health care services. In addition to those
recommendations, PVA believes that increased attention to
staffing, productivity and performance of providers, and
patient demand will further assist VA in providing care that
makes a difference in the lives of veterans.
The analysis and results from the VA OIG report on mental
health access data shines light on the inconsistencies of
policy implementation within VHA and how such inconsistencies
can negatively impact veterans' access to quality care. For
instance, VA requires that all first-time patients receive a
treatment planning evaluation no more than 14 days from the
initial request or referral for services.
As the VA OIG report makes clear, various mental health
offices within VA have been interpreting this policy to have
multiple meanings, and the end result is not having reliable
data to accurately assess veterans' access to care or the
performance of providers. The VA must ensure that staff adheres
to all policies that are put in place to guarantee a high
caliber of services for veterans, and must further develop
safeguards that ensure such policies are carried out correctly
from day to day.
As it relates to staffing for the past years, PVA's Medical
Services and Health Policy department has identified consistent
staffing deficiencies of mental health professionals within the
Spinal Cord Injury System of Care.
Deficiencies in mental health staffing directly impact
veterans' access to mental health services. For example, within
VA's SCI system, veterans receive annual examinations that
encompass a mental health screening. This annual mental health
screening is extremely important for veterans who have
sustained a catastrophic injury as they have a high propensity
to face challenges involving self-esteem, independence, and
quality of life. The aforementioned mental health staffing
shortages have the potential to compromise quality mental
health screenings and treatment for veterans within the SCI
system of care who are dealing with symptoms of mental health
conditions.
Another issue that impedes patient wellness involving VA
mental health care is the inpatient mental health services
readily available to veterans with catastrophic disabilities.
PVA's Medical Services team has found that inpatient care is
not always available to veterans with a spinal cord injury or
disorder due to a lack of accessible space, or the VA not being
able to provide the necessary physical and medical assistance
that is often needed when a veteran has a catastrophic injury
or illness. When this is the case, these veterans are referred
to alternative methods of treatment that may not always
adequately meet their needs. The VA must work to provide all
veterans with access to mental health services when they seek
the help. A physical disability or multiple complex health
conditions should not prevent veterans from receiving quality,
effective mental health care.
PVA thanks Congress and VA for investing a great deal of
resources into improving mental health services in recent
years. While PVA does not believe that there is just one
definite solution to improving veterans' access to VA mental
health services, we do believe that a comprehensive assessment
of veterans' needs and mental health staffing is a starting
point for identifying both strengths and weaknesses within the
delivery of mental health care. All veterans, regardless of
generation should have access to timely, quality mental health
services.
I would be happy to answer any questions that you might
have.
[The prepared statement of Alethea Predeoux appears in the
Appendix]
The Chairman. Thank you very much.
Mr. Ibson.
STATEMENT OF RALPH IBSON
Mr. Ibson. Thank you, Mr. Chairman. Chairman Miller,
Ranking Member Brown, and Members of the Committee. Speaking
for Wounded Warrior Project, VA can have few higher priorities
than providing both timely and effective care to those with
combat related mental health conditions.
Too often veterans are not getting either. Let me explain.
Some weeks ago, Wounded Warrior Project initiated a survey of
VA mental health staff to better understand the reality on the
ground. With responses from clinicians in 17 of VA's 22
networks, 87 percent say their clinics or programs are
understaffed. As one put it, ``VA in this area is entirely
overwhelmed and booked to capacity.'' 80 percent say staffing
shortages are the reasons for the long delays veterans are
facing, but most also indicate that staffing problems limit the
kind of treatment they can provide. For example, 55 percent
reported that OEF/OIF patients were either frequently or very
frequently assigned to group therapy even though individual
therapy would have been more appropriate. And almost 60 percent
disagreed or strongly disagreed with the statement that they
have leadership support to choose the most appropriate
treatment for their patients.
We welcome VA's plan to hire more staff, but it seems clear
from today's testimony that the Department really has no
reliable way to know how many staff are needed in any given
facility. And as is also attested to, many VA facilities don't
even have space for additional staff.
As further discussed, with serious shortages of mental
health professionals in this country, there are serious
questions about the Department's ability to hire the additional
staff and fill the many vacancies. That challenge, as earlier
discussed, is likely to be compounded, given that most of our
survey respondents describe their work environment as highly
stressful and more than 40 percent said they are considering
leaving VA employment.
Let me share the perspective of just one of those
clinicians. ``The reality is that VA is a top down organization
that wants strict obedience and does not want to hear about
problems. I have little hope there will be real improvement.
You'll only see bandaids and more useless performance measures
designed to make management look good.''
Just as some clinicians feel they are not heard, we
question whether the veteran is heard. Particularly striking is
VA's strong promotion of the use of two PTSD therapies that
involve repeated intense exposures to wartime trauma. Many
veterans just do not want that kind of therapy, but are not
getting any other choice.
Ultimately it is critical to understand the impact the
kinds of problems we have described today are having on the
veteran. And let me just read a few of the observations that
mental health staff shared with us:
``I have a patient who came very close to attempting
suicide in between appointments. I strongly believe that if I
could meet with him weekly or even more on occasion his
suicidal ideation would have decreased and he would be less
likely to act on his thoughts.''
``Even telling patients that the only therapy we can offer
them involves prolonged exposure to the traumas they have
experienced sends them elsewhere.''
``We have veterans who come hundreds of miles for their
appointment and they get, at most, 30 minutes with us.''
Mr. Walz's observations regarding mental health parity, I
thought, were very telling and I think there is a real question
as to whether or not there is mental health parity within the
VA--parity in terms of resources, parity in terms of staffing,
parity in terms of support for mental health care relative to
needs of veterans.
But let me say, acknowledging that VA has offered solutions
and is certainly trying very hard, that there's more that can
be done. I think Representative Buerkle said it well. VA cannot
do it alone. It is time for VA to reach out to its medical
school partners, to organizations of mental health
professionals, to the faith community and far wider, and be
clear and say we cannot do it all, we need your help.
Certainly, as Ms. Brown and others suggested, VA must use
community-based care options which are available on paper but
not necessarily as widely used as they should be when it cannot
provide Wounded Warriors timely effective treatment.
A second point: in a very real sense the VA operates two
mental health care systems, its Vet Center System and system of
care through medical facilities. Those two systems need to be
better integrated, but we can also recognize and should
recognize, in my view, that many Vet Centers are also under
staffed, heavily, very subscribed to and sometimes over booked.
They need additional staffing, too, and we probably need
additional Vet Centers.
And a third point, again, I recognize and appreciate the
hard work that a relatively small staff in VA Central Office is
doing to put out some of these mental health fires and to try
and solve these problems.
But I think the earlier testimony we heard from Dr. Sawyer
spoke to the strength, the dedication, the commitment, the zeal
of those dedicated mental health clinicians at the facilities
on the ground. Bring them into the process, too. Let them be
part of the solutions. I think that's a critical step toward
building the trust that is so critical to a healthy work place
and to successful recruitment and retention.
Let me thank you for your continued focus on these issues
through a long day and to your dedication to the importance of
timely effective VA mental health services for our warriors.
I, too, would be happy to address your questions.
[The prepared statement of Ralph Ibson appears in the
Appendix]
The Chairman. Thank you very much for your testimony and,
again, bearing with us all morning and this afternoon. Ms.
Ilem, I was struck in your testimony where you said it is a
common practice for resource Committees to deny authorization
to fill mental health and substance positions creating ghost
positions that are listed in the service FTEE allocations, but
can never be recruited. And we understand that in many
locations the 1,900 newly allocated FTEEs will not even be
sufficient to fill these vacancies. Would you elaborate on the
idea of ghost positions?
Ms. Ilem. Sure. You know, as part of preparing for the
hearing, we reach out to different mental health providers
around the system and we feel that their input is extremely
important. They are the people that are on the ground facing
the challenges that they are, and this is just some of the
information that a couple of folks have shared with us.
And we have heard that repeatedly. In the independent
budget I know we have worked on some H.R. issues and asking
what are these very long delays, why is it taking so long, and
it seems to be at, maybe, perhaps certain facilities, you know,
because of budget, budget concerns. That is a way to delay
hiring someone, although it is an authorized position.
The Chairman. I would like to ask if any of you have heard
reports that women whose combat experience is termed
``unofficial'' are being barred from group therapy sessions
dealing with post-traumatic stress because they are reserved
for combat veterans. Has this been brought to your attention?
If so, do you think that VA needs to change the eligibility
requirements for group therapy to include all patients
diagnosed with combat-related PTS? And I would ask any of you
that have heard of that, if you would comment. If you haven't,
that is fine, too.
Ms. Ilem. I have not heard that regarding women veterans
specifically. But certainly this has been an ongoing problem
that we hear. There are a number of films that have come,
brought to light, still, the recognition or the lack of
recognition that women really are participating in combat or
their exposure to combat is very, you know, is very real, and
when they are coming back, they need the same types of services
as male veterans. And oftentimes we are told that I am not
believed or they just don't understand. They just cannot
comprehend that as a woman I have been exposed to these
realities of combat.
So I think VA needs to work very hard and I know there are
a number of ongoing research projects in women's health
specifically about combat related PTSD. I mean, there are some
small groups and ongoing research that we have been very
closely monitoring and we think that we are going to see more
and more of that and it absolutely has to be adjusted to
accommodate women veterans as all veterans.
The Chairman. Thank you.
Ms. Predeoux, have you heard of that?
Ms. Predeoux. The same as my colleague, Joy, it has not
been reported to me, but I have heard it through attending
other sessions involving women veterans, and if that is the
case with regard to VA policy, then I wholeheartedly do think
the policy needs to be inclusive of all veterans regardless of
gender and generation.
The Chairman. Mr. Ibson?
Mr. Ibson. Yes, Mr. Chairman. I believe one of the
responses we got in our survey suggested that that was the
experience at that particular facility. I would not be able to
represent that that was widespread, sir.
The Chairman. Well, I appreciate that. It will be one of
the follow-up questions that we do send to VA because it was
buried in some questions I was going to ask the Secretary, but
I just wanted to know from the Veteran Service Organizations if
you are aware of it.
Ms. Brown?
Ms. Brown. Thank you, Mr. Chairman. I guess my question,
and I am glad you all were able to get lunch in that small
window, but what do you believe is the number one barrier
veterans are facing when they are accessing mental health
services because we have a lot of discussion? And I really kind
of like what the Admiral was saying the last time because I
have been pushing that we need to have partners, and it is just
not the VA. I don't see the VA going out hiring 3,000 people.
I see us working with people that are already doing it and,
for example, he said the tri-care. They have people that work
with tri-care, so they already are very familiar with working
with veterans/military personnel.
Ms. Predeoux. With regard to the number one issue, they're
all important, but I would say with regard to access, it would
be the wait times and actually being able to get in and
oftentimes that is due to the large patient panel and patient
load that the mental health providers are taking on in the VA.
We did the same as DAV, but we didn't send it out to mental
health professionals. We sent our questions out to our national
service officers through our benefits department, and there
were some facilities where there were no wait times. Veterans
were able to be seen in less than 14 days and then there were
other facilities where it was 30 days or more before that
initial, I guess, what was the create time from the initial
point of contact.
So it is more so of getting the veterans in at the initial
time and not having wait times discourage or further escalate
issues.
Mr. Ibson. If I could take a shot at that, Congressman, you
know, certainly staffing is a major issue and one could see
that as the major barrier, and yet even to say that would be to
oversimplify because staffing has so many elements.
It strikes me it is not just about recruitment as heard
today, but it is also about retention, and you have to ask
about VA's ability to retain clinicians when they don't have
the opportunity to provide the type of treatment they think is
clinically appropriate or when they don't have dedicated office
space or when, as Dr. Sawyer described, they don't feel they
have any independent judgment, but are recipients of directives
from on high.
So it is a complicated question and a multi-faceted
question as several have suggested earlier.
Ms. Brown. Well, let me just ask you this follow up
question because we are losing professionals in VA and in
Federal government because lack of pay. We are not competitive
with other areas. It is nice to think that you--pay is not a
factor, but let us say someone goes to medical school or
someone goes to a professional program. If there was some way
that the student loan could be tied into working into some of
the critical areas, then that would be incentive to encourage
people to work in, let us say, the rural areas. You know, I
live in Florida, so everyone wants to live in Florida, I guess.
But I wouldn't have the same to work in maybe a smaller
town in Georgia, but if you could tie it in some way to that
student loan, do you think that would encourage people to want
to work in the VA for a certain period of time?
Mr. Ibson. I think that is certainly one possible strategy,
but I would note Dr. Sawyer's very eloquent presentation of how
young men and women in the health professions are motivated to
help veterans and that pay is not necessarily the critical
factor. Rather what seems important is the opportunity to be
fulfilled and satisfied and work helping others, and to the
extent that the system fosters that kind of environment, I
think, VA would be a very conducive and attractive place to
work, and I think that is a challenge.
Ms. Brown. I agree with you, but I also heard someone
coming right out of professional school, and I would think that
some experience would be important working with, depending on
the area of care that the person encountered. You want them to
have experience, but you want them to have the academic book
also. So it is a combination.
Mr. Ibson. I would agree.
Ms. Brown. Yes, ma'am.
Ms. Predeoux. In our surveys that were sent out to our
national services officers, pay was not a question. However, it
did come up in a few responses with regard to structural issues
and I did not have an opportunity to research further with
regard to pay and I think it was specifically two
psychologists. But the other side of that, also, and we also
discussed it in the independent budget H.R. session, the VA
currently has educational reimbursement programs and different
scholarship programs, but they have not been increased for a
significant period of time, so that is something to consider
when addressing more of the systemic issues in keeping
retention issues within VHA.
Ms. Brown. Okay. I yield back.
The Chairman. Mr. Walz.
Mr. Walz. Thank you, Chairman. Thank you all for your
testimony.
I do come back to the parity issue, Ralph, and this is a
broader issue. I was thinking, looking at the numbers as we
talk about access. In this country there is 340 people for
every medical doctor. There are 3,400 for every psychologist or
mental health practitioner. We are graduating about 18,000 to
20,000 doctors per year and we are already experiencing a great
shortage in general practitioners. We are graduating about
4,000 psychologists. It is just impossible to keep up with
those numbers. I think it goes back to where Ms. Brown and
others were talking about of how we build this model to
collaborate to try and drop on the resources we have. There is
both a shortage in the private sector as well as the VA.
My concern is, and I will start with you, Mr. Ibson, and
maybe just ask each of you. I, for one, do believe that there
is an opportunity here to use some other people outside the
system. I have seen it happen. I also know one of the problems
is, is how do we ensure that these providers are providing
evidence-based care and the outcomes we want to see, too,
because if we are going to ask the VA to take taxpayer dollars
and fund it out, then we are going to be asked to be
accountable for every penny of that just like we are doing
today.
How do we know that we are going to get the care there
also, if we have to drop on outside resources? I don't know,
Ralph. Have you had any thought on that or how that moves
forward because I think--I just don't see the numbers here on
the ability for us to deliver care as quickly because there is
just not that many mental health care providers for the need
that is going to be there. We cannot even keep our head above
water and it is going to get worse.
Mr. Ibson. Well, at the risk of ducking your question, I
did want to observe the importance of your earlier emphasis and
reemphasis on outcomes because it is one thing that VA is not
measuring, and given a department that is so committed to being
a leader, this is an area where leadership is desperately
needed in terms of developing measures of outcomes. Ultimately,
having performance measures which give us indicators of inputs
and throughputs and numbers and percentages, but don't tell us
whether veterans are getting better. Such measures are not
going to advance our veterans' well being.
I think that would be an important step to VA's solving its
own problems.
Mr. Walz. You are not as concerned on this evidence-based
outcome because you are not convinced it is happening inside
the VA as it stands. I don't want to put words in your mouth,
but----
Mr. Ibson. I think that is fair, sir. But I think you are
certainly quite right. We can't just willy-nilly put veterans
in the hands of individuals who don't have the clinical
competence or the cultural competence to provide them effective
treatment.
Mr. Walz. Any of us who have been at this for a while
experiences this. We have the psychologist or the care provider
who has worked with veterans for decades, starting with Vietnam
and they do it brilliantly and then they don't get the ability,
in some cases to get fee for service. They come to us with
their veterans and say, I want to see Dr. So-and-so who is
outside the system and then they see it as the VA being, you
know, kind of provincial, kind of holding their stuff in and
they don't want to help anybody, but for every good Doctor A,
there may be one out there that doesn't have that experience or
isn't providing evidence based, so I am trying to find that
rationale of where we set those guidelines.
Mr. Ibson. You know, I think one step forward in the spirit
of this being a larger problem than just VA's, would be for VA
to provide training to community clinicians in terms of just
the military culture issues which are such an important part of
connecting with the veteran and developing the kind of trust
that Dr. Sawyer's testimony suggested was so important.
Mr. Walz. Do the rest of you have any comments on this as a
concern as we try and broaden the provider base for our
veterans?
Ms. Predeoux. I think it is a very complex issue,
especially when you are dealing with holes that are evident
within the VA system, and rather than being able to quick fix,
in the meantime we have veterans who need care. I do think that
making sure that there are standards and safeguards in place so
that there is accountability, is very important, and along the
same lines of not necessarily training, but making sure that
there are actual levels of literal standards that providers
must meet before the VA is able to enter into that type of
agreement for outside care.
Ms. Ilem. And I would just add, I think, from the previous
panel, it was noted, we have some of our tri-care provider
networks that obviously have that connection, the veteran
cultural competency in place. VA does have, I believe, a few
small pilots with a couple of them related to mental health. I
think it is more in rural health right now, at least they are
attempting to. It just has not been on any significant scale.
And given all of the remarks, you know, from all of the
panels today, we are hoping that VA will come away with at
least keeping an open mind to trying to address this problem. I
have had a couple of, you know, experts say we don't think VA
can buy their way out of this issue in terms of, you know, just
ramping up the numbers. We know how long it is taking them to
get actual people online----
Mr. Walz. Well, I think the potential is great here to run
both ways. As I said, my meetings with Mayo Clinic of looking
for partnerships on Tele-Health and those types of things, I
think, show that the private sector is willing to be there, and
I think at least the overtures from VA is their willingness to
go both ways.
I think there is a potential here for us to expand that
care in both sides, and I think there is a lot of good lessons
learned from our VA practitioners that can apply into the
public sector, whether it is domestic violence issues or
whatever they might be.
So, well, thank you, Mr. Chairman. I yield back.
The Chairman. Thank you very much, Mr. Ibson. Would you--in
your testimony you talked about cultural problems facing VA. We
know that there are cultural problems facing VA, but you talked
about a perception that leadership employs, and I am not
talking about any particular secretary. I am talking about
leadership as a whole, employs a command and control model
without regard to whether the facility's clinical staff
actually has the means to carry them out, and what I would like
to ask you to do is expand a little bit about that statement.
Mr. Ibson. Well, I am attempting in that statement to echo
the sentiments of many providers who responded to our survey
conveying that thought. This was an anonymous survey, but of
those who expressed a willingness to speak and with whom I
followed up, this was a common theme. I think Dr. Sawyer
expressed it perhaps better than I am. But it's about a
workplace climate, which is perhaps born of good will, but
which stems from centrally directed performance measures which
ultimately as they find their way to the clinic level, overtake
good clinical judgment and come across as mandates and
directives, and seem difficult to understand.
I am thinking, for example, of a provider who reflected on
a requirement to discuss smoking cessation therapy with
patients and who commented that ``I have a veteran sitting
across the table from me whose wife just died and how ludicrous
it is to think that I should set those compelling issues aside
to discuss his smoking habit with him.''
It is, again, I think, a matter of well intended measures
that are proxies for good care, but which at the clinic level,
at the provider level, don't necessarily translate to good care
and overtake and impede good care.
The Chairman. Ms. Brown, Mr. Walz, any other comments?
Ms. Brown. I do have one last question. How do you all
feel--I personally feel that the VA cannot go it alone. We need
to work with our partners and stakeholders and in that there
was a discussion about having a series of one-day conferences
to bring in the partners that were with us. How do you feel
about how we can get the community more involved? For example,
Jacksonville and CSX was the first wounded warrior program in
the country and I am very proud of that, but how do we get
more--because I don't see government just doing it alone.
I think we have to work with our partners and stakeholders
in the private sector and the universities and the community
colleges. It is really a team effort. And to think that the VA
can just do it by themselves is ludicrous. It is too many
veterans. It is too many issues. I mean we are talking about
mental health, mental health. It affects my mental health if I
can't pay my mortgage and I am about to lose my home. It
affects my mental health--many, many things affect my mental
health. When you lose a spouse, it is many things. It is not
just one. So it is the whole village, and how do we engage the
community and how do we get different stakeholders to
participate. And so any comments on that?
Mr. Ibson. I think this hearing offers a wonderful
opportunity to advance that theme. I think I hear it as a
bipartisan matter and I think Admiral Mullen has spoken so
eloquently of that sea of goodwill out there. I think it is a
matter of harnessing that spirit and offering some leadership,
and I think this Committee is in a position to do that.
Communities are desperate for avenues of engagement and I
don't know that the Department of Veterans Affairs feels it has
the clear signal to acknowledge its limitations and to reach
out in a way in which it, I think, very effectively could to
those communities such efforts would look different, community
to community, but there are, I think, enormous opportunities to
advance those goals through partnerships.
Ms. Brown. I think you all play a very important part
working with us to push for these efforts that I think is like
one team, one fight. I think you all, you all, the service
organization, play a very important part.
Mr. Ibson. It is certainly our view.
Ms. Ilem. And I would just add, I think the community over
seven or eight years ago, I mean, we have seen it repeatedly on
occasion to have, you know, them come and group together saying
we want to know how we can help our veterans and what we can
do.
I think one of the things VA might do--as we know, many
people choose not to go to VA for whatever reason. Not
everybody is going to go, but certainly they may need mental
health and touch the community and it may be a family member or
other people within the family that are struggling along with
that veteran, so if VA does have an opportunity to share their
expertise through their national center for PTSD for, you know,
perhaps in some cases for those who suffered trauma through
military sexual trauma and other traumas, it could be very
helpful if VA was able to offer that in some way for those that
are seeing people in the community already.
Ms. Brown. In closing, let me just say that I have
participated in numerous workshops and town hall meetings and
hearings that we had with women veterans and, you know, part of
the problem a lot of women are experiencing, that they
indicated, is the culture of the VA and the culture of the
military. So I suggested, well, maybe we could farm this out
using different organizations, outsource--oh, I hate that
word--but maybe we can outsource this to different providers.
And they said, no, we want the VA to provide it.
So basically we have this culture that I don't think is as
conducive to women, which is the fastest growing group, but
they want the VA to provide it and one example that they talked
about when they walked in, but you know, they had cat calls.
Well, you know, when you walk down the street, you may get cat
calls, but how do you change not the people that work there,
but the other people that are there in the facilities? How do
you not integrate the services to provide the kinds of services
that the female veterans want?
And I am not saying it for an answer. I am just spelling
out some of the challenges that the VA experienced and it is
going to take all of us working together to solve some of these
problems. It is not just the VA. It is us, you all and us,
Members of Congress, working bipartisan to try to solve these
challenging issues that are so many, many, many. Whether it is
our community getting together doing the stand downs that I
participate in or working to eradicate the homelessness among
veterans. You can't expect just veterans to do it, but it is
veterans, VA hard labor, all of us working together, everybody
doing their job, everybody being on their A game and not just
expecting the VA to go it alone. It is a team effort. Thank
you, and I yield back the balance of my time.
The Chairman. I thank you very much. I would ask unanimous
consent that all members would have five legislative days to
revise and extend their remarks.
And without objection, so ordered.
And I want to again thank the witnesses for remaining with
us. Dr. Petzel, thank you, sir, for remaining the entire time
of this lengthy hearing. We know that it is important to you
and we appreciate you being here.
And with that, this hearing is adjourned.
[Whereupon, at 3:58 p.m. the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Jeff Miller, Chairman
The Committee will come to order.
Good morning, and welcome to today's Full Committee hearing ``VA
Mental Health Care Staffing: Ensuring Quality and Quantity.''
Two weeks ago yesterday, the VA Inspector General (IG) released a
report reviewing veterans' access to mental health care.
To say that the findings in that report are troubling would be a
serious understatement.
Perhaps most disturbing is IG's discovery that more than half of
the veterans who seek mental health care through VA wait an average of
FIFTY days to receive a full mental health evaluation.
Let me be very clear--a veteran who comes to VA for help should
never--under any circumstance--have to wait almost two months to
receive the evaluation they have asked for and begin the treatment they
need. There is no excuse for this.
Given the gravity of the issues we will discuss this morning, I
invited Secretary Shinseki to participate in today's hearing.
Sir, I was concerned, based on a letter from you last week, that
you would not be joining us this morning.
I am very glad that is not the case.
As you know, leadership and accountability begin at the top.
These hearings are much more than just opportunities for the
Committee to hear from the Department.
They are also opportunities for the Department to hear from us.
And, in both respects, there is no one better positioned to
represent VA than you are.
Thank you for being here this morning.
Interestingly, just days before the IG report was released, VA made
a surprise announcement that VA would be increasing their mental health
staff by nineteen hundred--adding approximately sixteen hundred
clinicians and three hundred support staff to their current roster of
just over twenty-thousand mental health professionals.
Ensuring VA is staffed adequately to fulfill the care needs of our
veterans and their families is a priority of mine. On its face this is
an encouraging step.
However, I remain deeply concerned by the timing and implication of
this announcement.
The IG's report clearly illustrates that the VA does not have
meaningful or reliable data to accurately measure a veteran's access to
care or a facility's mental health staffing needs.
The IG states--and I quote--``. . . the complexity of the
computations and inaccuracies in some of the data sources, limits the
usability of productivity information to fully assess current capacity,
determine optimal resource distribution, evaluate productivity across
the system, and establish mental health staffing and productivity
standards.''
Which begs the question--if VA doesn't even have a complete picture
of the problem, how confident can we be that access will be increased
and care enhanced by VA's knee-jerk reaction?
This is not the first time we have been here.
There is a long history of IG, Government Accountability Office
(GAO) and stakeholder reports that have found serious deficiencies with
the VA mental health system of care, including appointment scheduling
processes and procedures, PROVIDER performance measures, and data
collection efforts.
There is an equally long history of Congressional oversight.
Strides have been taken, but they are far from enough.
I would like to give the Department the benefit of the doubt.
I believe that we all have the best interests of our veterans at
heart.
But, I am afraid that VA's response in this instance is yet another
example of a Federal bureaucracy providing a quick-fix, cookie-cutter
solution to a very serious, multifaceted problem.
A true definition of access to care can be found in a 1993
Institute of Medicine report which reads, in part, ``[t]he most
important consideration is whether [patients] have an opportunity for a
good outcome--especially in those instances in which medical care can
make a difference.''
The one point three million veterans who sought mental health care
through VA last year deserve better.
The very least we owe our veterans is a chance.
VA can make a difference and VA must make a difference.
Thank you all for being here today. I now yield to the Ranking
Member, Ms. Brown.
Prepared Statement of Robert L. Jesse, M.D., Ph. D.
Chairman Miller, Ranking Member Filner, and Members of the
Committee, I appreciate the opportunity to address access to, and
quality of, VA's mental healthcare. I am accompanied today by Mary
Schohn, Ph.D., Director, Office of Mental Health Operations, Antonette
Zeiss, Ph.D., Chief Consultant, Office of Mental Health Services, and
Annie Spiczak, Assistant Deputy Under Secretary for Health for
Workforce Service, supporting all of VHA.
Over the past several years VA has been transforming its mental
health delivery system in response to the growing demand for these
services. Over the previous year, VA has learned a great deal about
both the strengths of our mental healthcare system, as well as areas
that need improvement. VA's Office of Inspector General (OIG) recently
completed a review of our mental health programs and offered four
recommendations. The OIG cited a need for improvement in our wait time
measurements, improvement in patient experience metrics, development of
a staffing model, and provision of data to improve clinic management.
VA is using the OIG results along with our internal reviews to
implement important enhancements to VA mental healthcare. VA constantly
strives to improve, and any data and assessments--positive or
negative--will be used to help enhance services provided to our
Veterans.
The OIG confirmed that Veterans seeking an initial mental health
appointment did generally receive the required rapid triage evaluation
in a timely manner. This is an important step to identify high risk
patients who need immediate intervention. While a mental health
evaluation within 14 days following the triage referral generally
occurs, we agree with the OIG that not all Veterans were able to
receive a full diagnostic and treatment evaluation required by VA
policies, especially for some intensive services such as beginning a
course of evidence-based psychotherapy. While the explanations for
these findings are varied, none are satisfactory--VA must do more to
deliver the mental health services that Veterans need in a time period
that supports their care.
Based on these findings, we are enhancing staffing and recruitment
efforts, updating scheduling practices, and strengthening performance
measures to ensure accountability. By taking these steps, we are doing
more than ever to deliver accessible, high quality mental healthcare to
Veterans. My written statement describes how we have traditionally
evaluated access to mental healthcare and how we propose to evaluate
access in the future. It will then explain how we assess the quality of
care delivered and potential new considerations on this topic. In light
of these discussions, I will conclude with an explanation of VA's
recent enhancement of mental health staffing.
Access to Care
Ensuring access to appropriate care is essential to helping
Veterans recover from the injuries or illnesses they incurred during
their military service. Access can be realized in many ways: through
face-to-face visits, telehealth, phone calls, online systems, mobile
apps, and community partnerships. Over the last several years, VA has
enhanced its capacity to deliver needed mental health services and to
improve the system of care so that services can be more readily
accessed by Veterans. VA believes that mental healthcare must
constantly evolve and improve as new research knowledge becomes
available. As more Veterans access our services, we recognize their
unique needs and needs of their families--many of whom have been
affected by multiple, lengthy deployments. In addition, proactive
screening and an enhanced sensitivity to issues being raised by
Veterans have identified areas for improvement.
In an effort to increase access to mental healthcare and reduce the
stigma of seeking such care, VA has integrated mental health into
primary care settings. Since the start of fiscal year (FY) 2008, VA has
provided nearly two million Primary Care-Mental Health Integration (PC-
MHI) clinical visits to more than 575,000 unique Veterans. Primary care
physicians systematically screen Veterans for depression, post-
traumatic stress disorder (PTSD), problem drinking, and military sexual
trauma to identify those at risk for these conditions. Research on this
integration shows that as a result, Veterans who would not otherwise be
likely to accept referrals to separate specialty mental healthcare are
now receiving mental health treatment. Among primary care patients with
positive screens for depression, those who receive same-day PC-MHI
services are more than twice as likely to receive depression treatment
than those who did not. These are important advances, particularly
given the rising numbers of Veterans seeking mental healthcare.
In August 2011, VA conducted an informal survey of line-level staff
providers at several facilities and learned of concerns that Veterans'
ability to schedule timely appointments may not match data gathered by
VA's performance management system. These providers articulated
constraints on their ability to best serve Veterans, including
inadequate staffing, space shortages, limited hours of operation, and
competing demands for other types of appointments, particularly for
compensation and pension or disability evaluations. In response to this
finding, VA took three major actions. First, VA developed a
comprehensive action plan aimed at enhancing mental healthcare and
addressing the concerns raised by its staff. Second, VA conducted
external focus groups to better understand the issues raised by front-
line providers. Third, VA is conducting a comprehensive first-hand
assessment of the mental health program at every VA medical center. As
of April 25, 2012, 63 of 140 (45 percent) site visits have been
completed, and the remainder will be completed by the end of the fiscal
year.
Historically, VA has measured access to mental health services
through several data streams. First, VA defined what services should be
available in VA facilities in the 2008 VHA Handbook 1160.01 entitled
Uniform Mental Health Services in VA Medical Centers and Clinics, and
tracks the availability of these services throughout the system.
Moreover, VA has added a five-part mental health measure in the
performance contracts for VHA leadership, effective starting in October
2011. The new performance contract measure holds leadership accountable
for:
The percentage of new patients who have had a full
assessment and begun treatment within 14 days of the first mental
health appointment;
The proportion of Operation Enduring Freedom/Operation
Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans with newly
diagnosed PTSD who receive at least eight sessions of psychotherapy
within 14 weeks;
Proactive follow-up within 7 days by a mental health
professional for any patient who is discharged from an inpatient mental
health unit at a VA facility;
Proactive delivery of at least four mental health follow-
up visits within 30 days for any patient flagged as a high suicide
risk; and
The percentage of current mental health patients who
receive a new diagnosis of PTSD and are able to access care
specifically for PTSD within 14 days of referral for PTSD services.
VA policies require that for established patients, subsequent
mental health appointments be scheduled within 14 days of the date
desired by the Veteran. This has been a complicated indicator, as the
desired date can be influenced by several factors, including:
The Veteran's desire to delay or expedite treatment for
personal reasons;
The recommendation of the provider; and
Variance in how schedulers process requests for
appointments from Veterans.
VA understands virtually every healthcare system in the country
faces similar challenges in scheduling appointments, but as a leader in
the industry, and as the only healthcare system with the obligation and
honor of treating America's Veterans, we are committed to delivering
the very best service possible. As a result, VA will modify the current
appointment performance measurement system to include a combination of
measures that better captures each Veteran's unique needs throughout
all phases of his or her treatment. Some Veterans may need to be seen
more frequently than within 14 days (for example, if they need weekly
sessions as part of a course of evidence-based psychotherapy), while
others may not (for example, if they are doing well after intensive
treatment and will benefit most from a well-designed maintenance plan
with far less frequent meetings). VA will ensure this approach is
structured around a thoughtful, individualized treatment plan developed
for each Veteran to inform the timing of appointments.
VA has formed a work group to examine how best to measure Veterans'
wait time experiences and how to improve scheduling processes to define
how our facilities should respond to Veterans' needs. In the interim,
the work group has recommended a return to the use of the ``create
date'' metric (the metric used by the OIG during its review), which
will minimize the complexity of the current scheduling process. The
``create date'' refers to the date on which a Veteran requested an
appointment, and the wait time will be measured as the numbers of days
between the create date and the visit with a mental health
professional. The work group is currently developing an action plan to
be reviewed by the Under Secretary for Health by June 1, 2012.
Performance measurement and accountability will remain the cornerstones
of our program to ensure that resources are being devoted where they
need to go and being used to the benefit of Veterans. Our priority is
leading the Nation in patient satisfaction regarding the quality and
timeliness of their appointments.
Quality of Care
VA has made deployment of evidence-based therapies a critical
element of its approach to mental healthcare. Mental health
professionals across the system must provide the most effective
treatments for PTSD and other mental health conditions. We have
instituted national training programs to educate therapists in two
particularly effective exposure-based psycho-therapies for PTSD:
cognitive processing therapy and prolonged exposure therapy. The
Institute of Medicine and the Clinical Practice Guidelines developed
jointly by VA and the DoD have consistently concluded the efficacy of
these treatment approaches.
Not everyone with PTSD who receives evidence-based treatment may
have a favorable response. Although VA uses the most effective
treatments available, some Veterans will need lifetime care for their
mental health problems and may see slow initial improvement. Almost
everyone can improve, but some wounds are deep and require a close,
consistent relationship between VA and the Veteran to find the most
effective individualized approaches over time. Veterans and their
families should not expect ``quick fixes,'' but they should expect an
ongoing commitment to intensive efforts at care for any problems.
A recent analysis of data shows that Veterans with the most severe
PTSD are least likely to benefit from a standard course of treatment
and to achieve remission. Other factors that predicted poor response
were unemployment, co-morbid mood disorder, and lower education. In
other words, those with the worst PTSD are least likely to achieve
remission, as is true with any other medical problem.
Even when Veterans are able to begin and sustain participation in
treatment, timing, parenting, social, and community factors all matter
a great deal. Treatment, especially treatment of severe PTSD, may take
a long time. Evidence also shows that whereas a positive response to
treatment may reduce symptom severity and increase functional status
among severely affected Veterans, the magnitude of improvement may not
always be enough to achieve full clinical remission. This is no
different than what is found with other severe and chronic medical
disorders. Providing the best treatments with the strongest evidence
base is crucial to care, but is only one piece of a broader, ongoing
commitment to rehabilitative care and treatments for other co-occurring
mental health problems or other psychosocial problems that may develop.
Based on ongoing surveys, we know that all VA facilities have staff
trained at least in either prolonged exposure or cognitive processing
therapy, and usually both. In addition, one of the preliminary results
of our site visits found that many facilities have a strong practice of
training more staff in these and other evidence-based therapies for a
wide array of mental health problems.
As more providers are trained in these approaches to care,
facilities are shifting from their more traditional counseling approach
to these newer treatments. We have not always communicated well enough
to Veterans the nature or reason behind these changes. These new
programs emphasize a recovery model, which is strengths-based,
individualized, and Veteran-centered. A recovery-oriented model does
not focus exclusively on symptom reduction, but has as its goal helping
Veterans achieve personal life goals that will improve functioning
while managing symptoms. These efforts have been recognized as
successful in the academic literature and through a Government
Performance and Results Act review conducted by RAND/Altarum, which
concluded that VA mental healthcare was superior to other mental
healthcare offered in the United States in almost every dimension
evaluated.
Before the development of these evidence-based approaches, VA made
every effort to offer clinical services for PTSD based on clinical
experience and innovation. Some of these approaches have developed into
the evidence-based approaches we have now, while others have not been
shown to offer the help that was expected. Even those therapies that
did not help in truly alleviating PTSD could come to feel like
``lifelines'' to those receiving them. For example, some sites hold
group educational sessions to help Veterans understand PTSD symptoms
and causes, and these sometimes developed into ongoing groups. While
group therapy for PTSD can be effective and is cited in the VA/DoD
Clinical Practice guidelines, group therapy is understood (and
validated) as possible only in fairly small groups--usually fewer than
10 participants. Educational groups often have far more members,
sometimes up to 50 or more; while this can be an effective way to
conduct psycho-education, it cannot be considered ``group therapy.''
Veterans who have used some of the PTSD services previously adopted
by VA may not be familiar or comfortable with newer approaches, and we
must continuously educate Veterans and others about what treatments are
most likely to be effective and how Veterans can access them. Some of
our own providers have not understood these changes. The National
Center for PTSD has been providing guidance through the PTSD mentoring
program to help facilities collaborate with providers and Veterans in
the transition. We have developed educational processes to help clarify
the need for and rationale behind efforts to change clinical practice
patterns to ensure best possible care for VA.
VA's realignment of VHA last year created an Office of Mental
Health Operations with oversight of mental health programs across the
country. This has aligned operational needs and connected resources
across the agency with data collection efforts to bring the full
picture of VA's mental health system into focus. In fiscal year 2011,
VA developed a comprehensive mental health information system that is
available to all staff to support management decisions and quality
improvement efforts. This year, a collaborative effort between VA
Central Office and field staff is underway to review mental health
operations throughout the system and to develop quality improvement
plans to address opportunities for improvement through dissemination of
strong practices across the country.
Enhancing Mental Health Staffing
Decisions concerning staffing and programs were determined
historically at the facility level to allow flexibility based on local
resources and needs. In the past year, as evidence accumulates, it has
become clear that sites can benefit from more central guidance on best
practices in determining needed mental health staff. While no industry
standards for accurate mental health staffing ratios exist, VA
developed and is piloting a national prototype staffing level model for
general mental health outpatient care. This staffing level model uses a
methodology that considered findings in academic literature,
consultation with other healthcare systems, and utilization and
staffing data. This staffing model will be further refined as VA
monitors its effectiveness and incorporates team-based concepts. VA
will build upon the successes of the primary care staffing model and
apply these principles to mental health practices. The model is based
on the following guiding principles:
Delivering quality comprehensive mental healthcare;
Coordinating mental healthcare across all MH disciplines
and the integration with primary care;
Ensuring effectiveness and efficiency of service delivery
by having all staff working at their highest level possible;
Promoting team staffing to support all providers to
function at the highest level;
Dedicating time for indirect patient care activities (for
example, care planning and team coordination); and
Supporting a team response to emergent and non-emergent
patient and family needs (for example, unscheduled phone calls).
The model's clinical staffing ratio is as follows:
----------------------------------------------------------------------------------------------------------------
Full Time Employee Equivalent for Mental Health Clinic
Employee Category Panel Size of 1,000
----------------------------------------------------------------------------------------------------------------
Total Mental Health Clinician 5.1-5.5
----------------------------------------------------------------------------------------------------------------
Administrative Clerical Support 0.5-1
----------------------------------------------------------------------------------------------------------------
Clinical Support Direct 1
----------------------------------------------------------------------------------------------------------------
Total FTEE 6.6-7.5
----------------------------------------------------------------------------------------------------------------
Applying this model and these ratios, VA determined an additional
1,700 mental health staff members (including administrative and
clerical staff) were needed to augment existing resources across the
country. Clinical staff will represent all specialties, including
psychologists, psychiatrists, social workers, mental health nurse,
licensed professional counselors (LPC), licensed marriage and family
therapists (MFT), and others. In addition, VHA projected an additional
100 compensation and pension examiners would be needed. Each Veterans
Integrated Service Network (VISN) is receiving some additional support
in either clinical or clerical staff or compensation and pension
examiners. VA is also adding 100 staff to the Veterans Crisis Line to
support projected increases in the use of this service. These
enhancements in total will add more than 1,900 employees to VA's
existing mental health staff of more than 20,500. VA Central Office is
providing technical assistance to VISNs to help them with
implementation and is providing additional funding to aid recruitment
and hiring. VA's Office of Mental Health Operations will obtain monthly
updates from facilities receiving funding to ensure implementation is
timely and that resources are used appropriately.
We are testing this model through a pilot program in VISNs 1, 4,
and 22, and we anticipate national implementation of this new model by
the end of this fiscal year. While the model may be refined as a result
of the pilot testing, it provides a clear basis for assessing staffing
for mental health services, and shows that currently there are
shortfalls at some sites nationally that VA is addressing. We will use
this staffing level model, with refinements made over time, to guide
staffing decisions in the future. This will be combined with a review
of revised clinical outcome measures, to be developed in consultation
with other subject matter experts from VHA and the OIG, to evaluate
whether enhanced staffing results in enhanced performance on more valid
measures. We will reassess levels of care needs and specialty services
based on these multiple data sources.
Despite the national challenges with recruitment of mental
healthcare professionals, VA continues to make significant improvements
in its recruitment and retention efforts. Specialty mental healthcare
occupations, such as psychologists, psychiatrists, and others, are
difficult to fill and will require a very aggressive recruitment and
marketing effort. VA has developed a strategy for this effort focusing
on the following key factors:
Implementing a highly visible, multi-faceted and
sustained marketing and outreach campaign targeted to mental healthcare
providers;
Engaging VHA's National Health Care Recruiters for the
most difficult to recruit positions;
Recruiting from an active pipeline of qualified
candidates to leverage against vacancies; and
Ensuring complete involvement and support from VA
leadership.
VA anticipates the majority of hires for this effort will be
selected within approximately 6 months, with the most ``hard-to-fill''
positions filled by the end of the second quarter of FY 2013. A VHA
task force is targeting the recruitment and staffing requirements to
bring these new employees into VA as effectively and efficiently as
possible to meet our goals leveraging all available tools to bring
needed providers on board.
Implementation of the model will also support linking patients to
their Patient Aligned Care Team (PACT) for care management (including
medication maintenance and monitoring), enhance care transitions,
expand peer-led services and community engagement for supportive care,
and increase access to evidence-based individual and group
psychotherapies, family and marital psychotherapies, and psycho-
pharmacological treatments. The model will guide optimal team
composition and provider-to-patient ratios assessed based on facility
complexity levels and patient care needs.
VA Central Office began collecting monthly vacancy data in January
2012 to assess the impact of vacancies on operations and to develop
recommendations for further improvement. In addition, VA is ensuring
that accurate projections for future needs for mental health services
are generated. Finally, VA is planning proactively for the expected
needs of Veterans who will separate soon from the Department of Defense
(DoD) as they return from Afghanistan. We track this population to
estimate the number of such Veterans, how many are anticipated to seek
VA care, and how many who seek care are anticipated to need mental
health evaluation and treatment services. These processes will
continue, with special attention to whether patterns established up to
this point may change with the expected increase in separations from
active duty military.
As part of VA's efforts to implement section 304 of Public Law 111-
163 (Caregivers and Veterans Omnibus Health Services Act of 2010), VA
is increasing the number of peer specialists working in our medical
centers to support Veterans seeking mental healthcare. These additional
staff will increase access by allowing more providers to schedule more
appointments with Veterans. Simultaneously, VA is providing additional
resources to expand peer support services across the Nation to support
full-time, paid peer support technicians. While providing evidence-
based psychotherapies is critical, VA understands Veterans benefit from
supportive services other Veterans can provide.
Finally, VA's efforts to nurture and sustain our academic
affiliations provide opportunities across the country for residents in
different disciplines, including psychiatry and psychology, to continue
their education while helping our Veterans. VA currently supports more
than 2,500 training positions in mental health occupations (including
psychiatry, psychology, social work, and clinical pastoral education
residency positions).
Conclusion
By adding staff, offering better guidance on appointment scheduling
processes, and enhancing our emphasis on patient and provider
experiences through specific performance measures, we are confident we
are building a more accessible system that will be responsive to the
needs of our Veterans while being responsible with the resources
appropriated by Congress. OEF/OIF/OND Veterans have faced more and
longer deployments than previous generations of Servicemembers, and
their families have shared these challenges. Many of these Veterans
also have survived battlefield injuries that previously would have been
fatal. Other challenges are presented by Vietnam era Veterans who seek
mental healthcare at far higher levels than prior generations of older
adults. In part, that is because we did not have the effective
treatments for them when they returned from service more than 40 years
ago. We know that the therapies discussed previously are effective for
this population, and we welcome their search for mental healthcare. As
VA reaches out to serve all generations, and as our intensive,
effective outreach programs bring in greater numbers of Veterans to
VA's healthcare system, we must constantly find ways to keep pace with
the need for expanded capacity for mental health services and for those
services to be based on the best possible known treatments.
Mr. Chairman, we know our work to improve the delivery of mental
healthcare to Veterans will never be done. We appreciate your support
and encouragement in identifying and resolving challenges as we find
new ways to care for Veterans. This concludes my prepared statement. My
colleagues and I are prepared to respond to any questions you may have.
Prepared Statement of John D. Daigh, Jr., M.D.
INTRODUCTION
Mr. Chairman and Members of the Committee, thank you for the
opportunity to discuss the results of a recent Office of Inspector
General (OIG) report, Veterans Health Administration--Review of
Veterans' Access to Mental Health Care, on veteran access to mental
healthcare services at VA facilities. We conducted the review at the
request of the Committee, the VA Secretary, and the Senate Veterans'
Affairs Committee. The OIG is represented by Ms. Linda A. Halliday,
Assistant Inspector General for Audits and Evaluations; Dr. John D.
Daigh, Jr., Assistant Inspector General for Healthcare Inspections; Dr.
Michael Shepherd, Senior Physician in the OIG's Office of Healthcare
Inspections; and Mr. Larry Reinkemeyer, Director of the OIG's Kansas
City Office of Audits and Evaluations.
BACKGROUND
Based on concerns that veterans may not be able to access the
mental healthcare they need in a timely manner, the OIG was asked to
determine how accurately the Veterans Health Administration (VHA)
records wait times for mental health services for both initial (new
patients) and follow-up (established patients) visits and if the wait
time data VA collects is an accurate depiction of veterans' ability to
access those services.
VHA policy requires all first-time patients referred to or
requesting mental health services receive an initial evaluation within
24 hours and a more comprehensive mental health diagnostic and
treatment planning evaluation within 14 days. The primary goal of the
initial 24-hour evaluation is to identify patients with urgent care
needs and to trigger hospitalization or the immediate initiation of
outpatient care when needed. Primary care providers, mental health
providers, other referring licensed independent providers, or licensed
independent mental health providers can conduct the initial 24-hour
evaluation.
VHA uses two principal measures to monitor access to mental
healthcare. One measure looks at the percentage of comprehensive
patient evaluations completed within 14 days of an initial encounter
for patients new to mental health services. Another method VHA uses is
to calculate patient waiting times by measuring the elapsed days from
the desired dates \1\ of care to the dates of the treatment
appointments. Medical facility schedulers must enter the correct
desired dates of care in the system to ensure the accuracy of this
measurement. VHA's goal is to see patients within 14 days of the
desired dates of care.
---------------------------------------------------------------------------
\1\ The desired date of care is defined as the earliest date that
the patient or clinician specifies the patient needs to be seen
---------------------------------------------------------------------------
REVIEW RESULTS
Our review focused on how accurately VHA records wait times for
mental health services for initial and follow-up visits and if the wait
time data VA collects is an accurate depiction of the veterans' ability
to access those services. We found:
VHA's mental health performance data is not accurate or
reliable.
VHA's measures do not adequately reflect critical
dimensions of mental healthcare access.
Although VHA collects and reports mental health staffing and
productivity data, the inaccuracies in some of the data sources
presently hinder the usability of information by VHA decision makers to
fully assess current capacity, determine optimal resource distribution,
evaluate productivity across the system, and establish mental health
staffing and productivity standards.
VHA's Performance Data Is Not Accurate or Reliable
In VA's fiscal year (FY) 2011 Performance and Accountability Report
(PAR), VHA reported 95 percent of first-time patients received a full
mental health evaluation within 14 days. However, the 14-day measure
has no real value as VHA measured how long it took VHA to conduct the
evaluation, not how long the patient waited to receive an evaluation.
VHA's measurement differed from the measure's objective that veterans
should have further evaluation and initiation of mental healthcare in
14 days of a trigger encounter. VHA defined the trigger encounter as
the veteran's contact with the mental health clinic or the veteran's
referral to the mental health service from another provider.
Using the same data VHA used to calculate the 95 percent success
rate shown in the FY 2011 PAR, we conducted an independent assessment
to identify the exact date of the trigger encounter (the date the
patient initially contacted mental health seeking services, or when
another provider referred the patient to mental health). We then
determined when the full evaluation containing a patient history,
diagnosis, and treatment plan was completed. Based on our analysis of
that information, we calculated the number of days between a first-time
patient's initial contact in mental health and their full mental health
evaluation. Our analysis projected that VHA provided only 49 percent
(approximately 184,000) of first-time patients their evaluation within
14 days.
VHA does not consider the full mental health evaluation as an
appointment for treatment, but rather the evaluation is the
prerequisite for VHA to develop a patient-appropriate treatment plan.
Once VHA provides the patient with a full mental health evaluation, VHA
schedules the patient for an appointment to begin treatment. We found
that VHA did not always provide both new and established patients their
treatment appointments within 14 days of the patients' desired date. We
reviewed patient records to identify the desired date (generally
located in the physician's note as the date the patient needed to
return to the clinic or shown as a referral from another provider) and
calculated the elapsed days to the date of the patient's completed
treatment appointment date.
We projected nationwide that in FY 2011, VHA:
Completed approximately 168,000 (64 percent) new patient
appointments for treatment within 14 days of their desired date; thus,
approximately 94,000 (36 percent) appointments nationwide exceeded 14
days. VHA data reported in the PAR showed that 95 percent received
timely care.
Completed approximately 8.8 million (88 percent) follow-
up appointments for treatment within 14 days of the desired date; thus,
approximately 1.2 million (12 percent) appointments nationwide exceeded
14 days. VHA data reported in the PAR showed that 98 percent received
timely care for treatment. Although we based our analysis on dates
documented in VHA's medical records, we have less confidence in the
integrity of this date information because providers at three of the
four medical centers we visited told us they requested a desired date
of care based on their schedule availability.
Scheduling Process
Generally, VHA schedulers were not following procedures outlined in
VHA directives and, as a result, data was not accurate or reliable. For
new patients, the scheduling clerks frequently stated they used the
next available appointment slot as the desired appointment date for new
patients. Even though a consult referral, or contact from the veteran
requesting care, may have been submitted weeks or months earlier than
the patient's appointment date, the desired appointment date was
determined by and recorded as the next available appointment date. For
established patients, medical providers told us they frequently
scheduled the return to clinic date based on their known availability
rather than the patient's clinical need. Providers may not have
availability for 2-3 months, so they specify their availability as the
return to clinic time frame.
OIG first reported concerns with VHA's calculated wait time data in
our Audit of VHA's Outpatient Scheduling Procedures (July 8, 2005) and
Audit of VHA's Outpatient Wait Times (September 10, 2007). During both
audits, OIG found that schedulers were entering an incorrect desired
date. Nearly 7 years later, we still find that the patient scheduling
system is broken, the appointment data is inaccurate, and schedulers
implement inconsistent practices capturing appointment information.
Workload and Staffing
According to VHA, from 2005 to 2010, mental health services
increased their staff by 46 percent and treated 39 percent more
patients. Despite the increase in mental healthcare providers, VHA's
mental healthcare service staff still do not believe they have enough
staff to handle the increased workload and to consistently see patients
within 14 days of the desired dates. In July 2011, the Senate Committee
on Veterans' Affairs requested VA to conduct a survey that among other
questions asked mental health professionals whether their medical
center had adequate mental health staff to meet current veteran demands
for care; 71 percent responded their medical center did not have
adequate numbers of mental health staff.
Based on our interviews at four VA medical centers (Denver,
Colorado; Spokane, Washington; Milwaukee, Wisconsin; and Salisbury,
North Carolina), staff in charge of mental health services reported
VHA's greatest challenge has been to hire and retain psychiatrists. We
analyzed access to psychiatrists at the four visited medical centers by
determining how long a patient would have to wait for the physician's
third next available appointment. Calculating the wait time to the
third next available appointment is a common practice for assessing a
provider's ability to see patients in a timely manner. On average at
the four VA medical centers we visited, a patient had to wait 41 days.
VHA's Measures Do Not Adequately Reflect Critical Dimensions of Mental
Health Care Access
The data and measures needed by decision makers for effective
planning and service provision may differ at the national, Veterans
Integrated Service Network, and facility level. No measure of access is
perfect or provides a complete picture. Meaningful analysis and
decision making requires reliable data, on not only the timeliness of
access but also on trends in demand for mental health services,
treatments, and providers; the availability and mix of mental health
staffing; provider productivity; and treatment capacity. These demand
and supply variables in turn feed back upon a system's ability to
provide treatment that is patient centered and timely.
Decision makers need measures that:
Are derived from data that is reliable and has been
consistently determined system-wide.
Are based on reasonable assumptions and anchored by a
reasonable and consistent set of business rules.
Are measureable in practice given existing
infrastructure.
Are clinically or administratively relevant.
Provide complementary or competing information to other
measures used by decision makers.
Measure what they intend to measure.
Measuring Access to VHA Mental Health Care
Included in the FY 2012 Network Director Performance Plan are the
following measures: the percentage of eligible patient evaluations
documented within 14 days of a new mental health patient initial
encounter; a metric requiring a follow-up encounter within 7 days of
discharge from inpatient hospitalization; a measure requiring four
follow-up encounters within 4 weeks of discharge from inpatient
treatment for high risk patients; and a measure of the percentage of
new Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
veterans receiving eight psychotherapy sessions within a 14-week period
during 1-year period.
VHA's 14-day measure calculates the percentage of comprehensive
patient evaluations documented within 14 days of an initial encounter
for patients new to mental health services. In practice, the 14-day
measure is usually not triggered until the veteran is actually seen in
a mental health clinic and a comprehensive mental health evaluation is
initiated. For example, a new-to-VHA veteran presents to a primary care
clinic, screens positive for depression, and the primary care provider
refers the veteran for further evaluation by a mental health provider.
The ``clock'' for the 14-day follow-up measure will start when the
veteran is actually seen in a mental health clinic and a comprehensive
mental health evaluation is initiated, not at the time of the primary
care appointment. Consequently, the data underlying this measure only
provides information about the timeliness within which comprehensive
new patient evaluations are completed but not necessarily the
timeliness between referral or consult to evaluation.
Veterans access VHA care through various routes, such as VA medical
center emergency departments, primary and specialty care clinics,
women's clinics, or mental health walk-in clinics. Alternatively, they
may seek services at community based outpatient clinics or Vet Centers
in their communities. They may also initiate mental health services
with private providers and later come to VA seeking more comprehensive
services. The 14-day measure does not apply to veterans who access
services through Vet Centers or non-VA-based fee basis providers.
A series of complementary and competing timeliness and treatment
engagement measures that better reflect the various dimensions of
access would provide decision makers with a more comprehensive view of
the ability with which new patients can access mental health treatment.
The timeframe immediately following inpatient discharge is a period
of high risk. The 7-day post-hospitalization and the four follow-up
appointments in 4 weeks for high-risk patient measures are clinically
relevant. The eight psychotherapy session in 14 weeks measure attempts
to be a proxy for whether OEF/OIF patients are receiving evidence-based
psychotherapy. The measure is clinically relevant but the utility is
presently marred by inaccurate data or unreliable methodology.
Beyond measures of timeliness (or delay) to mental healthcare, user
friendly measures that incorporate aspects of patient demand,
availability and mix of mental health clinical staffing, provider
productivity, and treatment capacity, anchored by a consistent set of
business rules, might provide VHA decision makers with more information
from which to assess and timely respond to changes in access
parameters.
Recommendations
Our report contained four recommendations for the Under Secretary
for Health:
Revise the current full mental health evaluation
measurement to ensure the measurement is calculated from the veterans
contact with the mental health clinic or the veteran's referral to the
mental health service from another provider to the completion of the
evaluation.
Reevaluate alternative measures or combinations of
measures that could effectively and accurately reflect the patient
experience of access to mental health appointments.
Conduct a staffing analysis to determine if mental health
staff vacancies represent a systemic issue impeding the Veterans Health
Administration's ability to meet mental health timeliness goals, and if
so, develop an action plan to correct the impediments.
Ensure that data collection efforts related to mental
health access are aligned with the operational needs of relevant
decision makers throughout the organization.
The Under Secretary for Health concurred with our recommendations
and presented an action plan. We will follow-up as appropriate.
CONCLUSION
VHA does not have a reliable and accurate method of determining
whether they are providing patients timely access to mental healthcare
services. VHA did not provide first-time patients with timely mental
health evaluations and existing patients often waited more than 14 days
past their desired date of care for their treatment appointment. As a
result, performance measures used to report patient's access to mental
healthcare do not depict the true picture of a patient's waiting time
to see a mental health provider.
While no measure will be complete, meaningful analysis and decision
making requires reliable data. A series of paired timeliness and
treatment engagement measures might provide decision makers with a more
comprehensive view of the ability with which new patients can access
mental health treatment.
Mr. Chairman, thank you for the opportunity to discuss our work. We
would be pleased to answer any questions that you or other members of
the Committee may have.
Prepared Statement of Nicole L. Sawyer, PSYD
Chairman Miller, Ranking Member Filner and Members of the
Committee:
Thank you for inviting me to participate in this important
discussion regarding the ``quality versus quantity'' dilemma facing VA
mental healthcare.
I want to convey my appreciation for the efforts of this Committee
and its clear commitment to the mental healthcare of our veterans. I
recognize that mental health is only one of the vast concerns under
your authority and I value your diligence in this matter.
I am a licensed clinical psychologist with a primary focus on the
treatment of trauma in both the veteran and civilian population. In
addition to having worked at a VA medical center, I have worked in a
number of clinical settings including Federal prison, an urban
psychiatric inpatient facility, a college campus, two community mental
health centers, and currently in my own private practice where the
majority of my caseload consists of combat veterans and adult survivors
of such traumas as childhood sexual abuse, domestic violence and sexual
assault.
In addition to my clinical practice I am an appointed member of the
New Hampshire Legislative Commission on (military service-connected)
PTSD and TBI (SB102), an active member of the New Hampshire
Psychological Association Continuing Education Committee, and I am also
a training board member and mentor for psychology interns and post-
doctoral fellows working in my local community mental health center.
In October of 2009, in addition to my established private practice,
I took a part-time position as the Local Evidence-Based Psychotherapy
Coordinator for the mental health service line at the Manchester VA
Medical Center in Manchester, NH. My job was to coordinate clinician
training and implementation of the Evidence-Based Psychotherapies
(EBPs) the VA had been rolling out since 2005. I soon found that I
needed to be more involved with the structure and function of the
service to do my job effectively, so I took a significant role in the
Mental Health Systems Redesign Committee and began working on several
projects important to improving the function of our service line and
thus the application of EBPs in our clinic. In these roles I had the
opportunity to work closely with our veterans and also work intimately
with the clinicians on the service. I met with clinicians regularly,
both formally and informally, to discuss their needs as providers and
the problems they were encountering clinically and with regard to self-
care. In addition, my roles brought me into close and frequent contact
with the leadership of our mental health service where I worked to get
training opportunities approved and lobbied for clinic and clinician
availability to provide the treatments required by the Uniform Mental
Health Service Handbook. My role also required at least monthly contact
with other EBP Coordinators in the network and nation-wide as well as
attendance at required conferences and trainings that brought all of us
together to discuss the successes and failures we were facing at our
respective facilities.
Due to increasing ethical concerns about the care and treatment of
our veterans in Manchester, I chose to resign my position this recent
February. I hope to share with you here some of the concerns that led
to this difficult decision, as well as the impact that VA culture and
common practices have on the ability of dedicated clinicians to provide
quality mental healthcare to our veterans.
PTSD and the Veteran's Dilemma
Many of the men and women that cross the threshold of a VA medical
center have been faced with decisions, and taken action, on matters far
out reaching the imaginations of most. Many have made choices, and
followed orders, that carry weight impossible to endure alone, though
they try. For most, the decision to seek mental health treatment is an
admission of failure, an inability to ``hack it.'' For many, the
decision feels humiliating and shameful; it is the admission of
weakness and the declaration of vulnerability.
Many combat veterans spend years trying to cover their invisible
wounds; they carefully tend the scabs they have created to protect
those exposed places. Many of the symptoms of PTSD are reinforced
through misguided attempts to tend and protect their mental injuries.
They may avoid things that remind them of experiences and actions they
would rather forget. They may push loved ones away in order to ensure
no one sees their weakness. They may drink to numb the memories, the
nightmares, and the pain. And tragically some take their own lives to
escape the hurt, or to protect others from the hurt that they believe
they will inevitably cause.
``If she only knew . . . '' is an all too common phrase I hear in
my therapy sessions with combat veterans. The deep belief, and fear,
that if others, especially loved ones, ``knew'' what they had done,
they would no longer love them. They would be ashamed, angry, and worst
of all, afraid of them.
Most of us have only the vaguest sense of the experience of combat
and war. The successful military leaves its civilians largely ignorant
of war's horrors. Combat veterans are no longer ignorant, but try to
play along, because for them, even at home, the job never ends.
Entering into mental health treatment is wrought with gut-wrenching
decisions. Admitting the need for help is the first one, making the
telephone call is the second, showing up for the appointment is the
third; but the fourth is the heaviest of all, speaking the pain.
Endless research, and certainly my experience, informs me that the
closer together decisions 1 through 3 occur, the more likely the
veteran will commit to the task. This is not rocket-science: the more
rapid the decision-making process the less likely any of us are to let
our doubts and fears derail us. But VA healthcare facilities too often
fail our veterans before they are even faced with the critical fourth
decision--unburdening themselves of the trauma they have experienced.
This was clearly demonstrated in the recent OIG report that identified
the lack of timely access to mental healthcare, resulting in a majority
of veterans having to wait more than 50 days to begin treatment.
The Fourth Decision: Speaking the Pain
In my experience, and from my perspective, nearly 70% of the work
of combat trauma treatment is in the telling. The telling doesn't have
to be to the therapist, though it often is at first. But the telling
must occur. Speaking the story, the pain, the regret, the guilt, and
the shame that are fixed to the experiences that drive a veteran into
treatment marks a beginning on the road to recovery, but it is NOT the
beginning of treatment.
Treatment begins long before the story is told. It begins with
trust. Our veterans must trust in the system meant to serve them, trust
in the process of therapy, and trust in the clinician assigned to their
care.
Trust for the combat veteran does not come easy. Trust is the
belief that one's story will not be judged, that the individual's
feelings will be validated and accepted, and that despite having spoken
one's pain to another soul, the veteran remains in control of that
information. For a person who has done things, seen things and felt
things that--if they had occurred at home--would be considered
monstrous and evil, trust is a myth. Don't get me wrong, a soldier
knows trust, he knows what it is to believe that the person next to him
cares as much about his life as he does, but to trust in a person who
does not share your pain is a risk exceeding all manner of bravery.
Fear of judgment tends to lead the pack of fears held by those
considering mental health treatment. They fear that their actions and
the feelings attached to them are rare and will be misunderstood by
those unfamiliar with war.
Most VA clinicians are ready to hear the pain. They are well
trained, dedicated, committed and passionate about veterans. They
understand the fears and reservations and are prepared to knock them
out at a pace that provides safety and comfort for the veteran sitting
across from them. Most do not know the pain themselves, but they know
what it takes to connect with their veterans and they know what it
means to trust.
But trust takes time, and time is NOT what most VA clinicians have
when it comes to the treatment of their veterans.
The Clinician's Dilemma: Professional Ethics or Performance Measures
Mental health is subjective. It is not easily defined and nearly
impossible to measure. It does not fit neatly into a medical model the
way the diagnosis and treatment of hypertension or diabetes often does,
and the stigma associated with the need for care is nearly unmatched by
any other health issue. But the VA, like most managed care
organizations, attempts to squeeze mental healthcare into a medical
framework. Inevitably, corners are cut in order to make it fit.
Psychotherapy is a process, not a prescription. It is work that
takes time and builds upon the successes and failures of the previous
sessions, and life lived in between. The professional psychotherapist
is trained to help the patient identify needs, feelings, and goals that
are often hidden or buried under old habits, experiences, and beliefs
about themselves and the world. We are all shaped by our experiences
and we all develop methods for understanding and coping with those
experiences, for better or for worse. For some, our strategies for
coping and understanding lead us astray and we find ourselves drifting
or trapped in patterns that are harmful and destructive. Psychotherapy
is intended to steer us back on track with new strategies and better
understanding that will lead to acceptance. Some types of psychotherapy
are strictly guided and directed, other types are more evolving and
flowing; both have their place in quality mental healthcare, and both
require the patient to trust in the process and in the clinician, to be
successful.
The VA struggles to understand and value the importance of trust in
the success of mental health treatment. We all value trust in our
lives. We trust our children with babysitters, we trust our accountants
with our money. We took time to develop trust in these individuals. Why
is it not obvious and a priority to value the development of trust in
the service of mental health treatment? It is not a difficult task to
achieve, hire competent staff and give them the time to do their jobs
well: trust will follow.
Given a small mental health staff relative to the ever-growing
numbers of veterans seeking mental healthcare, the dedicated clinicians
with whom I worked at the Manchester VA Medical Center faced a daily
ethical dilemma: the veterans sitting before them were often in great
need, and might be motivated and anxious to open up old wounds, air
them out, and begin the healing process. But often, the clinicians
could not join them in this journey. Ethically, they could not rip open
those wounds. Faced with a patient caseload that was growing
exponentially, and no open appointments in sight, that clinician could
not, and rightfully would not, open a wound only to let it fester
untreated for the weeks or months it might take to see that veteran
again.
As I said, psychotherapy builds upon the successes and failures of
the previous sessions; it requires consistency and predictability in
scheduling and frequency of appointments. Trauma cannot be treated
haphazardly based on random blocks of availability. Trauma treatment
demands a session every week or every other week. Too much time between
sessions allows suffering to linger too long after wounds have been
opened. Too much lingering leads to re-traumatization and bolstering of
the negative patterns the treatment is intended to dismantle.
It is apparent that at many facilities across the country, VA
clinicians are overrun with veterans in need. Mental Health Service
Lines are pushing as many veterans into clinician schedules as possible
to meet their performance measures, but those veterans are not getting
effective treatment. Effective treatment takes time. It requires a full
and timely evaluation of needs, a chronic and nationwide deficit noted
by the recent OIG report. It requires a frequency of sessions in a
timely manner consistent with the clinical needs identified by that
full evaluation, another chronic deficit noted by the OIG. It requires
trust and predictability. Too often, under the circumstances which VA
facilities and mental health clinicians are working, an emphasis on
addressing ``quantity'' is overtaking a commitment to the quality of
treatment.
The effects of a ``quantity over quality'' approach to mental
health treatment has obvious and not-so-obvious repercussions for
veterans. Some veterans cling to the hope for years that somehow those
randomly occurring sessions with their therapist will help them find
relief from their demons. They arrive for every appointment, but as I
have discussed, little in the way of demons can be explored. Others
drop out quickly, angrily muttering about the ``waste of time'' and
conclude that therapy can't help them. Often, they never return, to the
VA or elsewhere, for mental health treatment. But what is most tragic
is that many of those veterans blame themselves for not getting better.
Like most people, they do not know what effective mental healthcare is
supposed to look like. They assume, deep in that place where their
guilt and shame lay, that they have failed to get better, that they are
too far gone to be helped. I have heard those words from the mouths of
the veterans I have had the honor to treat, on the off-chance that they
gave psychotherapy one more try.
Caseload and Productivity
Staffing is an obvious weakness in VA mental healthcare and
Secretary Shinseki's announcement last month of 1900 additional mental
health staff is a welcome attempt at strengthening this service. But
how do we know if 1900 is enough?
In order for a service to be able to evaluate its need for staff
and resources it must be able to assess the demand on its clinicians.
The VA, however, lacks any definitive expectation for clinical
productivity. Without such parameters it is impossible to identify a
clinician's caseload as ``full'' and therefore it is impossible to
determine if the flow of veterans into the service exceeds the capacity
of the clinic. Without this critical information a service struggles to
know how many clinicians it needs to meet the demand.
Determining clinician caseload is exceedingly important and must be
a priority for VA. Community mental health clinics and other mental
health facilities, including group practices in the private sector have
defined the expectations for their clinicians. The factors that go into
making these determinations exceed the scope of my testimony, but the
benefits to clinicians, patients, and to organizations are clear. When
a clinician has a productivity expectation, that is, a clear
expectation of how many hours per week he or she is expected to be
providing direct services to veterans, he or she can build into their
day the time necessary to meet the administrative demands essential to
effective treatment. The clinician can plan for writing of session
notes, treatment plan reviews, formal consultation with other providers
on a case, and returning patient phone calls. The clinician might even
have the flexibility to see more urgently, an established patient who
is on the verge of a crisis, and stave off an emergency. All of the
tasks I noted here are basic requirements of effective mental
healthcare. They are tasks demanded by the ethics that govern all
mental health professions, and yet, in my experience, they are seen as
luxuries at the VA. These important tasks are given no priority because
the system relies on so-called ``workload'' data, and this important
work is not easily captured.
When productivity for a clinician is defined, a caseload definition
easily follows. The size of a clinician's caseload can be somewhat
flexible when consideration is given to the intensity of treatment
needed by each veteran. When a clinician's productivity is measured
based on the number of hours they spent providing therapy that week,
the caseload is defined by how many veterans that clinician can treat
in a clinically responsible way. For example, in a community mental
health center in which I worked, clinicians in the adult outpatient
department were expected to provide 22 hours of psychotherapy per 36
hour work week. This productivity expectation rounded out to roughly 40
patients on a full-time clinician's caseload. The caseload would
inevitably be composed of some patients in need of weekly sessions,
some in need of every other week sessions, some coming only for monthly
maintenance check-ins and still others who were not yet committed to a
treatment schedule. The challenge for the clinician and the service was
to juggle the number of outgoing (discharged) patients who had achieved
their goals and were no longer in need of services with the number of
new patients to accept into their caseload. This particular mental
health center simply required all clinicians to conduct two ``intakes''
per week to be included in their 22 hours of productivity. It wasn't a
perfect system, but it provided an access expectation along with a
productivity expectation that easily communicated our staffing needs
and allowed us to prepare for and predict seasonal influxes of
referrals. In contrast, at the Manchester VA and other facilities, a
clinician could easily have hundreds of veterans on his or her
``caseload.'' Caseloads grew exponentially for a number of reasons:
among them, 1) Incoming veterans were doled out like cards in a deck
with no regard for the number of veterans each clinician was already
trying to serve, no regard for availability of appointments, or
expertise in the area of need. 2) When a veteran is only able to be
seen on a sporadic basis with weeks and even months between
appointments, psychotherapy is impossible and little clinical progress
is made. With little clinical progress veterans do not achieve their
goals and/or find relief from their symptoms, and without these markers
a clinician cannot effectively discharge veterans from care. 3) Chronic
understaffing, clinician turnover, and facilities refusing to backfill
positions lead to other clinicians having to ``pick up'' hundreds of
veterans left abandoned when a clinician resigns.
This lack of administrative management of caseload interferes with
the quality of care a clinician can provide. While trying to attend to
the veteran in front of them, clinicians are forced to think about how
far out they are booked before asking a question, challenging a
thought, exploring a perception. Knowing that the veteran is not likely
to make his or her way back into their office for several weeks, if not
months, is enough to derail what might have been a poignant
intervention with big potential for healing. Clinicians are virtually
gagged under such circumstances and stressed by the helplessness they
face with unfettered inflow of veterans and minimal potential for
outflow. This ongoing experience creates a chronic sense of failure and
undermines the expertise and skill required to be an effective
psychotherapist.
In short, development of productivity expectations and clinician
caseload definitions are essential to the accurate determination of
staffing needs at the facility level. Without this data there is no way
to determine if 3, 5, or 20 additional clinicians will be enough to
meet the demand of an individual mental health service. And without
these parameters, there is no way a clinician and a service can ensure
adequate frequency and timely access for a veteran to get the kind of
care they deserve.
Why VA Can't Fill Vacancies
Veterans, particularly combat veterans and victims of military
sexual trauma, are an intense population to treat. From my perspective
the rewards are unmatched, but in order to reap the rewards a provider
has to be in a position to help.
The VA has 1500 vacant mental health positions for which they are
currently recruiting. Secretary Shinseki recently approved 1900 more
positions. I have already discussed the difficulty in knowing if this
number will be enough, but one can reasonably ask how VA will fill
these new positions when 1500 positions are currently sitting empty,
and have been for months and even years.
But this is not the only pertinent question. Many VA facilities
across the Nation simply do not have space for more clinicians.
Buildings are outdated, space is poorly distributed among specialty
departments; services have simply outgrown their walls. At Manchester,
for example, clinicians hired recently spend time dragging carts full
of paperwork and other necessary resources around the hallways because
they lack offices. They show up to work each day unsure whose, if
anyone's, office they might be able to use for the afternoon or maybe
for an hour. This is not simply inconvenient, unprofessional and
demeaning for the clinician, but it has a significant impact on the
patient. Continuity and predictability are important aspects of quality
clinical care. In particular, safety in their space and predictability
in their environment are important to many veterans struggling with
PTSD. Attending therapy sessions in a different office, possibly on a
different floor of the building, every time they arrive, is distressing
and can impede progress, possibly even contribute to abandonment of
treatment. The lack of space is a significant barrier not only to
quality care for veterans, but for the hiring and retention of staff.
Psychologists and psychiatrists, in particular, have among the
highest turnover rates in the VA for mental health service. These
higher rates are likely a result of the pay versus ``hassle'' ratio
that is difficult to overcome in the current VA system. VA compensation
for psychologists and psychiatrists, in most regions, is comparable, if
not less, than what the same professional could make in another
facility or on his or her own. It is not surprising that some
psychologists and psychiatrists will choose to go elsewhere for
employment. Those that do choose to work for the VA often become
overwhelmed and frustrated by what some feel are ethical compromises
and minimal respect.
Clinical social workers, on the other hand, face a different
dilemma. VA compensation for a clinical social worker, in most regions,
is well above, even double, what he or she could make at another
facility in the community. The compensation can become a trap for these
dedicated professionals. Seeking employment elsewhere is not typically
an option but the chronic disrespect and ethical compromises some
experience lead to burn-out and high levels of personal stress.
Much of the stress and disrespect felt by many clinicians stems
from the very limited clinical independence most are afforded. In most
facilities, clinicians have little or no control over their schedule or
how their time is allotted, have no control over their caseload, and
are required to provide services and use methodology that they believe
clinically inappropriate for their veteran. And worst of all, many VA
mental health clinicians must set aside their own clinical judgment in
response to the overriding requirements dictated by Central Office
performance measures and other mandates that direct how veterans are to
be treated. The need to meet numbers motivates facilities to abandon
some treatment modalities in favor of others, regardless of the
clinical indication for the veteran. Clinicians are generally helpless
to fight against this, though they try, as many clinicians at my
facility did. This can be humiliating for a mental health professional
with an advanced degree, passion, and experience in helping those in
need.
Without a real effort to address these cultural issues, the VA will
be hard pressed to hire and retain the quality professionals our
veterans deserve.
Conclusion
In conclusion, I want to thank the Committee again for the
opportunity to share my experience and insights. I hope that if there
is anything I have communicated here, it is that quality care--and by
that I mean effective care--must not be sacrificed for quantity. VA has
a responsibility to provide veterans timely, effective mental
healthcare. Among the critical steps it must take to meet that
responsibility is to establish a productivity and caseload model for
mental health clinicians and ensure that adequate space is available to
provide treatment. But it must go further: in raising the standard of
care, it must also reinstate trust--a critical element in making VA a
place where veterans in need want to get their care, and where
dedicated, skilled clinicians want to be employed.
I am happy to answer any questions you may have.
Thank you.
Prepared Statement of Diana Birkett Rakow
Good morning, Chairman Miller, Ranking Member Filner, and members
of the Committee. I am Diana Birkett Rakow, Executive Director of
Public Policy at Group Health Cooperative, an integrated healthcare
coverage and delivery system based in Seattle, Washington.
Thank you for inviting me to be here this morning to discuss Group
Health's experience managing mental health appointments for our
members. We recognize and appreciate your leadership in ensuring our
Nation's veterans receive the high-quality mental healthcare they
deserve. While our patient population and the context in which we
provide care differ from the Veterans Health Administration, we share a
commitment to ensuring that patients get the care they need, in a
timely and effective manner, to improve and preserve their health. We
are grateful for the opportunity to share our best practices, and hope
this information is useful as the Committee and the Veterans
Administration work to continually improve mental healthcare for our
Nation's veterans.
Group Health Cooperative is a nonprofit health system that provides
both coverage and care. Directly and through our subsidiaries, we cover
more than 660,000 residents of Washington State and northern Idaho,
about 60 percent of whom receive care in Group Health owned and
operated medical facilities. Over 1,000 physicians are part of the
Group Health group practice, and we contract with more than 9,000
providers throughout the state. We offer health coverage through public
programs and in the commercial market--in Medicare, Medicaid, the State
Basic Health Plan, State and Federal employee programs, in the
individual market, and to small, medium, and large employer groups. We
also support employers who have elected to self-fund their employee
health coverage.
Today I will discuss how Group Health has created a model and
systems that have allowed us to provide, track, and ensure timely
access and high-quality care for our patients, in particular those with
mental health needs. Our success in this area is due to the interaction
of our philosophy, our model of care, and the tools we employ to
establish processes and systems to track and continuously improve
performance.
Group Health is committed to patient-centered care and coverage, a
philosophy that guides our approach to mental health services, the
subject of this hearing, as well as every other type of healthcare we
provide. This philosophy provides a foundation for our model of care,
which is based on the Chronic Care Model. This model, designed by Dr.
Ed Wagner--the founding Director of the Group Health Research
Institute--is an evidence-based framework for healthcare that delivers
safe, effective, and collaborative care to patients. In simple terms,
this means that our model is designed to link all aspects of the
healthcare system together--health insurance, healthcare providers,
clinical information systems, and more--to facilitate productive,
continuous interaction between engaged, informed patients and a multi-
disciplinary care team.
This philosophy and model of care have been critical to our
success, but it has been the more recent implementation of Lean tools
and processes that have enabled us to take our work to a new level.
Lean is a management method made famous by companies like Toyota, and
in healthcare it provides the discipline and focus to commit to
understanding the needs of patients, to building systems and processes
designed around the patient's needs, and to continuously track outcomes
and improve processes to meet to meet quality and performance goals.
Behavioral Health at Group Health
Research shows that 25 percent of people have a diagnosable
behavioral health issue--whether a mental health issue or a chemical
dependency--arise within a given year, and 50 percent over the course
of a lifetime. Among those with a behavioral health issue, about 80
percent seek help in the primary care environment. This can be for
several reasons: because the patient is more comfortable in that
environment, because his condition has presented as or alongside a
physical ailment, or because primary care services are most readily
available. About one-third of patients with a behavioral health issue
ultimately access help in Behavioral Health Services.
At Group Health, the Behavioral Health Services department is
responsible for delivering mental healthcare in seven of our own
outpatient clinics, managing behavioral healthcare delivered by our
contracted network providers, and providing consultative specialty
services to primary care physicians who provide care through our
Patient-Centered Medical Home.
We employ over 150 behavioral health professionals including
psychiatrists, clinical psychologists, Masters-level psychotherapists,
nurses, care managers, and chemical dependency providers. In addition,
we have contracts with approximately 800 behavioral health specialists
in the network. Together, these providers offer a full continuum of
mental health and chemical dependency treatment services from
outpatient to acute inpatient care. In 2011, Group Health provided
specialty behavioral healthcare to over 50,000 members, about 8 percent
of our patient population. Approximately 45 percent (22,550) of members
receiving specialty behavioral health services are served in the group
practice clinics and 55 percent (27,561) were served in the network.
The majority of chemical dependency services and all inpatient services
are provided in the network.
The combination of philosophy, model of care, and Lean tools
described above has enabled Group Health to address and improvements in
three areas critical to mental health services: initial appointment
access, follow-up appointment access, and provider capacity and
productivity.
Initial Appointment Access
For some patients, ensuring timely access to behavioral health
services can literally be a matter of life or death; for all patients,
timeliness is important. Our data have shown that timely appointing is
one of the top drivers of a patient's satisfaction with her behavioral
healthcare experience. But timely access--both initially and for
follow-up care--requires collaboration, sound clinical judgment,
rigorous processes, and consistent measurement and evaluation.
Collaboration is illustrated by the close relationship developed
between primary care providers, specially-trained appointing and triage
staff, and behavioral health professionals. When a patient contacts us
seeking an appointment, either directly or after having been referred
by his primary care provider, a standard process to assess the urgency
of the patient's needs is triggered. Appointing staff ask the patient a
series of evidence-based questions and rate the patient's level of
urgency as routine, urgent, or emergent. A routine patient is of low to
moderate risk and verbalizes that she can wait between 7 and 14 days to
be seen. An urgent patient is in severe emotional distress but able to
wait 48 hours for an appointment. A patient considered emergent may be
psychotic, suicidal, have withdrawal symptoms, or a sense of
desperation, and needs to be seen within 6 hours.
Under our standard process, patients who convey a sense of urgency
on the initial call are immediately transferred to a care coordinator--
a Master's level counselor--to further assess the urgency of her needs.
At this stage, clinical judgment is critical. Patients judged to be at
immediate risk for a suicide attempt, who are going through acute
withdrawal, or who are gravely disabled are sent to the emergency room
or urgent care. In some cases the police are called.
These standards for scheduling an initial appointment were adopted
from the National Committee for Quality Assurance's (NCQA) standards
for behavioral health appointment access. Group Health has maintained
an NCQA ``excellent'' level of accreditation since the late nineties,
based upon a set of measures that includes access to behavioral health
services. At Group Health, we aim to ensure that 90 percent of our
patients with emergent needs receive an appointment within 6 hours, 85
percent of patients with urgent needs receive an appointment within 48
hours, and 80 percent of patients with routine needs receive an
appointment within 14 days. These targets were set based on the
clinical urgency of the patients and to factor in patient preferences
and scheduling needs.
We are able to measure access to routine appointments that occur in
our group practice model electronically, thanks to our system-wide
electronic medical record, and do so monthly. For routine patients who
seek care within our contracted network, we do not have an automated
way to measure initial access, but review claims data at the end of the
year to monitor access.
Collaboration comes into play in one other area related to initial
appointing access, and that is in collaboration between primary and
behavioral healthcare providers. For some patients, primary care is
their preferred source of mental healthcare; for others, it is simply
an essential complement. In 2010, Group Health researcher and physician
Elizabeth Lin developed a model called TEAMcare, \1\ an intervention
for multiple chronic conditions, which has been integrated into
standard care in the Group Health Patient-Centered Medical Home. Within
one year--compared with the standard care control group--patients with
the TEAMcare intervention were significantly less depressed and also
had improved levels of blood glucose, low-density lipoprotein (LDL)
cholesterol, and systolic blood pressure. A recent study showed that by
starting medications sooner and managing them more effectively, primary
care physicians and nurses could improve their patients' outcomes for
both medical and mental health conditions. \2\
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\1\ New England Journal of Medicine 2010 Dec 30; 363(27):2611-20
\2\ Annals of Family Medicine January/February 2012 10:6-14;
doi:10.1370/afm.1343
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Follow-up Appointment Access
The ability to be seen in a timely manner for follow-up
appointments is as important to patients as timely intake appointments.
Our patient-centered approach, combined with proactive planning and,
again, rigorous tracking, has led to our positive outcomes in this
area. We track the use of group therapy (a measure that leads to
increased capacity and improved follow-up access), the percentage of
new patients seen three times in the first six weeks of treatment, and
patient satisfaction with access to follow-up appointments.
Since behavioral health is a continuous, as well as episodic,
concern--different from many medical issues but similar to other
chronic illnesses--we have developed several ways that patients can
access mental healthcare, increasing the likelihood that one or more of
these routes will lead to timely access. Through our electronic health
record system, patients can send secure messages back and forth via
email with members of their care team, including mental health
providers. Patients can also set up phone visits for times when getting
into the clinic is either unnecessary or not feasible. And, responding
to a need among a certain sub-group of patients, in 2010 our staff
designed a group psychotherapy program for patients with anxiety and
depression.
In 2011, we established a goal of seeing at least 70 percent of
patients three times within a six-week period. This measure is
objective, based on what our patients said they wanted and what is
indicated in relevant research literature. Over the last year, we have
met and exceeded our target in this area, thanks to strategies and
processes monitored by many of the other measures described here.
We have also begun tracking access as a part of our patient
experience survey. We know that a positive therapeutic relationship
significantly contributes to patient experience, but have found, not
surprisingly, that access matters too. Like many things at Group
Health, we have decided to approach access from an evidence-based
perspective, as illustrated by the measure above, but also from a
patient-centered one. To assess patient satisfaction, we have chosen to
ask whether patients are getting back into the office in a timeframe
suitable to them. For some patients, this could mean a matter of days--
others, weeks. But over the last year we have seen a statistically
significant increase in this measure, with patients saying that they
were seen again by a behavioral health provider when they needed to be.
Supply & Demand, Measures of Capacity and Productivity
Behavioral health is a poignantly human issue, but access to care
can also be a simple one of supply and demand. To meet the demand for
care, we must ensure that there is adequate supply, as measured by
capacity in the system, and productivity to make the most of existing
capacity.
In a group practice model, such as Group Health, unused capacity in
the system (such as unfilled appointment slots and providers being less
productive than benchmarks) leads to waste that can ultimately impact
patient access. Therefore, we track a number of capacity and
productivity measures, including appointment fill rate, number of new
cases per provider, and relative value units (RVU). (RVUs are a measure
of value used in the Medicare reimbursement formula for physician
services. They are nonmonetary standard units of measurement that
indicate the value of services provided by a healthcare provider.)
We seek to fill at least 90 percent of the appointments available
in a provider's schedule on a given day. Each morning, clinic
administrative staff members try to fill any open slots in a provider's
schedule first by calling patients who are on a waiting list for an
earlier appointment, and then by calling patients who are scheduled
beyond 14 days to see whether they are available to come in earlier.
Through this process, we have seen a reduction in wasted appointment
slots and are currently filling 91 percent of all appointment slots. We
have also set standards for new case targets. Each Masters-level
counselor and psychiatrist has a weekly target number of new cases to
ensure adequate initial patient access.
Developing and Monitoring the Measures
While measurement is critical, measurement in a vacuum is
worthless. The Lean approach starts with a focus on assessing and
working around the needs of the patient, then developing systems and
processes to meet those needs, developing measures to assess
performance, and continuously looking for and developing new ways to
improve. Leadership, in commitment to this system, is key, but so is
listening to patients, and to the people on the front lines who are
caring for them and working with them directly.
To continuously track performance and to make it visible and
transparent to staff at all levels, visual systems and checking tools
are developed to monitor metrics on a daily, weekly and monthly basis,
and to reflect whether targets are met. Lean suggests what are called
``tiered checking tools'' to ensure that information is shared up and
down a management chain. For example, an identified metric will be
measured at the tier one level by the staff doing the work; at the tier
two, or departmental, level; and at tier three by primary care
leadership. The highest-priority metrics are reflected and reviewed in
tiers four and five by our CEO and Executive Leadership Team. These
tiers refer to visual illustration of performance on these measures,
over time and by clinic in the form of charts, graphs, and other tools,
which are posted conspicuously on the walls in our clinics so that
performance is visible to staff doing the work and to unit managers.
Clinic staff meet each morning to review challenges for the day and
discuss how to address them. Departmental leaders conduct ``rounds'' on
the clinics' visual systems at least monthly to monitor performance,
and more importantly, to coach the staff in solving problems that
arise.
These tools can help give patients, staff, and leaders confidence
that performance is high, but they can also identify gaps. Our culture
supports continuous improvement through the identification of gaps and
the application of countermeasures to ameliorate these gaps. For
example, last year a group of behavioral health staff tracked
appointment patterns and identified a high number of appointments that
went unfilled, were cancelled, or weren't attended by the patient. They
used these data to develop a new process of monthly checks and
adjustments of appointments across the week and time of day to increase
the probability of increasing the number of appointments kept, and they
began to review medical records monthly to identify and track patient
preferences for appointment times. These strategies and others have
allowed us to meet challenges as they arise, to address the needs of a
broad range of patients, and to significantly improve the access to and
quality of behavioral healthcare in our system over the last several
years.
Group Health's journey with Lean began in 2007, and in behavioral
health we first began using Lean to develop a care management system
for our most vulnerable patients. Lean offered us a method for making
work standard, visible and actionable via the coordinated efforts of
individuals and teams. Although there were some significant challenges
in changing and adapting to new processes and a new culture, the
results were unquestionably positive. Patients received better care
that reduced their suffering and improved their lives. And, our total
cost of care (per member per month) was less in 2009 than 2008. In part
that was a result of better management of inpatient care--our largest
controllable expense.
Over the last five years, our systems, processes, and measures have
continued to develop and improve. We are proud of our model and its
ability to provide timely, high-quality access to behavioral
healthcare--and all health services--for our members. But we also
acknowledge that this is a journey. Our system is built around a
culture of continuous improvement--putting the patient and her needs
first. Thank you again for the opportunity to share our experience and
for your attention. I welcome your questions.
Prepared Statement of James Schuster, MD, MBA
INTRODUCTION
I begin by first providing some background information as to the
context from which I approach the very important topic of adequate and
timely access to behavioral health services here today. I am the Chief
Medical Offer for Community Care Behavioral Health Organization of
UPMC.
Community Care Behavioral Health Organization is a 501(c)(3) tax
exempt, nonprofit Pennsylvania-based behavioral health managed care
organization. Community Care was created primarily to respond to the
behavioral health needs of members of HealthChoices, Pennsylvania's
mandatory behavioral health managed care program for Medicaid
recipients. Community Care also serves UPMC Health Plan's commercial
and Medicare members, via service cooperation agreements. Community
Care currently employs more than 500 people to serve individuals in 36
counties in Pennsylvania and 16 counties in New York. We manage the
behavioral health services for over 650,000 Medicaid eligible persons,
approximately 23% of whom are active consumers of care.
Community Care's approach to behavioral health managed care is
grounded in public sector commitment, expert clinical competencies, and
both program and fiscal accountability. It is and has long been
Community Care's philosophy that, in the end, quality is best measured
by the improved health and well-being of the communities that we serve.
Community Care is committed to continuous and systematic quality
improvement across all domains.
UPMC is an integrated payer-provider headquartered in Pittsburgh,
Pennsylvania, which includes a comprehensive provider-based clinical
delivery system, a suite of health insurance and health management
companies, and a longstanding collaboration with the University of
Pittsburgh, a premier academic institution. With 20 hospitals, more
than 55,000 employees, 2,700 employed physicians, 2,500 independent but
affiliated physicians, thousands of mid-level providers, 400 clinical
locations, and insurance companies offering commercial, Medicare and
Medicaid products, all of which have large contracted networks, UPMC
operates amongst the largest integrated delivery and financing systems
in the Nation.
UPMC is organized into four major operating units: Physician
Services, Hospital Operations, Insurance Services, and International
and Commercial Services. Community Care is in the UPMC Insurance
Services Division which also includes physical health plans that
operate in the Commercial, Medicare and Medicaid markets. Collectively,
Community Care and the associated companies of the UPMC Health Plan
offer health coverage products and services to nearly 1.8 million
members.
UPMC Health Plan, the second-largest health insurer in western
Pennsylvania, offers a full range of commercial and government products
and services, including commercial group health insurance, Medicare,
Medical Assistance, Special Needs (SNP), and Children's Health
Insurance (CHIP), as well as disease management and behavioral health
programs. The UPMC Health Plan's provider network includes more than 90
hospitals (including academic, advanced care, and specialty hospitals),
cancer centers, physician practices (including more than 9,800
physicians), and long-term care facilities. Collectively, the network
represents one of the largest and most diverse teams of healthcare
professionals in Pennsylvania.
ACCESS AND BEHAVIORAL HEALTH SERVICE DELIVERY AND PAYMENT
Achieving and maintaining only the highest quality over a wide-
range of metrics has been a goal toward which Community Care, UPMC
Health Plan, and UPMC have long dedicated their efforts, including
ensuring that members have adequate and timely access to behavioral
health services.
We believe that ensuring such access requires concerted effort
across five areas: (1) defining the criteria that are reliable and
valid measures of adequate and timely access; (2) developing measures
to accurately capture variability within chosen criteria; (3) training
and educating individuals tasked with applying chosen measures to do so
in a consistent and systematic manner that produces meaningful results;
(4) identifying patterns, progress, and opportunities for improvements;
and (5) targeting meaningful solutions and/or corrective action plans
for those areas in which the need for improvement is identified. We
have found that a problem in any of the aforementioned functional areas
can render our best intentions to ensure adequate and timely access
meaningless. Accordingly, through various internal initiatives as well
as through stakeholder partnerships and collaboration, all of which are
focused on outcomes, we systematically address all 5 requisite areas.
I'd like to talk a little bit about the steps we at Community Care
and UPMC Health Plan have taken to implement best practices in each of
these areas mentioned above. While the majority of my comments below
will be provided from a payor perspective, many if not most are
fundamentally applicable and relevant from a provider vantage as well.
Defining Criteria that are Representative of Timely and Adequate Access
Most would agree that, insofar as healthcare delivery is concerned,
adequate and timely access to services is a critical component of
quality. If members cannot access a service, that service is of little
or no use. In the context of access, however, ``adequacy'' and
``timeliness'' are relative terms that do not necessarily lend
themselves to standard definitions, particularly in the behavioral
health arena. Whereas a 24-hour access standard may seem like nothing
short of overkill for most healthcare services, anything longer would
simply not be sufficient in the face of potential lethality or other
psychiatric emergency. As such, identifying timely and adequate access
as a marker of quality is merely a first-step; establishing measurable
standards necessarily follows.
Despite the relative nature of ``timeliness'' and the endless array
of factors that impact this relativity, a failure to settle upon a
measurable standard or to allow each unique circumstance to define or
determine its own standard were not options for Community Care or UPMC;
specific adequacy and timeliness standards had to be identified. To
assist in this end, Community Care turned to other stakeholders,
accrediting bodies (including NCQA and the Pennsylvania Department of
Public Welfare), and existing statutory and regulatory requirements for
guidance in setting appropriate timeliness benchmarks. Through these
efforts and collaborations, Community Care has derived a comprehensive
set of timeliness standards, beginning, for example, with a 24-hour
telephonic triage and referral team assembled to assess members'
immediate needs and determine the most appropriate levels of
intervention. Team members assist callers with emergent or urgent needs
and ensure that provider visits are arranged as quickly as possible and
always within the following timeframes: immediately for life-
threatening emergencies; within one hour for non-life-threatening
emergencies; and within 24 hours for urgent referrals.
While identifying these specific and/or mandatory timeframes as
``quality-indicators'' based upon objectively defined urgency standards
is critical and important, Community Care recognized early in the
process that members' opinions of accessibility were equally important.
While, for example, a 14-day timeframe within which to be seen for an
evaluation has a certain appeal, it is equally (if not more) important
to ascertain what members view as reasonable or adequate timeframes;
members are our best barometers of what should be. As described in the
section below, Community Care and UPMC developed a number of different
means by which to capture such subjective input.
After identifying the timeframes within which it thought members
should be seen and surveying members for additional input, Community
Care considered the additional factors that could directly or
indirectly impact adequate and timely access. It was important that
Community Care and UPMC Health Plan as payors (and UPMC as a provider)
not lose sight of the fact that timeframes are not met (or missed) in a
vacuum. To the contrary, often a timeframe is little more than the
consequence of competing variables. For Community Care these variables
include things such as penetration rates, which identify the proportion
of a member population who are actually utilizing services. The higher
the penetration rate, the higher number of providers necessary to
satisfy access standards. Additional variables include network
adequacy, the member's self-identified needs, the member's clinical
condition(s), and the array of available services. On the UPMC
provider-side, variables such as staff-to-patient ratios and the type
and range of staff employed are critical. Failing to recognize the
interrelationship between these variables and timeliness could result
in a failure to satisfy timeliness standards going forward; as such, a
multi-dimensional assessment and approach to timely and adequate access
is essential.
Measuring the Quality Metric ``Timely and Adequate Access''
After identifying those standards and indicators that Community
Care and UPMC Health Plan considered to be quality indicators with
respect to timely and adequate access, it was necessary to develop
valid and reliable means by which to measure and track those
indicators. Community Care and UPMC Health Plan employ a number of
different strategies to accomplish this end.
Community Care and UPMC Health Plan both include timeliness access
standards within their respective network provider agreements;
contracting entities are expected to maintain established timeframes or
will be considered in breach of the agreement. Timeliness standards
vary based upon urgency of care, i.e., emergent, urgent, and routine.
Providers are additionally required to notify Community Care
immediately when they are unable to accept new members into treatment.
While contractually imposing these requirements may seem severe,
Community Care and UPMC Health Plan believe that clearly delineating
timeliness standards in advance is preferable to allowing contracting
parties to be uncertain about amorphous standards.
Providers contracted with Community Care and UPMC Health Plan
additionally agree to allow us to audit their compliance with these
contractual requirements. Pursuant to these audit requirements,
Community Care and UPMC Health Plan routinely audit contracting parties
for compliance with these standards. Site visit surveys are conducted
for non-licensed or non-accredited facilities (both at time of
credentialing and at recredentialing), or whenever Community Care
receives three or more site complaints within a 6-month period. If
deficiencies are identified, quality improvement plans are required.
As set forth above, while auditing contractual compliance is an
efficient means by which to measure the more objective timeliness
standards imposed by Community Care and UPMC Health Plan, particularly
those contractually required, Community Care/UPMC utilizes member
satisfaction surveys to assess member sentiments in terms of timely and
adequate access. Over the past few years, Community Care has seen an
increase in member-reported satisfaction as to timely access (76.1% in
2008 to 78.2% in 2011).
Another means by which Community Care/UPMC tracks member
satisfaction (or dissatisfaction) with access standards is via member
complaints. Community Care, for the purposes of member complaints,
defines dissatisfaction with access to services as ``difficulty
obtaining an appointment within a certain time period or within a
certain distance, or the failure of a provider to meet the above
required timeframes for providing a service.'' In 2011, less than 1% of
all Community Care complaints were related to access to services.
During the same time period, UPMC Health Plan received no complaints
related to access.
Given that timely access is impacted directly and indirectly by
variables such as network adequacy, member need, and array of providers
within provider network, Community Care tracks and measures these
variables as well. Here again, Community Care relies upon requirements
and benchmarks imposed by accrediting bodies such as NCQA and the
Department of Public Welfare to serve as a guide to minimum
sufficiency. For example, NCQA requires that Community Care contract
with inpatient, residential, and ambulatory providers. As detailed more
fully below, simply monitoring a timeliness standard alone would not be
productive. Instead, Community Care carefully measures the sufficiency
of and changes in the many ancillary factors that collectively result
in or impact timeliness overall.
Training and Educating Those Measuring Access
Evaluating the success (or lack of success) of Community Care and
UPMC Health Plan's efforts to define and measure timely and adequate
access standards could be undermined absent the comprehensive training,
education, and outreach of all of those individuals tasked with
measuring chosen criteria. It appears that this is one of the
confounding factors experienced by the Veteran's Administration despite
its efforts to adequately track and monitor access.
Community Care/UPMC utilizes a broad array of means by which to
make certain all stakeholders measure access in a consistent and
standardized manner. Information about access requirements is included
in both our provider manual and provider newsletters. We also routinely
disseminate supplemental information during provider meetings and at
any time upon request. All new providers are required to attend a
comprehensive provider orientation, during which both the member access
requirements and the means by which to capture and measure adherence
are detailed.
Community Care uses its audit and site-visit process as yet another
educational touch point with providers. Included in Community Care's
``Site Visit Tool'' is a requirement to review the provider's policy on
appointment availability. Among the requirements are that (i) routine
appointments are provided within 7 calendar days of request, (ii) life
threatening emergencies are given immediate appointments; (iii) non-
life threatening emergency are seen within 1 hour of contact; and (iv)
members with urgent needs are seen within 24 hours of first contact.
Community Care is of the mindset that the audit process is not a
punitive process or a process aimed necessarily at identifying
problems. Rather, it is valuable opportunity to share information and
to work with providers toward understanding the myriad requirements
facing them, including accurately and consistently tracking and
measuring access.
In addition to educating providers on the standards expected of
them, we inform members of what they can expect regarding access
timeframes. We believe that members equipped with adequate information
in this regard are in the best position to provide real-time,
meaningful feedback as to how successful our providers and we are in
meeting requisite standards. We rely on the member-complaint process as
well as the care-management process for additional information
regarding access performance. Furthermore, we routinely review triage
and other referral calls to ensure access.
While adequately educating all stakeholders upfront is of critical
importance, Community Care and UPMC Health Plan have learned that
consistent monitoring thereafter cannot be overstated. A failure to
reinforce the specific access requirements or the means by which to
measure and track those requirements could weaken all of our efforts in
these regards. As such, we employ a dedicated staff across multiple
departments to accomplish these ends.
Analyzing Data Collected
The data gathered and maintained by Community Care and UPMC Health
Plan is useful only to the extent that it tells us something about how
we are performing with respect to access benchmarks. Here again, we
engage a dedicated staff to analyze the information gathered via the
myriad sources mentioned above. Such analyses are performed both for
specific providers and sub-populations and for our collective provider
networks; identifiable and aggregate reporting and analyses provide
different but equally critical types of information. Where, for
example, targeted information can inform us as to a given provider's
progress in meeting requisite benchmarks and serve as an indicator of
compliance with contractual obligations, aggregate data provides
insight into broader systemic trends.
As discussed above, our analyses are not limited merely to
resultant timeliness. In addition, we routinely track and analyze
provider sufficiency, both in terms of overall network capacity and
within specific provider-types, such as psychiatrists or psychologists.
We also closely monitor existing and anticipated member need (including
diagnostic trends and condition prevalence) to anticipate and predict
where added specialists may be required going forward. As discussed
below, this information is then used for targeted contracting and/or
hiring purposes.
Community Care and UPMC Health Plan track penetration rates to
determine the rates at which members are accessing services. We believe
that increased use, for example, of ambulatory and/or outpatient
services ultimately contributes to decreasing the use of more
restrictive levels of care. Generally, we have witnessed a trend toward
increased penetration rates for less restrictive services. Over the
past decade the percentage of dollars spent for inpatient services in
Community Care's behavioral health HealthChoices contracts has fallen
from about 50% to just over 20%. In fact, when reviewing the results of
the Community Care approach to care management, we have succeeding in
significantly increasing overall number of users of service, while
holding costs steady or even decreasing costs per member served.
Among Community Care's routine reports is an ``availability of
providers'' report, prepared by plotting the location of each member
using address and zip code information and then comparing it to
similarly plotted provider information. The resulting report shows the
overall coverage for various provider types of service overlaid with
the geographic location of our members. The report demonstrates the
travel time for each member and then summarizes the precise percentage
of members with access within the established drive time standards for
each level of care. This information is used to enhance network
development activities.
Our quality Committees share analyses and results such as those
described above both with targeted providers and with broader groups of
stakeholders, including county administrators, accrediting bodies such
as the Department of Public Welfare and NCQA, provider groups, and
members. We believe strongly that, until this feedback is looped back
to those providing, funding, and receiving care, it is of limited
value.
Using Analyses to Prompt Change
While data for data's sake may be interesting to some, its true
value to Community Care and UPMC Health Plan is its usefulness in
targeting necessary change and intervention. Over the years, data-
analyses have prompted a wide range of change. These changes include
traditional type of interventions such as targeted increases in certain
types of providers, e.g., psychiatrists, as well as systematic planned
development, such as increased funding dedicated to community-based
services. If upon analyses, it is determined that timely access is only
problematic within certain sub-specialties, Community Care may target
its employment and/or contracting efforts to increase providers of this
type. Hiring and/or contracting with more professionals, however, has
been only one of many solutions implemented by us over time. A one-
dimensional approach to change would be ineffective, particularly given
the finite number of professionals in any given area, particularly in
more rural regions. Moreover, records maintained by UPMC's human
resources department suggest that the time it takes to fill at least
some behavioral health positions can be substantially longer than
positions of other types.
Access feedback has also prompted Community Care/UPMC to explore
and implement newer potentially revolutionary types of service-
delivery, including telepsychiatry initiatives. Community Care now
supports approximately 20 telepsychiatry sites throughout Pennsylvania
using secure forms of video transmission. Psychiatrists working across
locations within the same agency staff some sites. Other sites are
staffed by UPMC psychiatrists who are supporting service providers in
more rural parts of Pennsylvania. Community Care has tracked both
provider and member satisfaction of these services with very positive
results. Published research on telepsychiatry indicates that patient
satisfaction is generally as high as with in-person services.
Mobile service delivery is another creative solution garnering
increased interest by Community Care. Mobile therapy is particularly
useful with those populations least likely to leave their homes to seek
care, including the frail and elderly and individuals living in rural
areas, as well as those whose behavioral health conditions render
routine outpatient care difficult. An ample network is meaningless
unless those persons who need services are able to access them. We have
also worked with other stakeholders to substantially expand the range
of services available to members. These additions include crisis
services, hospital diversion programs, psychiatric rehabilitation, and
certified peer services. All of these services have created new ways to
access services and alternatives to traditional inpatient and
outpatient models.
Community Care routinely works with a wide-range of stakeholders,
including providers, county authorities, and members, in all
implementation efforts. We feel strongly that collaboration is
essential to sustainability.
CONCLUSION
Adequate and timely access to services is a critical component of
quality. Ensuring access to services requires a sustained, systematic,
and coordinated approach. We at Community Care, UPMC Health Plan, and
UPMC believe that we have made great strides in these regards. I
personally would like to thank you for the opportunity to discuss the
work that we have done to improve access to services for members. I
speak for Community Care and all UPMC affiliates when I offer any and
all assistance that may be helpful going forward.
Prepared Statement of Thomas Carrato, USPHS (Ret)
Biography of RADM Thomas Carrato, USPHS (Ret)
Thomas Carrato is President of Health Net Federal Services,
responsible for the daily leadership and management of Health Net's
Government Services Division. His responsibilities include the
management and oversight of Health Net's Department of Defense and
Department of Veterans Affairs lines of business to include the DoD's
TRICARE program for the North Region and the worldwide Military &
Family Life Counseling contract.
Mr. Carrato has over 30 years of experience, success and
accomplishments in both the public and private healthcare sector as
senior executive, chief operating officer and clinician. He served as
Assistant Surgeon General of the United States, Regional Health
Administrator for the U.S. Department of Health and Human Services,
Deputy Assistant Secretary of Defense for Health Plan Administration,
and Group Vice President for a publicly traded government services
company. Mr. Carrato joined Health Net in March 2006 as Vice President
and DoD Program Executive.
Previously, Mr. Carrato served as Deputy Assistant Secretary of
Defense for Health Plan Administration and Executive Director of the
TRICARE Management Activity where he directed and managed worldwide
operations and performance of the TRICARE health plan. In an earlier
role as the Department of Health and Human Services' Regional Health
Administrator for Region IV, Mr. Carrato was the Department's principal
representative, providing advice and participating in policy
development and implementation of key healthcare initiatives in the
southeastern United States. He managed regionally based programs of the
Office of Public Health and Science including the Offices of Emergency
Preparedness, Minority Health, Women's Health, and Population Affairs.
Mr. Carrato holds a Master of Science in Accounting from Georgetown
University and is a licensed Certified Public Accountant. In addition,
he holds a Master of Social Work from the University of South Carolina
and is a licensed clinical social worker.
Mr. Carrato, retired as a Rear Admiral in the Commissioned Corps of
United States Public Health Service. His decorations include the
Defense Distinguished Service Medal and the Public Health Service
Distinguished Service Medal.
A Partnership History
Chairman Miller, Ranking Member Filner and Members of the
Committee, I appreciate the opportunity to testify on Veterans' access
to mental healthcare services.
Health Net is proud to be one of the largest and longest serving
healthcare administrators of government and military healthcare
programs for the Departments of Defense (DoD) and Department of
Veterans Affairs (VA).
In partnership with DoD, Health Net serves as the Managed Care
Support Contractor in the TRICARE North Region, providing healthcare
and administrative support services for three million active duty
family members, military retirees and their dependents in 23 states. We
also deliver a broad range of customized behavioral health and wellness
services to military services members and their families, including
Guardsmen and reservists. These services include the Military Family
Life Counseling (MFLC) Program providing non-medical, short-term
problem solving counseling, financial counseling, rapid response
counseling to deploying units, victim advocacy services, and
reintegration counseling.
In collaboration with VA, Health Net supports Veterans' physical
and behavioral healthcare needs through Community Based Outpatient
Clinics and the Rural Mental Health Program. The Rural Mental Health
Program was launched by VA in 2010 to provide access to community
mental health services in select rural counties in three Veterans
Integrated Service Networks (VISNs). Health Net delivers these services
for VA in VISNs 19 and 20.
While helping VA meet the needs of Veterans, Health Net also has
collaborated with VA in its efforts to ensure efficiency in the non-VA
care (Fee) program, helping VA save and recover millions of dollars
since 1998. The monies recovered through these programs (less program
expenses) are available to provide or enhance services for our Nation's
Veterans.
Health Net also is proud to support a number of VA's national
sports and rehabilitation programs, such as the Disabled Veterans
Winter Sports Clinic and the National Veterans Summer Sports Clinic. At
the summer clinic, we provide behavioral health coaches who conduct
education sessions designed to help Veterans take what they learn at
the summer clinic home with them and apply it to their everyday lives.
It is from this long-standing commitment to serving servicemembers,
Veterans and their families that we offer our thoughts on addressing
Veteran access to mental health services.
Call to Action
According to the Department of Veterans Affairs, the number of
Veterans seeking mental health services has climbed by a third. VA
faces a significant challenge with respect to providing access to care
with more and more servicemembers returning from Iraq and Afghanistan
with mental health issues stemming from their military service \1\. It
is imperative that Veterans receive care in a timely manner. With the
rising tide of suicides \2\, access to timely care can mean the
difference between life and death. Untreated mental illness impacts
overall health and reintegration into the community, as well as the
long term security, productivity, and well-being of this generation of
Veterans, their families, and their communities. Chairman Miller, as
you stated in a recent news release, ``These are wounds that cannot
wait.''
---------------------------------------------------------------------------
\1\ GAO VA Mental Health Report to Ranking Member, HVAC: Number of
Veterans Receiving Care, Barriers Faced, and Efforts to Increase
Access; 10/14/11.
\2\ Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using
VA Health Care: Facts and Figures; Congressional Research Service; 8/
16/11.
---------------------------------------------------------------------------
As this Committee knows, the VA Office of Inspector General (OIG)
recently released a report that was critical of VA's methods for
recording patient wait times for both initial and follow up mental
health visits, as well as its ability to provide access to these
services in a timely manner. VA has been quick to respond to the April
2012 OIG report. Likewise, we understand the urgency of the situation
identified in the OIG report and the need for a prompt response.
Addressing the dramatic increase in the demand for VA mental health
services is challenging. Clearly, the demand has stretched VA's
capacity to its limits. We appreciate VA's efforts to enhance capacity
for the unique care needs of today's Veterans and respect its
leadership in developing comprehensive guidelines for ensuring clinical
quality, particularly in the area of Post Traumatic Stress Disorder
(PTSD).
VA has led in the validation of evidence-based treatment and, in
collaboration with the DoD, in the development of clinical practice
guidelines and provider educational materials addressing PTSD. VA also
has taken steps to address access and to reduce the stigma associated
with seeking these services. The DoD and VA are both actively training
behavioral health providers in the delivery of these treatment
modalities, and the VA has endeavored to make evidence-based mental
health services available to Veterans across the range of treatment
settings.
Based on current services we provide to VA, as well as the DoD, we
believe there are ready approaches to address this urgent need quickly
and effectively. Moreover, these proven solutions for addressing both
short-term and ongoing access issues can be performed without
sacrificing clinical excellence which is so appropriately a priority
for VA.
Access Pressure Points
The demographics of the Veteran population are changing. There are
more Veterans living in rural areas and a growing number of female
Veterans. For example, of the over 8.3 million Veterans currently
enrolled in the VA Health System, about 41 percent live in rural or
highly rural areas, and approximately 30 percent of rural enrolled
Veterans have served in Operation Enduring Freedom and Operation Iraqi
Freedom (OEF/OIF). \3\ Currently, women Veterans comprise over eight
percent of the total United States Veteran population, and their
numbers have grown by 31 percent since 2006. \4\ It is expected that
the proportion of women Veterans will continue to grow--VHA projects
that women will represent ten percent of the total Veteran population
in 2020, increasing to nearly 14 percent by 2030. \5\ Women comprise
nearly 12 percent of OEF/OIF Veterans. \6\
---------------------------------------------------------------------------
\3\ Presentation for National Rural Health Day: Caring for Rural
Veterans; Dr. Mary Beth Skupien, Director of VHA Office of Rural
Health; 11/17/11.
\4\ http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
\5\ Women Veterans by the Numbers, Lisa Foster and Scott Vince;
California Research Bureau; 9/09/09.
\6\ http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
---------------------------------------------------------------------------
From Surge to Rural Access
Building upon over 20 years of experience serving active duty
military servicemembers, their families, and Veterans, Health Net has
developed a full continuum of programs to meet the behavioral health
needs of this population. Throughout the design and implementation of
these various programs, Health Net has collaborated with VA and DoD in
delivering high quality, accessible programs which augment existing
capacity and capability, both within VA and DoD.
Overview of Programs Offered by Health Net
------------------------------------------------------------------------
(please refer to Attachment 1 for detailed description)
-------------------------------------------------------------------------
Military & Family Life Counseling Program (MFLC) Program:
Provides short-term, problem-solving situational counseling; program
includes a network of more than 5,000 credentialed, trained, and
experienced counselors supporting 320 military installations in 50
states, 4 territories, and 13 countries
TRICARE North Region: Provides managed care support services to
3 million activity duty servicemembers, military retirees, and their
families in 23 states and the District of Columbia, provider network
includes 22,500 licensed, credentialed behavioral health providers and
392 facilities, have offered web-enabled, video short-tem counseling
Community Based Outpatient Clinics: Provides primary care,
mental health and preventive health services to Veterans
Rural Mental Health Program: Provides care to Veterans close to
home, behavioral health services provided by a network of clinicians
and peer support specialists
------------------------------------------------------------------------
These programs are very flexible in meeting demand, from supporting
a ``surge'' of returning servicemembers to reaching out to Veterans
living in remote geographic areas located many hours away from a VA
Medical Center. We are able to deliver a full spectrum of services from
preclinical to clinical, using a combination of face-to-face,
telephonic, and video counseling with licensed clinicians to help
servicemembers and their families and Veterans to address the unique
issues of the military lifestyle and the challenges of transitioning
from active duty to Veteran status. In addition, these programs are
further enhanced through educational training and workshop
presentations led by clinicians for patients and community providers.
The success of these various programs has been noted by military
leaders and beneficiaries. For example, the Military Family Life
Counseling Program was the subject of a recent independent study
performed on behalf of the Deputy Assistant Secretary of Defense
(Military Community and Family Policy) by Virginia Tech University. In
this study, recipients of MFLC support were asked to complete a brief
survey, which indicated that 96 percent were mostly or completely
satisfied with MFLC services. \7\
---------------------------------------------------------------------------
\7\ DoD Counseling Program Evaluation, Partner: Virginia Tech;
Examining the Perceived Effectiveness of Two Innovative Models of
Mental Health Service Provision to Service Members and Their Families:
Military One Source (MOS) and the Military Family Life Consultants
(MFLC); January, 2001.
---------------------------------------------------------------------------
Established Best Practices
The Department of Defense has engaged private sector firms like
Health Net as partners in addressing the needs of servicemembers and
their families up to the point of discharge from the service. Many of
the services developed for servicemembers and their families as a
result of this partnership are innovative, proven effective, and now
considered ``best practices'' throughout the military. Among the ``best
practices'' developed through this partnership are the following:
The development and deployment of a standby capacity that
is delivered when and where it is needed on a temporary basis. This
``surge'' capability can provide brief, non-medical, problem-oriented
counseling to address issues that arise in connection with deployment-
demobilization-re-deployment cycles of the troops and their families.
This standby capacity is comprised of a network of highly trained,
credentialed mental health professionals who are willing to serve in
this standby force.
The engagement of civilian and community-based networks
of trained, credentialed, mental health professionals to reach the
servicemembers and their families who are not in the vicinity of a
Military Treatment Facility. This is often the case for the National
Guard and Reserve components. The networks also meet the clinical
behavioral health needs of military beneficiaries assigned to a
Military Treatment Facility when the demand for behavioral health
services exceed the capacity or the scope of care which can be provided
within the military facility.
The use of telephonic and web-based tools to provide fast
access to resources that can assist with identifying serious cases
early, before anything dramatic can occur.
The Department of Veterans Affairs, likewise, has developed a
number of innovations and ``best practices'' to deliver quality
clinical services to Veterans.
Through the Rural Mental Health Program, Veterans may
access mental health or peer support services through a network of
licensed behavioral health specialists and peer support specialists.
All providers are trained on VA benefits and are able to address
specific Veteran issues and conditions which occur among the Veteran
population, including traumatic brain injury (TBI) and PTSD. VA
specific training covers the mission of VA, describes the patient
population, explains VA customer service, instructs providers on VA
documentation of health records and outlines VA patient rights.
Through the Claims Repricing Program, Health Net has
helped VA reduce Fee Program claims costs by identifying more than $650
million in discounts since the program's inception in August 1999.
These discounts are the result of applying claims pricing available
with Health Net's nationwide provider networks.
Through a national recovery audit program, Health Net has
helped VA in identifying over $113 million in overpayments for
inpatient and outpatient care.
Access to Care Solutions
Recruitment and training of clinical staff is paramount to the
effective delivery of behavioral health services. Overall, Health Net
has a national network of over 50,000 behavioral health providers. For
the Military Family Life Counseling Program, we have a network of over
5,200 licensed counselors who have been carefully selected, are fully
trained, and ready to deploy on short notice as needed. These networks
are further supported by 22,500 behavioral health providers in the
TRICARE provider network.
In this program, Military Family Life Counselors provide brief,
problem-oriented non-clinical counseling services. They are required to
assess risk in the context of non-medical interactions and to make
referral into clinical behavioral health services when indicated. They
have particular expertise in engaging servicemembers and their families
in ways that minimize or mitigate stigma.
Military Family Life Counselors are deployed on an as needed basis.
When they are not deployed in support of the MFLC program, many of
these masters-level behavioral health providers maintain clinical
behavioral health practices in their home communities.
As part of our program, MFLC counselors receive extensive core
training and orientation. To ensure clinical approaches are current, we
have established an independent Expert Curriculum Review Panel composed
of an expert panel of retired military and academic researchers who
specialize in deployment related psychology and military family
resiliency.
Health Net also has recognized the need to educate and train
community providers about the unique needs of the military and Veteran
population. Health Net, along with the American Red Cross and the Penn
State Hershey College of Medicine, sponsored 1-day conferences
targeting primary care and behavioral health providers. The conference
was designed for primary care and behavioral health-care professionals
to improve understanding, assessment, and treatment of the invisible
wounds of war: PSTD and TBI.
Providers expressed satisfaction with the content, based on a
survey performed 6-12 months following participation: 84 percent of
respondents expressed increased confidence in caring for returning
servicemembers; 41 percent had implemented new strategies of asking
about military service in their clinical practice. Additional programs
are planned for 2012 in New York, Washington, D.C., and Ohio.
As an industry leader in behavioral health, Health Net has
committed extensive resources to developing effective programs to
support the military and Veteran populations. Our highly trained and
credentialed provider network is the foundation for healthcare
delivery, whether on a military installation, in nearby population
centers, or in rural, hard -to-reach locations.
A Path Forward
We believe that these same clinical resources--a highly trained,
credentialed mental health surge capacity, along with community-based,
specially trained mental health providers--could effectively supplement
VA's capacity to quickly and effectively address the access issues
identified by the OIG without sacrificing VA's clinical excellence.
In addition, enhanced use of telephonic and web-based tools, many
of which VA has pioneered, offer Veterans with easy access to ongoing
support, helping to de-stigmatize the care, as well as facilitating
access for harder to reach Veterans.
Specifically, we believe the urgent need created by today's
environment--increased demand, strained resources, stressed facility
capacity--requires a comprehensive approach, one that is designed to
augment and enhance VA, based on the specific needs of each VA Medical
Center. The components of this approach should include:
A standby capacity to address urgent, short-term demand,
similar to models used by the Department of Defense. Such an approach
would be an effective and efficient model to provide rapid deployment
of resources to alleviate short-term demand requirements at a VA
Medical Center (VAMC) or a Community Based Outpatient Clinic (CBOC). In
short, it would be an effective means to address the urgent mental
health needs of today's Veterans, ``wounds that cannot wait.''
These rapid-response or surge providers would work alongside VA
providers, using the same clinical guidelines. In addition, this
standby capacity would enable the early identification of Veterans who
might be at risk for suicide or have other serious mental health
issues. Such Veterans could then be triaged into a high priority
process to gain access to VA providers and facilities as soon as
possible.
Telephonic and web-based tools that would offer the
possibility of reaching deeper into the Veteran population to identify
and serve those in need.
A network of community-based mental health providers that
would augment VA's capacity and reach, enabling VA to meet the needs of
Veterans who do not live near a VA Medical Center or a Community Based
Outpatient Clinic. Since this capacity already exists, it could be
brought to bear almost instantaneously. An added benefit of using
community-based provider networks similar to the ones we use for the
Military Family Life Counseling Program and TRICARE is that they
include a number of female clinicians to support treating the special
needs of women Veterans.
Specific considerations for VA to consider in developing this
approach include:
Deploy only a cadre of supplemental providers who are
professionally competent and credentialed, as well as specifically
trained in military culture.
Exploit existing network and standby capacity to
implement the solution very quickly. Time is critical here.
Utilize surge techniques to concentrate the mobilization
of the supplemental capacity in areas where the demand arises quickly
as a consequence of force downsizing.
Use of a single VA medical record system to record all
services provided to ensure that care is delivered in close
coordination with other VA providers.
Taken together, the components of this model could transform the
experience of Veterans in gaining access to their earned benefits in a
timely fashion.
Conclusion
We commend the VA for promptly responding to the VA OIG report on
Veterans' access to mental healthcare. As VA seeks to address this
urgent issue, we strongly encourage consideration of a comprehensive
approach that builds upon VA's strengths in clinical quality
excellence; one that draws upon best practices of not only the
Department of Veterans Affairs, but also other Federal agencies and the
private sector. Doing so provides VA with the fastest means for
providing more immediate results for this Nation's well-deserving
Veterans.
Chairman Miller and Ranking Member Filner, thank you again for the
opportunity to testify before this Committee today. More importantly,
thank you for your strong leadership over this critical issue for our
Nation's Veterans. I am happy to answer any questions you may have of
me.
Background on Health Net, Inc.
Health Net, Inc. is one of the Nation's largest publicly traded
managed healthcare companies and is currently ranked #179 on the 2011
Fortune 500. Health Net's government services division is one of the
largest and longest performing administrators of government and
military healthcare programs. Our health plans and government contracts
subsidiaries provide health benefits to approximately six million
individuals across the country through DoD, VA, as well as group,
individual, Medicare, and Medicaid programs. As a leader in behavioral
health, Health Net provides behavioral health benefits to approximately
five million individuals across the U.S. and internationally through
its subsidiaries, MHN, Inc. and MHN Government Services.
Health Net Federal Services manages several large contracts for the
government operations' division of Health Net, Inc. and is proud to be
one of the largest and longest serving healthcare administrators of
government and military healthcare programs for the DoD and VA.
In partnership with DoD, Health Net serves as the Managed Care
Support Contractor in the TRICARE North Region, providing managed care
services for three million active duty family members, military
retirees and their dependents in 23 states. In collaboration with VA,
Health Net supports Veteran healthcare to meet the physical and
behavioral health needs of Veterans through CBOCs and the Rural Mental
Program. Additionally, Health Net also supports VA by applying sound
business practices to achieve greater efficiency in claims auditing,
recovery and re-pricing.
MHNGS delivers a broad range of customized behavioral health and
wellness services to the military services' members and their families
and to Veterans. These services include military family counseling,
financial counseling, rapid response counseling to deploying units,
victim advocacy services, and reintegration counseling.
Attachment 1
------------------------------------------------------------------------
Program Brief Description
------------------------------------------------------------------------
Military & Family Life Counseling (MFLC) Develop and manage
Program a network of more than
5,000 credentialed,
trained, and experienced
licensed counselors,
including 1000 qualified
personal financial
counselors, who serve 320
installations in 50 states,
4 territories, and 13
countries
Deploy on average
1,400 consultants world-
wide in any given month to
provide private and
confidential, non-medical
and financial short-term,
situational, problem-
solving counseling
assistance and support
services to Service Members
(including the National
Guard) and their families
An additional 280
MFLCs [on average, per
month] travel throughout
geographically dispersed
areas to ensure access to
care for National Guard
families; these MFLCs
provide support at Pre-
Deployment training events,
welcome home ceremonies,
departure ceremonies, and
Yellow Ribbon events on
weekends through the On
Demand component of the
MFLC Program
Provide problem-
solving, situational
counseling in support of
active duty service, guard,
and reserve members and
their families, during
reunion/reintegration and
mobilization/de-
mobilization; non-medical
problem-solving counseling
support is intended to
augment existing military
and civilian support
services
Develop and support
other components: the
Marine Individual Ready
Reserve (IRR) Outreach
program and Joint Family
Support Assistance Program
(JFSAP), Child and Youth
Services, Personal
Financial Counseling, DoDEA
Summer Enrichment Program,
Victim Advocacy Support,
Purple Camps, Recruiting
Command, Victory
Resilience, and the U.S.
Army Recruiting Command
effort
-- Marine IRR Outreach--
Provide support to Marine
Reservists who often live
far from their command
structure and other
Reservists, with limited
support network to address
the experiences of combat
and the inevitable changes
that have occurred while at
war; provide telephone
outreach to homecoming IRR
citizen warriors; Address
administrative issues
associated with activation/
deactivation, as well as
life issues typical for
returning servicemembers,
such as readjusting to
family life, reestablishing
sleep habits, and
rebuilding relationships at
work; Placed over 22,000
outreach calls to Marine
Reservists
-- JFSAP--Provide services
at geographically dispersed
and rural locations; Bring
behavioral health and
financial support services
to active duty
servicemembers, Guardsmen,
and Reservists and their
family members who might
otherwise be unable to
access such support through
MFLCs personal financial
counselors; Help reduce
deployment and
reintegration stress, teach
coping skills, build
resiliency, develop
community resources, and
support mobilization and
reintegration activities
TRICARE North Region Serve over 3
million active duty
servicemembers, military
retirees, and family
members in 23 states and
the District of Columbia
Provide behavioral
health services contracting
and credentialing
Established network
of 22,500 licensed,
credentialed, behavioral
health providers, and
contracts with 392
behavioral health
facilities
Awarded original
TRICARE North Region
contract in 2004 (post DoD
consolidating 12 regions
into three: North, South,
and West); re-awarded
contract in May 2010
Provided healthcare
and associated services in
California and Hawaii
through CHAMPUS Reform
Initiative (CRI), first
contract awarded in 1988
and became the foundation
for future TRICARE
contracts
Awarded three
contracts for five regions
in 11 states to provide
managed healthcare services
to over 2.5 million
beneficiaries following CRI
------------------------------------------------------------------------
table continued on following page.
table continued
------------------------------------------------------------------------
Program Brief Description
------------------------------------------------------------------------
TRIAP Program Provided expert
short-term services
available on demand to help
beneficiaries cope with
normal reactions to
abnormal/adverse situations
Delivered short-
term, solution-focused
counseling for situations
resulting from deployment
stress, relationships,
personal loss, and parent-
child communications
Tested the use of
web-based technologies to
quickly provide information
and short-term services to
beneficiaries, and
determined if services and
platform increase DoD's
ability to:
-- Identify beneficiaries in
need of medical mental
healthcare at an early
stage
-- Refer beneficiaries
quickly or facilitate
access to appropriate level
of mental healthcare
VetAdvisor Support Program (subcontractor Provided behavioral
to a SDVOSB) health counseling, military
family counseling, and
rapid response counseling
to deploying units, victim
advocacy services, and
reintegration counseling
programs for this pilot
program
Provided telephonic
outreach offering benefits
and behavioral-health risk
assessments for returning
Veterans
Rural Mental Health (VISNs 19 and 20) Delivers care to
Veterans at locations
closer to the Veteran's
home than the nearest VA
Medical Center or Community
Based Outpatient Clinic
Veterans are
eligible to receive therapy
services as well as peer
support services
All providers are
trained on VA benefits, and
on addressing specific
Veteran issues (i.e.,
Military sensitivity, women
Veteran issues, TBI, and
PTSD)
Peer support
specialists are certified
through a nationally
accredited organization;
network providers are
licensed psychiatrists,
psychologists, and master's
level therapists
Available to OEF/
OIF Veterans within certain
counties
Rural Mental Health (VISN 6) Used excess funds
to establish a Rural Mental
Health program that
mirrored many of the pilot
program's requirements (the
VISN 19/20 Rural Mental
Health program is a pilot
program)
Veterans were
eligible to receive therapy
services (peer support was
not included).
All providers were
trained on VA benefits, and
on addressing specific
Veteran issues (i.e.,
Military sensitivity, women
Veteran issues, TBI, and
PTSD)
Program was
available to all Veterans
(not just OEF/OIF Veterans)
within certain counties
Program ended in
December 2011 due to lack
of funding
Warrior Care Support Provide complete
healthcare planning and
coordination services for
warriors severely injured
or with combat-related
behavioral health
diagnoses, and support for
their families through
TRICARE Program
Assist Veterans
transition from military to
VA care
Provide warrior
with a ``Health Care
Coordinator''--acts as
single point of contact for
healthcare services and
works with military and VA
to achieve a seamless
transition
------------------------------------------------------------------------
Prepared Statement of Joy J. Ilem
Mr. Chairman and Members of the Committee:
Thank you for inviting Disabled American Veterans (DAV) to testify
at this important hearing. We appreciate the opportunity to offer our
views on the problems confronting the Department of Veterans Affairs
Veterans (VA) and its Veterans Health Administration (VHA) in meeting
the critical mental health needs of some of our Nation's veterans--
particularly newer veterans now struggling with post-deployment mental
health challenges. As requested by the Committee, we focus this
testimony on mental healthcare staffing; barriers to access; quality of
care; reliability of data; and, systemic issues impeding care, wellness
and recovery.
Over the past five years both the House and Senate Committees on
Veterans' Affairs have held numerous hearings on VA mental health.
Topics included access to care; closing the gaps; waiting times;
invisible wounds; suicide and its prevention; treatment of post-
traumatic stress disorder (PTSD); and, VA's Mental Health Strategic
Plan and its Uniform Mental Health Services Handbook. \1\ Both the
Government Accountability Office (GAO) and VA's Office of Inspector
General (OIG) have evaluated and examined many of these issues,
sometimes at the request of Congress, including the latest report,
issued on April 23, 2012--Review of Veterans' Access to Mental Health
Care. Likewise, for over a decade the print and electronic media has
widely and repeatedly covered the many challenges new war veterans face
with physical and mental health--including the perception that VA seems
unable or has failed to help some of them. Predictably, this coverage
focuses predominantly on veterans who have fallen through the cracks,
taken their own lives, or has highlighted gaps in VA and DOD care,
documented particular mistakes and failures in individual cases, cited
the ever-present bureaucracy, and made observations examining barriers
to care, including mental health stigma that prevents some veterans
from even seeking VA care. It is rare to see media coverage of VA
mental health in a positive light although over the past five years it
has made remarkable progress in establishing a strong foundation of
mental health services. DAV continues to be concerned about the
constant negativity of the reports on VA mental health. Without proper
balance in reporting we fear many veterans who need care the most may
not come to the system designed to meet their unique needs.
---------------------------------------------------------------------------
\1\ April 25, 2012, Senate Veterans Affairs Committee, ``VA Mental
Health Care: Evaluating Access and Assessing Care.'' http://
veterans.senate.gov/hearings.cfm?action=release.display&release--
id=b030f350-2b9f-4e85-9903-0731e03be8e1
November 20, 2011, Senate Veterans Affairs Committee, ``VA Mental
Health Care: Addressing Wait Times and Access to Care.'' http://
veterans.senate.gov/hearings.cfm?action=release.display&release--
id=a9c9fd7c-36e8-4e4b-a9a4-dbff47a4fe5d
July 14, 2011, Senate Veterans Affairs Committee, ``VA Mental
Health Care: Closing the Gaps.'' http://veterans.senate.gov/
hearings.cfm?action=release.display&release--id=a005eefd-f357-4f33-
b702-196597a9a187
June 14, 2011, House Veterans Affairs Committee, ``Mental Health:
Bridging the Gap Between Care and Compensation for Veterans.'' http://
www.gpo.gov/fdsys/pkg/CHRG-111hhrg67193/pdf/CHRG-111hhrg67193.pdf
March 3, 2010, Senate Veterans Affairs Committee, ``Mental Health
Care and Suicide Prevention for Veterans.'' http://veterans.senate.gov/
hearings.cfm?action=release.display&release--id=d1a8548c-de2c-49a8-
b7f9-d0855265d435
April 30, 2009, House Veterans Affairs Committee, Subcommittee on
Health, ``Charting the US Department of Veterans Affairs' Progress on
Meeting the Mental Health Needs of Our Veterans: Discussion of Funding,
Mental Health Strategic Plan, and the Uniform Mental Health Services
Handbook.'' http://veterans.house.gov/hearing-transcript/charting-the-
us-department-of-veterans-affairs-progress-on-meeting-the-mental
June 4, 2008, Senate Veterans Affairs Committee, ``Systemic
Indifference to Invisible Wounds.'' http://veterans.senate.gov/
hearings.cfm?action=release.display&release--id=74f01638-542e-49d7-
b3bb-f0ac55671f28
May 5, 2008, House Veterans Affairs Committee, ``The Truth about
Veterans' Suicides.'' http://veterans.house.gov/hearing/the-truth-
about-veterans%E2%80%99-suicides
April 1, 2008, House Veterans Affairs Committee, Subcommittee on
Health, ``Post Traumatic Stress Disorder Treatment and Research: Moving
Ahead Toward Recovery.'' http://veterans.house.gov/hearing/post-
traumatic-stress-disorder-treatment-and-research-moving-ahead-toward-
recovery
December 11, 2007, House Veterans Affairs Committee, ``Stopping
Suicides: Mental Health Challenges Within the US Department of Veterans
Affairs.'' http://veterans.house.gov/hearing/stopping-suicides-mental-
health-challenges-within-the-us-department-of-veterans-affairs
---------------------------------------------------------------------------
As noted, the unprecedented efforts made by VA over recent years to
transform itself and improve consistency, timeliness, and effectiveness
of VA's mental health programs, provide evidenced-based treatments and
care that bring veterans hope for recovery, and reduce stigma
associated with mental health, are rarely discussed and virtually never
applauded. Likewise, published reports and research on the tens of
thousands of dedicated VA healthcare professionals and staff who
provide specialized mental health services to troubled and ill veterans
frequently go without any recognition, thanks or gratitude.
Unfortunately, in the current environment it is difficult to shift
public perception to the positive gains VA has actually made. Compared
to the private sector, VA's mental health and substance abuse system
gets high marks. However, given the troubling findings of the Senate's
informal July 2011 mental health query of mental health providers \2\
and the most recent OIG report \3\ pointing out lingering and
significant flaws and limits, VA seems to have fallen short of its own
goals to provide the best possible accessible care to veterans, many of
whom are in desperate need of receiving VA's specialized mental health
services. VA is not meeting its access standards and has not provided
the needed services consistently to every veteran in every VA facility
across the country. While not true in most cases, VA bears the brunt of
this perception and consequently pays a high price in the minds of the
public and the veteran community.
---------------------------------------------------------------------------
\2\ United States Senator Patty Murray, Official News Release,
``VETERANS: After VA Survey Shows Long Wait Times for Mental Health
Care, Chairman Murray Calls for Action.'' October 4, 2011. http://
www.murray.senate.gov/public/index.cfm/newsreleases?ID=87890f52-e2dd-
4f01-af31-43329f09adec
\3\ VA Office of the Inspector General, Offices of Audits and
Evaluations and Healthcare Inspections, ``Veterans Health
Administration, Review of Veterans' Access to Mental Health Care.''
April 23, 2012 http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf
---------------------------------------------------------------------------
The informal query VA conducted at the request of your counterparts
in the Senate found that mental healthcare providers did not agree that
veterans' ability to schedule timely appointments matched data reported
by VA's performance management system and identified a number of
constraints on their abilities to best serve veterans, including
inadequate staffing, space shortages, limited hours of operation and
competing demands for scarce appointment slots. Seventy-one percent of
those survey respondents indicated that their medical centers had
inadequate numbers of mental health staff. VA recently testified that
it was taking two major actions as a result of the findings of this
survey. VA developed a comprehensive action plan to enhance services
and to address the VA staffs' concerns and it conducted an external
focus group to better understand the issues raised by front-line
providers. VA also stated it is conducting site visits to each VA
medical center this year to evaluate mental health programs. \4\
---------------------------------------------------------------------------
\4\ Senate Veterans Affairs Committee, ``VA Mental Health Care:
Evaluating Access and Assessing Care,'' April 25, 2012. http://
veterans.senate.gov/hearings.cfm?action=release.display&release--
id=b030f350-2b9f-4e85-9903-0731e03be8e1
---------------------------------------------------------------------------
The OIG was asked to determine how accurately VHA documents waiting
times for mental health services for new and established patients, and
whether the data VA collects is an accurate depiction of veterans'
ability to access needed services. VHA policy requires new patients who
are referred to, or who are requesting, mental health services, to
receive initial evaluations within 24 hours of request, and be provided
a more comprehensive diagnostic and treatment planning evaluation
within 14 days of request. VA has reported that 95 percent of its
first-time patients receive a full mental health evaluation within VA's
14-day goal. Nevertheless, the OIG report found that VHA's mental
health performance data is not accurate or reliable and that VHA's
measurement of first-time access to a full mental health evaluation was
not a meaningful measure of waiting times.
The OIG conducted its own analysis and projected that in VHA only
49 percent of patients (versus 95 percent) received full evaluations,
to include patient history, diagnosis, and treatment plan, within 14
days and for the remainder of patients, it took 50 days on average.
Additionally, VHA could not always provide existing patients their
treatment appointments within 14 days of their desired dates. DAV began
an informal, anonymous online survey for veterans in December 2011,
asking about their experience seeking and receiving VA mental health
services. To date, nearly 1,050 veterans from all eras of service have
responded to the survey, and our findings were close to those reported
by the OIG on waiting times for follow up appointments. A complete
report of DAV's survey results can be found on line at http://
www.standup4vets.org. The OIG report also noted that several mental
health providers whom inspectors interviewed had requested desired
dates for patients for follow up care based on their personal schedule
availabilities rather than the patients' requests, or based on observed
clinical need in some cases. Likewise, VHA schedulers did not
consistently follow VHA policy or procedures but scheduled return
clinic appointments based on the next available appointment slots,
while recording the patients' ``desired'' and actual dates as if they
were compliant with VA policies. Since the OIG had found a similar
practice in previous audits nearly seven years earlier, and given that
VHA had not addressed the long-standing problem, OIG urged VHA to
reassess its training, competency and oversight methods and to develop
appropriate controls to collect reliable and accurate appointment data
for mental health patients. The OIG concluded that the VHA `` . . .
patient scheduling system is broken, the appointment data is inaccurate
and schedulers implement inconsistent practices capturing appointment
information.'' These deficiencies in VHA scheduling system have been
documented in numerous reports. After more than a decade, VA's Office
of Information and Technology has still not completed development of a
state-of-the-art scheduling system that can effectively manage the
scheduling process or provide accurate tracking and reporting.
The OIG also recommended that VHA conduct a comprehensive analysis
of staffing to determine if mental health provider vacancies were
systemic issues impeding VA's ability to meet its published mental
health timeliness standards. Most importantly, the OIG report noted
that meaningful analysis and decision making required reliable data,
not only related to veterans' access but on shifting trends in demand
for services, the range of treatment availability and mix of staffing,
provider productivity and treatment capacity of the facilities.
References were provided by the OIG to VHA on managing a better
response to a number of shifting dynamics, through ``dashboard
reports'' used in the private sector that incorporate patient demand,
clinic capacity and provider productivity in a consistent set of
business rules in which to assess and respond quickly to changes in
access parameters. The OIG made four major recommendations to VHA on
the above noted issues. Similar to previous external reviews, the VA
Under Secretary for Health has agreed with all these recommendations
and stated that a number of measures are currently underway. \5\
---------------------------------------------------------------------------
\5\ Ibid.
---------------------------------------------------------------------------
As we noted earlier in this testimony, despite obvious progress, it
is clear to us that much still needs to be accomplished by VHA to
fulfill the Nation's obligations to veterans who are challenged by
serious and chronic mental illness, and particularly to those with
post-deployment mental health and transition challenges. VA's duty is
clear--all enrolled veterans, and especially servicemembers, Guardsmen
and reservists returning from current or recent war deployments, should
be afforded maximal opportunities to recover and successfully readjust
to civilian and domestic life. They must gain user-friendly access to
VA mental health services that have been demonstrated by current
research evidence to offer them the best opportunity for full recovery.
We must stress the urgency of this commitment. Sadly, we have
learned from our experiences in other wars, notably in the post-Vietnam
period, that psychological reactions to combat exposure are not
unusual: they are common. If they are not readily addressed at onset,
they can easily compound and become chronic and lifelong. The costs
mount in personal, family, emotional, medical, financial and social
damage to those who have honorably served their Nation, and to society
in general. Delays or failures in addressing these problems can result
in self-destructive acts, including suicide, job and family loss,
incarceration and homelessness. Currently, we see the pressing need for
mental health services for many of our returning war veterans,
particularly early intervention services for substance-use disorder and
evidence-based care for those with PTSD, depression and other
consequences of combat exposure. As we have learned from experience,
when failures occur, the consequences can be catastrophic. We have an
opportunity to save a generation of veterans, and help them heal from
war, but decisive action is essential.
Mr. Chairman, in mental health, VA is now at a crossroads, and its
next steps are critical ones. This issue is extremely serious--and
everyone wants to ensure that VA gets it right. We observe that
Congress is frustrated, as are we. Billions of new dollars and
personnel for improving VA mental health services have been pumped into
the system over the past five years--and despite the significant number
of new hires, a 46 percent increase in staff between 2005-2010, \6\ VA
recently reported it still needs to hire 1,600 additional mental health
clinical and 300 support staff. \7\ Many have pointed out \8\ this
increment alone will not fix the problem. So, the question is what can
and should be done at this critical juncture? What are the best
solutions to solve the existing problems? Within the next couple of
years, more combat veterans will be returning home and many will need
VA's services. We concur with remarks made by Deputy Under Secretary
for Health for Operations and Management, William Schoenhard, at the
April, 25, 2012, Senate Veterans' Affairs Committee Hearing that
sending these veterans out of the system en masse is not the answer--
this group particularly can benefit from VA's expertise in treating
post-traumatic stress, PTSD, substance-use disorders, traumatic brain
injury and other post deployment transition issues. To that end, it is
essential that VHA address and resolve the issues that tolerate
variable provision of mental health and substance abuse care and
prevent consistent, timely access to care at VA facilities nationwide.
---------------------------------------------------------------------------
\6\ VA Office of the Inspector General, Offices of Audits and
Evaluations and Healthcare Inspections, ``Veterans Health
Administration, Review of Veterans' Access to Mental Health Care.''
April 23, 2012 http://www.va.gov/oig/pubs/VAOIG--12-00900-168.pdf
\7\ United States Department of Veterans Affairs, Official Press
Release, ``VA to Increase Mental Health Staff by 1,900,'' April 19,
2012. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2302
\8\ The New York Times, Editorial, ``Does the V.A. Get It?'' April
24, 2012. http://www.nytimes.com/2012/04/25/opinion/does-the-va-get-
it.html
---------------------------------------------------------------------------
Unfortunately, the problems in VA's mental health programs are
complex, and cannot be resolved within any single dimension. The VHA is
facing systemic challenges that are similar in nature to the
organizational problems that the Veterans Benefits Administration (VBA)
is facing with respect to its seemingly intractable backlog of
disability claims. The root causes are multiple, systems-based,
longstanding, and complex. DAV has been a staunch advocate for
correcting the root problems in VBA--not just managing a symptom of the
problem by reducing the backlog on a crash basis. We believe the same
holds true for VA's mental health clinical programs.
One of the most troubling barriers that prevents VA from being more
effective in many of its programs is VA's own human resources (HR)
policies and the practices surrounding them. Practitioners and clinical
program leaders across the VA system have told DAV for years that
recruitment of new professionals is a vexing and frustrating challenge
that contributes to VA's failings and deficits. Even when new
candidates are plentiful, well-qualified, and eager to join VA
employment, the process that leads to offers of VA employment can
linger for months, and in rare cases, years, before an employment
commitment can be made. Many excellent candidates wait for months
without feedback from VHA and simply move on to other opportunities.
Delays of such magnitude are due to a variety of factors, but one
principal reason for them is that human resources personnel are
accountable only to their program officials in HR, but not to clinical
selecting officials. In our opinion, they do not treat recruitment as
an urgent process requiring the highest level of customer service to
both the internal and external customers. This is especially ironic,
given that about 100,000 health professionals train in VA facilities
annually. Many of these young professionals may want to stay in VA but
their personal and financial circumstances prevent them from waiting
months or years for a VA job offer.
As a part of the Independent Budget (IB), DAV has been calling for
reform in VA's human resources policies. \9\ Recent hearings on VA
mental health in the Senate confirm that the lack of responsiveness of
human resources offices and management policies are contributing to
deficits in VA's mental health programs. Sadly, unresponsive HR
practices are also affecting all of VA's key missions. We urge the
Committee to carefully examine VA and Office of Personnel Management
appointment authorities in statute and how they are being applied
within VA to determine whether additional legislation would offer any
helpful resolution. VA should develop and track measures of performance
in HR recruitment, on-boarding and retention of clinical staff. Almost
as important, the Committee should provide targeted oversight in
examining why VA human resources programs are so weak and unaccountable
at a time when they should be acting forcefully and supportively to
ensure VA programs in VHA, VBA and Memorial Affairs are properly
staffed to meet their missions. With help from Congress, we believe
this aspect of VA's challenges can be solved with better leadership and
more responsiveness, beginning at the local level and extending
throughout the system.
---------------------------------------------------------------------------
\9\ The FY 2013 Independent Budget, ``The Department of Veterans
Affairs Must Strengthen Its Human Resources Program,'' pp 178-182.
http://www.independentbudget.org/2013/05-47-220-MC-C.pdf
---------------------------------------------------------------------------
I must also report that many VA facility executives seem to tacitly
support current bureaucratic practices in HR as a means to conserve
facility funding and stretching healthcare budgets. Almost every VA
facility operates a ``resources committee'' or similar function to
examine every vacancy occurring and then to require selecting officials
to justify in writing (and sometimes by making personal appearances and
appeals before the Committee) why vacancies should be filled at all.
This grueling process that constitutes a ``soft freeze,'' can consume
months, all the while allowing the facility to ``save'' the personal
services funds that would have been paid in salary and benefits
associated with those unencumbered positions. It is common practice for
resource committees to deny authorization to fill mental health and
substance positions, creating ``ghost'' positions that are listed in
the Service FTEE allocations but can never be recruited. We understand
that in many locations, the 1,600 newly allocated FTEE will not even be
sufficient to fill these vacancies. We believe, certainly now in the
face of inadequate mental health access, that such practices should be
halted. With the massive and rising unmet needs being reported today,
VA must become very sensitized and make every effort to quickly fill
all mental health provider vacancies and their support staff positions
as a high priority in HR offices. VHA Central Office and VA Medical
Center leadership should be accountable to ensure that this occurs.
Despite all these staffing challenges, the transformation of the
VHA's mental health program over the past decade has been
revolutionary. As the wars in Afghanistan and Iraq were raging, VA
inaugurated its internal reforms in the beginning of 2004 and developed
a Mental Health Strategic Plan rooted in the principles of recovery-
oriented care. In 2008, VA instituted a national Uniform Mental Health
Services Handbook to ensure consistency of available services
throughout the healthcare system's 1,400 sites of care. Full
implementation of the Handbook is still ongoing, and now a patient-
centered care model has been added to the mix for all of VA healthcare.
Likewise, state-of-the-art approaches to care, evidenced-based
treatments and new technologies have been validated by research for
some mental health challenges, including PTSD. All of these activities
have occurred during a time of steadily increasing patient care
workloads and rising demand for services. Despite the addition of
thousands of new mental health staff, demand for these services by tens
of thousands of new veterans has obviously overwhelmed the system and
made it difficult for VA mental health providers to translate
transformational mental health policies and cutting edge clinical
services into consistently delivered clinical practices.
Today's wars are truly different, and accompanied by multiple and
longer deployments than any previous experience of military
servicemembers, National Guard or reserve personnel. Additionally, the
VA must not only contend with a new generation of war veterans but
continue longer term treatment of a significant number of veterans from
prior eras of military service with mental health challenges and a
large, older population with debilitating chronic and serious mental
illnesses. We believe the clinical policy changes VA has made over the
past eight years are positive and will ultimately equate to better
patient care and improved mental health outcomes--but significant
challenges have arisen now on a daily basis, and these will need
continued attention, intensity, resources and oversight--and the
development of sound and workable solutions to ease the pressure while
meeting veterans' needs. The VHA must develop a number of short and
long range goals to resolve existing problems identified by the OIG,
Congress and the veterans service organization (VSO) community.
However, even those gains will not be enough unless VA conquers the
challenge of making its own transformational cultural change across the
healthcare system and at every service delivery point nationally. The
HR function discussed is but one significant challenge that cries out
for immediate reform.
VHA must develop reliable data systems; fix the flaws in its
appointment and scheduling system with effective policies and IT
systems that fill the current gaps, and is responsive to mental health
needs; develop an accurate mental health staffing model that accounts
for both primary and a multitude of complex specialty mental health
capacity demands; revolutionize its hiring practices and eliminate the
barriers that obstruct timely hiring of mental health providers and
support staff; adjust its practices to address the complexities of co-
occurring general health, mental health and psychosocial problems of
veterans in a truly patient-centered manner, and re-establish
credibility and trust with the veterans that VA is charged to serve.
In addition to these general principles we have recommended to
guide VA reforms, DAV also makes the following specific recommendations
for additional oversight or legislation, as warranted:
There is an immediate need for VHA to implement a
National Tele-mental Health Program, modeled on the National Tele-
radiology Program, that provides the infrastructure, professional
expertise and staff support needed to deliver consistent, evidence-
based mental health services at all VA healthcare facilities.
Facilities could access the program to address surge demand for
services and meet the challenges of staffing shortages. If sites were
established on the East Coast, West Coast and in Hawaii, extended
evening clinic hours could be offered that would ease the burden on
veterans for time off work and child care. An effective tele-mental
health program could also help ease the recruitment challenges being
reported by smaller and more rural VA facilities that have difficulties
recruiting and retaining mental health professionals.
With Congressional oversight, VA should institute a
Secretary's Task Force or Commission on Mental Health and Substance-Use
Services, composed of VA and non-VA mental health and policy leaders
and with participation by VSOs. This body should be given a broad
directive, the staff, resources and mandate to provide comprehensive
analysis and advice on the organization and delivery of VA mental
health, substance abuse, and suicide prevention programs.
The VHA should institute an external Mental Health
Assessment and Site Visit Program to evaluate local fidelity and
adherence to national mental health and substance-use disorder policy
in the Uniform Services Handbook, as well as become a monitor for
access, satisfaction, and quality of care issues. An external
assessment will increase the objectivity and visibility of the site
visit process. The current internal, VA staff review should serve as a
pilot for this external comprehensive program evaluation and reporting
process.
The recent VHA reorganization divided the mental health
program management responsibility and organized them under two
different Deputy Under Secretaries--the the Deputy Under Secretary for
Operations and Management and the Deputy Under Secretary for Policy and
Services. This management change was implemented to ostensibly increase
``integration'' but, in our opinion, instead has increased VA Central
Office staff redundancy, reduced responsibility and accountability, and
removed valuable professional staff resources from coordinated care
delivery. Given the deteriorating performance of mental health programs
and the difficulties now being highlighted, the wisdom of this
reorganization should be reexamined and full authority returned to the
Patient Care Services and the Office of Mental Health.
As a high priority, VHA should address the co-morbidity
of mental health and chronic pain syndromes in Operation Iraqi Freedom/
Operation Enduring Freedom veterans in order to provide better
treatment guidance and reduce the epidemic of prescription drug misuse
and the use of high risk opioid prescriptions.
The VHA should revise the Veterans Equitable Resource
Allocation (VERA) funding model to account for, and fund, the rising
cost and complexity of comprehensive mental health and substance-use
care in VHA.
The Committee on Care of Veterans with Serious Mental
Illness, which was authorized by law as a monitor on the quality of
mental healthcare in VHA, and has been staffed by VHA, does not meet
the original congressional intent, functions, and responsibilities.
Congress should re-charter this Committee to ensure that it provides
input from expert advisors in the mental health, substance abuse, and
veterans communities, receives staff support and access to data in
order to assess the performance of the program and healthcare
facilities, present its findings to VHA and VA leaders, and advocate
for all veterans who need outreach and anti-stigma, mental health,
substance use, and especially suicide prevention programs. The VSOs
should be active, full members of the Committee, rather than be part of
its external consumer liaison group.
Mr. Chairman and Members of the Committee, in closing we applaud
VHA for its focus on providing veteran-centered care and changing to a
recovery-based model of care with the goal of not only symptom control
and reduction but a goal of helping veterans achieve improvement in
their overall wellness and functionality in society. Likewise, we
appreciate the Committee's continued oversight efforts in VA mental
health and for continuing to insist that VA dedicate sufficient
resources in pursuit of comprehensive mental health services to meet
the needs of veterans VA serves--particularly the post-deployment
mental and transition readjustment needs of returning war veterans. DAV
recognizes this strong support and progress, but it is eclipsed and
obscured by the problems we are discussing here today, and happening at
the worst possible moment when expectations are highest. VA should
expeditiously work toward real reforms to make the system stronger,
while properly prioritizing and addressing the urgency of the current
findings. We believe the recommendations provided by the OIG and the
VSO community, along with VA's measures, can collectively be used to
solve these challenges.
Chairman Miller, this concludes my prepared statement. I am pleased
to address any questions you or other Members of the Committee may wish
to ask.
Prepared Statement of Alethea Predeoux
Chairman Miller, Ranking Member Filner, and members of the
Committee, thank you for allowing Paralyzed Veterans of America (PVA)
to testify today on one of the most important healthcare issues facing
America's veterans and the healthcare system of the Department of
Veterans Affairs (VA). PVA believes that when veterans have timely
access to quality mental healthcare services they in turn have the
opportunity to establish productive personal and professional lives.
PVA thanks this Committee for their continued oversight and hard work
on this important healthcare issue.
In recent years, the VA has made tremendous strides in the quality
of care and variety of services provided to veterans in the area of
mental health. These improvements include incorporating mental health
into VA's primary care delivery model, increasing the number of Vet
Centers, launching mental health public awareness campaigns, and
creating call centers that are available to veterans 24 hours a day, 7
days a week. While these improvements were much needed and have helped
many veterans, PVA believes that issues of access to mental healthcare
within the VA continue to exist and more must be done to make certain
that all veterans receive mental healthcare that is timely and
effective.
The VA's Office of Inspector General (OIG) report, entitled,
``Veterans Health Administration: Review of Veterans' Access to Mental
Health Care,'' identified many weaknesses within VA's Department of
Mental Health that if improved upon will allow VA to continue in its
progression of providing high quality mental health services to
veterans. Overall, the report concluded that the Veterans Health
Administration (VHA) mental health performance data is not ``accurate
or reliable, and VHA measures do not fully reflect critical dimensions
of mental healthcare access.'' More specifically, the report stated
that ``VHA's measurement of a first time patient's access to a full
mental health evaluation was not a meaningful measure of wait time; VHA
was not providing all first time patients a full mental health
evaluation within 14 days as required by VA policy; VHA schedulers did
not consistently follow procedures; and VHA overstated its success in
providing veterans new and follow-up appointments for treatment within
14 days as required by VA policy.'' \1\
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\1\ The Department of Veteran Affairs, Office of Inspector General,
Offices of Audits and Evaluations and healthcare Inspections;
``Veterans Health Administration, Review of Veterans Access to Mental
Health Care.'' April 23, 2102, 12-00900-168; http://www.va.gov/oig/
pubs/VAOIG-12-00900-168.pdf
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While PVA is deeply concerned by these findings, such conclusions
were not completely surprising. In fact, this year's Independent Budget
states, ``One overreaching concern of the IBVSOs is the lack of clear
and unambiguous data to document the rate of change occurring in VA's
mental health programs, as noted in the May 2010 GAO report . . . VA
needs more effective measures to record and validate progress.'' \2\
Four main recommendations were made by the VA OIG: 1) Revise the
current full mental health evaluation measurement to ensure the
measurement is calculated to reflect the veteran's wait time experience
upon contact with the mental health clinic; 2) Reevaluate alternative
measures or combinations of measures that could effectively and
accurately reflect the patient experience of access to mental health
appointments; 3) Conduct staffing analysis to determine if mental
health staff vacancies represent a systemic issue that impedes VA's
ability to meet mental health timeliness goals; and 4) Align data
collection efforts related to mental health access with the operational
needs throughout the organization. \3\
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\2\ The Independent Budget, FY 2013, pg. 71;
www.independentbudget.org
\3\ United States Government Accountability Office, Report to the
Ranking Member, Committee on Veteran Affairs, House of Representatives,
``VA Mental Health: Number of Veterans Receiving Care, Barriers Faced,
and Efforts to Increase Access.'' GAO-12-12; October 2011; http://
www.gao.gov/assets/590/585743.pdf
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PVA supports these recommendations and believes that the
recommended actions will allow for VA to better identify and address
the issue of access to VA mental healthcare services. In addition to
these recommendations, PVA believes that increased attention to
staffing, productivity and performance of providers, and patient demand
will further assist VA in providing care that makes a difference in the
lives of veterans.
The analysis and results from the VA OIG report on mental health
access data shines light on the inconsistencies of policy
implementation within VHA, and how such inconsistencies can negatively
impact veterans' access to quality care. For instance, VA requires that
all first-time patients receive a treatment planning evaluation no more
than 14 days from the initial request or referral for services. As the
VA OIG reports states, various mental health offices within VA have
been interpreting this policy to have multiple meanings, and the end
result is not having reliable data to accurately assess veterans'
access to care or the performance of providers. The VA must not have
policies just for the sake of having policies. The VA must ensure that
staff adheres to all policies that are put in place to guarantee a high
caliber of services for veterans, and must further develop safeguards
that ensure such policies are carried out correctly from day to day.
On April 25, 2011, the Senate Veterans Affairs' Committee held a
hearing entitled, ``VA Mental Health Care: Evaluating Access and
Assessing Care.'' During this hearing a veteran and former VA mental
health professional testified that too often the VA mental health
system places a burdensome emphasis on having staff meet numerical
performance goals at the expense of providing veterans with the best
care possible. \4\ PVA believes that VA leadership must make certain
that policies and regulations are developed to provide safe, quality
health services for veterans, without compromising the professional
integrity of the qualified providers who deliver the care. VA policies
must be pragmatic and attainable, and improve the delivery of care by
creating benchmarks and measures that help assess strengths and
weaknesses of healthcare services and delivery.
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\4\ 4 Senate Veterans Affairs Committee, ``VA Mental Health Care:
Evaluating Access and Assessing Care.'' April 25, 2012. http://
www.veterans.senate.gov/hearings.cfm?action=release.display&release--
id=f485cb0d-3ad4-407f-99a8-9f517d9c3af6
---------------------------------------------------------------------------
PVA's Medical Services and Health Policy Department conducts
regular site visits to VA Spinal Cord Injury Centers on a monthly
basis. PVA's medical professionals that facilitate these visits, along
with VA leadership from the various medical centers, compile staffing
and bed capacity data for a monthly report. Included in these reports
is the required number of staff that is needed to care for patients
within a medical center as determined by VA policy. The reports also
include the actual number of staff available for duty during the month
of the visit. Staff members counted in the report include nurses,
physicians, social workers, psychologists, and therapists.
For the past year there have been consistent deficits in one or
more of the mental health positions included in the report. Such
deficiencies in mental health staffing directly impact veterans' access
to mental health services. For example, within VA's Spinal Cord Injury
System of Care, veterans receive annual examinations that encompass a
mental health screening. This annual mental health screening is
extremely important for veterans who have sustained a catastrophic
injury as they have a high propensity to face challenges involving
self-esteem, independence, and quality of life. The aforementioned
mental health staffing shortages have the potential to compromise
quality mental health screenings and treatment for veterans within the
SCI system of care who are dealing with symptoms of mental health
conditions.
Without sufficient staffing, providing care when it is needed is
difficult. Timely care is critical to preventing and treating mental
health conditions. If VA is going to provide mental healthcare services
in a timely manner, it must be equipped with adequate staffing in the
various types of mental healthcare that it provides. For instance,
within VA SCI primary care, our site visit reports indicate that
psychologist positions in VA medical centers have extremely high
turnover rates due to low compensation scales and high patient panels.
This is a systemic issue within VA that involves various departments--
human resources, primary care, and mental health. Ultimately, staffing
issues such as this impede veterans' access to mental healthcare and
overall patient wellness.
The VA recently announced increasing the mental health workforce by
an additional 1,900 mental health professionals. To ensure that these
staff increases are effective, PVA recommends that the VA conduct a
comprehensive analysis of the mental healthcare needs of veterans and
hire additional staff based on those needs. The VA cannot accurately
assess the performance and productivity of providers if they do not
have an understanding of the needs that the providers are expected to
meet. As the VA OIG report emphasizes, accurate data on access, as well
as trends in demand and provider productivity will help provide care
that is timely and meets the healthcare needs of veterans. PVA also
encourages the VA to develop a mental health staffing model that
focuses on adequate staffing of mental health professionals throughout
the numerous systems of care within the VA. Again, this model should be
based on a patient needs assessment of veterans.
Another systemic issue that impedes patient wellness involving VA
mental healthcare is the lack of inpatient mental health services
readily available to veterans with catastrophic disabilities. PVA's
Medical Services team has found that inpatient care is not always
available to veterans with a spinal cord injury or disorder due to a
lack of accessible space, or the VA not being able to provide the
necessary physical and medical assistance that is often needed when a
veteran has a catastrophic injury or illness. When this is the case,
these veterans are referred to alternative methods of treatment that
may not always adequately meet their needs. The VA must work to provide
all veterans with access to mental health services when they seek help.
A physical disability or multiple complex health conditions should not
prevent veterans from receiving quality, effective mental healthcare.
PVA thanks Congress and VA for investing a great deal of resources
into improving mental health services in recent years. However, we
believe that more must be done to improve access. While PVA does not
believe that there is one definite solution to improving veterans'
access to VA mental health services, we do believe that a comprehensive
assessment of veterans needs and mental health staffing is a starting
point for identifying both strengths and weaknesses within the delivery
of mental healthcare, and improving the delivery of services to
veterans. All veterans regardless of generation should have access to
timely, quality mental health services.
PVA appreciates the continued oversight from this Committee on this
extremely important issue.
PVA would like to once again thank this Committee for the
opportunity to testify today, and we look forward to working with you
to improve VA mental health services for our veterans. I would be happy
to answer any questions that you might have. Thank you.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the
following information is provided regarding federal grants and
contracts.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$262,787.
Fiscal Year 2010
Court of Appeals for Veterans Claims, administered by the Legal
Services Corporation--National Veterans Legal Services Program--
$287,992.
Prepared Statement of Ralph Ibson,
Chairman Miller, Ranking Member Filner, and Members of the
Committee:
Thank you for conducting this important hearing and inviting
Wounded Warrior Project (WWP) to offer our perspective.
Mr. Chairman, you posed a critical question last June at a full
Committee hearing on mental health that asked, in essence, whether VA
is able to provide timely, effective, and accessible care to veterans
struggling with mental health conditions. In testifying at that
hearing, we observed that VA has instituted policies designed to
achieve those goals, but that the gap between VA mental-health policy
and practice can be wide. We have since learned much from both our
warriors and VA mental health staff as to how wide that gap is. Thank
you for your ongoing efforts to close that gap.
IG Findings: Symptoms of Deeper Problems
Late last month, VA's Inspector General released a hard-hitting
report that highlighted systemic flaws in both VA's scheduling of
patients for mental evaluations and appointments, and in the
reliability of its scheduling data. In our view, VA's scheduling
failures and inaccurate reporting on performance data are symptoms of
far deeper problems. In short, despite heroic efforts of dedicated
clinicians across the system, VA is not consistently meeting its
fundamental obligation to provide timely, effective mental healthcare
to OEF/OIF veterans who are struggling with combat-related mental
health conditions.
It has been our observation that the Department of Veterans Affairs
is quick to characterize many of the challenges it attempts to confront
as ``priorities.'' But we can think of few higher priorities for VA
than healing the psychic wounds of war.
Multiple surveys, including a survey last year of our own warriors,
\1\ have made it clear that many VA facilities lack sufficient mental
health and support staff, and many lack sufficient space to accommodate
the numbers who seek treatment. These and related problems have taken a
troubling toll. We've all seen the results: veterans facing long waits
for evaluation and treatment; veterans who need intense treatment being
seen too infrequently; and far too often, veterans getting treatment
that is simply inappropriate clinically, or dropping out of treatment
altogether.
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\1\ WWP asked Wounded Warriors to participate in a survey in
November 2011 that asked about their experiences with VA mental
healthcare. Of more than 935 respondents, 62% had tried to get mental
health treatment or counseling from a VA medical facility; some 2 in 5
of those indicated that they had difficulty getting that treatment. And
of those reporting that they had experienced difficulty, more than 40%
indicated that they did not receive treatment as a result. Getting
timely appointments was a frequent problem.
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For too long and as recently as during budget hearings earlier this
year, Department leaders assured the Veterans Affairs Committees--
despite strong evidence to the contrary--that VHA has all the mental
health staff it needs. In hearing after hearing, VHA officials have
testified to the large numbers of returning veterans with PTSD who had
been ``seen'' in VA facilities, as though being ``seen'' is the same as
receiving timely, effective treatment. VA testimony has described
multiple initiatives that have been mounted over a period of years, but
``new initiatives'' haven't necessarily translated into veterans
getting the help they needed. Late last year, the Department for the
first time acknowledged that real problems exist, and described
``action plans'' which in essence, promised further study rather than
specific action.
Squarely facing irrefutable documentation of deep problems and
unanswered questions regarding its plan to recruit 1900 additional
mental health staff and fill longstanding vacancies, VHA testified
recently to efforts currently underway. Appearing before the Senate
Veterans Affairs Committee last month, VHA representatives testified
that in addition to its plan to add staff, it (1) has convened a ``work
group'' related to scheduling, (2) is planning to implement an as yet
undefined mental health staffing model next fiscal year, (3) is
reviewing its data regarding patient access, and (4) is continuing a
process of facility site reviews. While we don't seek to denigrate
these efforts, the lack of specificity fails to constitute a real plan,
and certainly don't address what we see as underlying systemic
problems. Yet with no real remedy in place and mounting evidence that
veterans are falling through the cracks, VA's Under Secretary for
Health continues to urge veterans with mental health concerns to enroll
for VA care. \2\
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\2\ Department of Veterans Affairs press release, ``VA to Increase
Mental Health Staff by 1,900,'' (April 19, 2012), accessed on May 1,
2012 at http://www.va.gov/healthbenefits/
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We ask this Committee to press VA to make mental health a real,
ongoing top priority, and to ensure that it goes well beyond addressing
the broken scheduling system the IG identified. As one VA mental health
clinician described it to us--
``Getting someone in quickly for an initial appointment is
worthless if there is no treatment available following that
appointment.''
Our warriors certainly echo that view. But to understand even more
keenly the gravity and extent of those problems, WWP is currently
surveying VA mental health staff across the country to learn what
they're seeing at close hand. The survey \3\ is still underway and the
data we're sharing is only preliminary. We did not have an avenue to
distribute this survey to every VA mental health provider, but we
believe the data provide a helpful snapshot of the problems clinicians
are encountering daily. For example, with responses from VA staff in 17
of VA's 22 VISNs, 87% reported that their clinic or program lacks
adequate staffing to meet current demand. Two providers capsulized it
as follows:
\3\ Wounded Warrior Project, Survey of VA Mental Health Staff,
accessible at www.woundedwarriorproject.org/vasurvey
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``Understaffing is a huge problem . . . The mental health service
line has grown over the past several years in terms of veterans
enrolled, but has shrunk in terms of staff.'' ``VA in this area is
entirely overwhelmed and booked to capacity. The families and the
combat veterans are both suffering. Access to therapy on a timely basis
is non-existent.''
Among the most common reasons for understaffing, respondents (who
were invited to identify all applicable reasons) cited the following
problems at their facilities:
u administration policy against adding or filling positions (67%);
u increase in volume of veterans seen for mental healthcare (67%);
u funding constraints (63%);
u Human Resources' delays in recruiting/hiring (56%);
u greater intensity in patients' need for services (44%); and
u clinicians being detailed to other duties (43%).
To its credit, VA has at last acknowledged a staffing deficit. But
the lack of an operational staffing model raises real questions as to
how new staff positions will be allocated. And it's not clear that VA
clinicians themselves have any role in identifying staffing needs. As
one clinician described it,
``Staff at my facility have repeatedly been told that we are viewed
by the VISN as `overstaffed;' . . . I do not understand how we can be
viewed as overstaffed, given the clinical realities of caseload sizes,
waiting times for first appointments, and time between subsequent
appointments.''
We understand that VA Central Office is at last focused on mental
health staffing, but the reality on the ground certainly does not
inspire confidence in recent hiring practices. Citing the fact that it
has taken many months for the hiring process to be completed, one
clinician working in a VA mental health crisis program reported that
``my program was without a nurse practitioner for 11 months and we have
now been again without a nurse practitioner for 16 months.'' He
described these as ``ridiculous amounts of time for any clinic or team
to go without needed help,'' and observed that ``other staff burn out
and start looking elsewhere in the interim, and so the cycle seems to
go on and on.''
The implications of VA's staffing problems are stark. Some 80% of
survey respondents cited insufficient numbers of staff as the principal
factor in delaying veterans' access to needed mental healthcare.
Facility leadership appear to deal with staffing shortages in different
ways, but these shortages are clearly compromising quality of care, as
widely reflected in our survey responses. For example, 55% of
respondents reported that at their facility OEF/OIF patients were
either frequently or very frequently assigned to group therapy even
though individual therapy may have been more appropriate. And nearly
59% of respondents either disagreed or strongly disagreed with the
statement that they had leadership support to choose the most
appropriate treatment for their patients, including longer-term
psychotherapy.
Were VA able to hire 1900 additional staff and fill its 1500
existing vacancies, it would apparently confront other critical
shortages--from a basic need for space and privacy in which to provide
this sensitive kind of treatment, to having any support staff. As
survey-respondents put it,
``Let us not forget that space issues are significant as well. It's
hard for management to feel very compelled to hire additional staff
when they already have no idea where to put the staff they have. We
have had psychologists and social workers at this facility go literally
months without an office, relying on the daily absences of other staff
members to free up an office in which to see patients.''
``I have no waiting room, no on-site clerk, no one to schedule/
cancel appointments. I do it all and it takes a lot of time from direct
patient care.''
Impact on Veterans
Ultimately, it is critical to understand the impact these systemic
problems are having on veterans. Responding to our survey, VA mental
health staff shared the following observations:
``I have a patient who came very close to attempting suicide in
between appointments. I strongly believe that if I could meet with him
weekly, or even more on occasion, his suicidal ideation would have
decreased and he would be less likely to act on his thoughts.''
``One veteran whose appointment was cancelled several times at one
of our CBOC clinics ended up committing suicide.''
``Veterans who are ambivalent or anxious about therapy for problems
like PTSD need a fair amount of encouragement and contact in the
beginning if they are to engage optimally in treatment. I have seen
many veterans drop out of treatment, or relapse, or end up hospitalized
due to a crisis, due to time between contacts being too long.''
``Veterans have opted to utilize vet centers or private providers.
Those that continue to wait until their next appointment which could be
months, suffer in silence. Some veterans are afraid to speak up fearing
retaliation.''
``Effectively we have no mental health at our clinic. We are told
to tell Vets they need to go to the VA hospital for mental health.
However it is difficult for some because of travel distance . . . I
think there are a lot of vets who call or inquire about mental health
at our clinic, are told of lack of room, and then give up.''
``I am aware of several veterans who have attempted suicide, or who
have died by overdose . . . and believe that more time with clinicians
and easier access to programming may have changed things.''
``Even with two community based outpatient clinics, the catchment
area is so large that it is still very difficult for some patients to
access care AND in cases where a patient may be at high risk for
suicide, the outpatient clinics often cannot or will not accommodate
care due to it being a ``complicated case'' requiring care by the
`mother ship' [the VA medical center], so vets get NO care because they
are too debilitated to expend extra energy to get to the `mother ship.'
''
Improving the Culture of Caregiving
Finally, in setting out the array of systemic issues that
compromise the effort to provide veterans timely, effective mental
healthcare, it is important to consider the ``culture'' within which
care is provided. As one clinician described it succinctly,
``The reality is that the VA is a top-down organization that wants
strict obedience and does not want to hear about problems . . .
Consequently, I have little hope that there will be real improvement.
You will only see band-aids and more useless performance measures
designed to make management look good.''
This is not an isolated view. VA faces a real challenge as it
relates to the culture at many facilities, given at least the
perception that leadership employs a kind of command and control
model--issuing policy directives and setting performance standards--
without regard to whether facilities' clinical staff actually have the
means to carry them out, or whether they are really measures of--or
even reasonable proxies for--good care.
A clinician at a major VA tertiary-care facility put it even more
starkly:
``There is an environment of fear instigated by mental health
leadership. Staff are scared to bring patient care concerns to
leadership because of retaliation that happens frequently. Turnover is
high and mental health leadership explicitly tells clinicians that we
are replaceable.''
We commend VHA for conducting medical center site visits, and
including time in those visits to meet with mental health providers (as
schedules permit). It is not clear, though, how safe VA staff might
feel to share the honestly critical concerns that an anonymous survey
can elicit. VHA officials have been vague at best as to what those site
visits have revealed. But while our own survey is still ongoing, the
preliminary data suggest reason for real concern as it relates to an
often unhealthy work climate. Asked, for example, about factors staff
had experienced recently related to challenges in providing clinical
services, respondents (asked to identify all applicable challenges),
identified the following as among the greatest:
u experiencing high level of stress themselves (56%);
u feeling ethically compromised (50%); and
u considering leaving VA employment (44%).
Just as some staff perceive that they are not heard, one should
question the extent to which the veteran is heard. For example, VA has
been strongly promoting the use of particular modes of therapy for
treating PTSD that involve repeated intense exposures to their wartime
trauma. But, just as any patient would expect their doctor to respect a
decision to reject a recommended surgical intervention--even if that
surgery represents optimal, evidence-based treatment for the problem--a
veteran with PTSD should be afforded options. But that's not
necessarily the case, as some have reported. To illustrate----
``Even telling patients that the only therapy we can offer them
involves prolonged exposure [to the trauma they've experienced] sends
them elsewhere. These patients should not just be offered short term
treatment that may be too intense for them.''
``I know many unhappy clinical staff . . . related to requiring
them to provide [exposure-based therapies] whether appropriate or not,
and then having that be the end of the therapy.''
In that regard, VHA leaders seem so insistently focused on
evidence-based treatments that veterans' preferences can get lost. Last
year, for example, the Richmond VA Medical Center last year terminated
a group-therapy program over the strong objections of its participants
and defended the decision, asserting that the group-therapy didn't
constitute an evidence-based practice. VA Central Office officials'
rigid rejection of the veterans' position remains inexplicable. The
upshot, though, is that several of the group participants turned away
from any further VA treatment because of the broken trust they believe
they experienced.
Unfortunately, our warriors often perceive that VA medical
facilities don't offer them reasonable scheduling options. To
illustrate, numbers of our employee-survey respondents cited veterans'
concerns regarding this problem. The observations of two of who voiced
a similar perspective:
``I'm aware of a number of veterans who are trying to maintain jobs
or stay in school, and who have essentially been forced to choose
between treatment and those other obligations. This could be easily
ameliorated if our managers would agree to recent requests made by a
number of well-trained clinicians for flexible schedules. (Granting
these requests would also, incidentally, greatly improve the morale of
these therapists, whose personal reasons for wanting the change to a
flexible schedule are valid and are being dismissed; I know at least
one psychologist who will likely leave the VA because of this issue.)''
``Many patients have requested evening appointments because of
work/school schedules, and we cannot always accommodate them. Many
staff have requested alternative work schedules to accommodate patients
who request evening hours; however, mental health leadership at my
facility have a policy against approving alternative work schedules.''
It should go without saying that veterans' mental healthcare must
take account of patients' wishes. Indeed VA policy reflects that core
principle. \4\ But our concern again is with a system in which the gap
between policy and practice can seem like a chasm.
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\4\ Department of Veterans Affairs, VHA Handbook 1160.01, Uniform
Mental Health Services in VA medical facilities and clinics, (September
11, 2008), sec. 5.b.(2)(a).
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Needed: A New Paradigm for Transforming VA Mental Health Care
The problems that returning veterans--and dedicated VA mental
health clinicians--are encountering extend beyond gaining full
implementation of VA policy. In our view, the barriers that impede too
many OEF/OIF veterans from getting timely, effective mental healthcare
also make it critical that VA address several broader issues.
1. It is no longer reasonable, in our view, for the Department to
foster the belief that ``VA can do it all.'' The prevalence of war-
related mental health conditions among OEF/OIF veterans, the high
percentages of veterans either foregoing VA care or dropping out of
treatment, and the risks in their NOT getting needed treatment make it
imperative that VHA acknowledge the limitations of its own healthcare
system and seek out other partners. Limitations in VA mental health
staffing, space, and geography underscore that the Department cannot do
it all, and cannot go it alone. Institutional pride must give way to
engaging a broader community to lend support. It's time, in our view,
for VHA to reach out--to its medical school partners, to organizations
representing mental health professionals, to state and local
government, to the faith community and other communities--and state
clearly, ``We need your help in providing for the mental health needs
of returning warriors! We can't do it alone.'' As a bare minimum, VA
must employ community-based care options when it cannot provide wounded
warriors timely treatment.
2. In a very real sense, VHA operates two almost-parallel mental
health systems--one providing treatment through medical centers and
clinics, the other in Vet Centers. Our veterans are consistently
positive about their experience at Vet Centers, but with isolated
exceptions report problems in accessing treatment at VA medical centers
and clinics. Some 36% of those VA mental health staff who responded to
our recent survey effort reported that their facility either did not
have a close working relationship with the local Vet Center, or that
relationship was less than optimal. These two systems should be much
better coordinated, and should operate as though they are integral
parts of a single mental health system, but that is not the case today.
\5\ Moreover, VHA's acknowledgement of a need to increase staffing at
VA medical facilities begs the question of Vet Center staffing. Some
Vet Centers too are overwhelmed and require additional staffing, while
there are indications that some areas of the country need additional
sites. And as we testified last June, VA medical facilities have much
to learn from Vet Centers, particularly as it relates to providing
peer-support.
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\5\ VA's Uniform Mental Health Services Handbook, which ``defines
minimum clinical requirements for VHA Mental Health Services . . . that
must be provided'' addresses only what must be provided at each VA
medical center and clinic. It does not address Vet Centers.
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3. VA faces many challenges in remedying the problems we've
discussed--to include developing a reliable mental-health staffing
methodology, streamlining the clinician-hiring process, developing
mental-health performance requirements that measure patient outcomes
and cannot be ``gamed,'' and fostering a healthier work climate. The
Department has been attempting for some time, and with a relatively
small staff, to ``put out fires'' relating to veterans' mental health.
Without in any way minimizing the complexity of the issues and the hard
work dedicated staff have given these efforts, the gravity of the tasks
argues, in our view, for bolder steps than we have seen and for an
approach which is far less reactive. It is time, in our view, to move
beyond reliance on ad hoc work groups (whose members are likely pulled
from clinical care), and instead to enlist independent expertise
(whether through the Institute of Medicine or independent-expert
consultants) for needed help. Surely VHA can also more productively
enlist and engage its own mental health staff in cooperative problem-
solving at the facility level, and in doing so foster the trust and
confidence critical to a healthy workplace and to success in
recruitment and retention.
Thank you for your continued focus on the importance of timely
effective VA mental health services for our warriors.
I would be pleased to answer any questions you may have.
Statement For The Record
Hon. Tim S. McClain, President, Humana Government
Chairman Miller, Ranking Member Filner, and members of the
Committee:
Introduction
Thank you for the opportunity to submit a statement for the record
on the Department of Veterans Affairs' (VA) mental health staffing,
quality and quantity; a topic critical to the thousands of Veterans and
their families facing serious mental health issues. As mental health
issues among our Nation's Veterans and servicemembers continue to
dominate the headlines, VA faces the challenge of meeting this growing
demand for quality mental healthcare and services.
Humana Veterans Healthcare Services, Inc. (Humana Veterans), a part
of the Humana Government organization, has answered the call and is
helping VA to meet the mental health needs of our Veterans when the
Department is unable to provide the care at a VA facility. Through
contracts with VA, Humana Veterans provides access to quality non-VA
healthcare through two congressionally-mandated pilot programs--Project
HERO (Healthcare Effectiveness through Resource Optimization) and
Project ARCH (Access Received Closer to Home).
Last month, Secretary Shinseki announced VA's intent to hire 1,600
mental health clinicians and 300 support staff. As the Committee
examines the proper staffing levels of mental health providers at VA,
we urge the Committee to consider the existing contractual resources
such as Project HERO and ARCH, which are already available to Veterans
and can quickly be mobilized to help meet their mental health needs. An
understanding of all resources available to VA, including underutilized
non-VA and VA resources, will help this Committee and VA to make
informed decisions on the proper mental health staffing levels at the
Department.
Mental Healthcare Quality and Staffing
The quality of mental health providers certainly has a direct
impact on Veterans' health outcomes. The mental health providers in
Humana's network are fully credentialed and qualified to deliver a very
high level of care. When examining staffing quality and health
outcomes, care coordination is a critical element that should not be
overlooked. With Project HERO contract scheduled to end on September
30, 2012, VA is planning a follow-on national program referred to as
Patient Centered Community Care (PCCC). Because mental health is among
the planned services excluded from PCCC, this program will not result
in Veterans receiving patient-centric coordinated mental healthcare.
Exclusion of key services such as mental health goes against the very
concept of care coordination, and makes it impossible for Veterans to
fully realize the benefits of care coordination. Also, VA's decision to
exclude mental health from PCC is misguided, especially when research
clearly shows that physical issues often accompany mental conditions.
For example, Post Traumatic Stress Disorder (PTSD) is a mental health
condition that often coexists with Traumatic Brain Injury (TBI), which
is a physical condition. Last month the Substance Abuse and Mental
Health Services Administration (SAMHSA) issued a report that stated the
following:
Research has found a strong relationship between physical and
mental health. People with mental health illnesses are more likely to
have co-occurring physical health conditions, resulting in higher
healthcare costs and disability. Co-occurrence of mental and physical
health problems can increase healthcare utilization and complicate
treatment plans. \1\
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\1\ U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration (SAMHSA), National Survey on
Drug Use and Health. ``Physical Health Conditions Among Adults with
Mental Illness,'' April 5, 2012.
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The lack of care coordination is further exacerbated by VA's
apparent decision to remove the administrative functions from PCCC that
are associated with non-VA care authorizations, visits and treatment.
VA is in the process of implementing a national program called NVCC
(Non-VA Care Coordination), which requires the Department to invest
significant resources, both in staff and necessary tools, to build in-
house capacity to handle the ``back door'' administrative functions.
For example, this includes helping Veterans make and keep medical
appointments, ensuring the return of clinical information, and making
timely payments to non-VA providers. Humana Veterans is in the business
of providing cost-effective administrative services and has developed
an excellent personalized service model in Project HERO, which produces
excellent results through metrics reported every month to VA. VA
apparently intends to attempt to duplicate a large portion of the model
internally. VA intends to build internal functions that insurers and
health plans have as a core capability. VA should do what it does best
(i.e., providing excellent healthcare) and contract with commercial
companies for required administrative services, which is what they do
well. VA's proposed course moves them closer to becoming more like a
payor/insurance system similar to TRICARE and Medicare. Further, VA
must recognize that an unintended consequence of removing contractor-
provided administrative services from the proposed PCCC program
threatens the contractor's ability to maintain a provider network that
is responsive to VA's changing needs. It also means that VA will not be
able to obtain advantageous pricing, since the contractor cannot
negotiate a better price with their network providers in the absence of
a predictable minimum workload and without the ability to guarantee a
low no-show rate, and timely, predictable payments.
VA cannot ensure that Veterans receive high quality care if they
move forward with the current plans for PCCC, which excludes mental
health and other key administrative and care coordination functions.
Instead, Veterans will receive only fragmented care that is neither
effective, efficient nor timely, which is in effect the current Fee
system.
Long-Term Effects of Combat
Combat and exposure to combat condition, especially wounded, dead
and dying individuals, profoundly affects a servicemember's future
mental health status. A recently released research paper by the
Syracuse University Institute for Veterans and Military Families
includes the following findings:
Veterans exposed to combat experience the lingering mental health
effects of that trauma for decades after combat exposure; for many, the
effects are permanent. This research shows that the effects of combat
exposure are more pronounced for those whose service includes more
traumatic events, such as exposure to dead, dying, or wounded people.
Knowing this, our society can better predict the outcomes that these
veterans will experience over time and the VA can better target
resources and predict long-term resource demand.
Based on our Gulf War parameters, we estimate that the costs of
mental health declines to be between $87 and $318 per year for each
soldier with combat service and exposure to dead, dying, and wounded
people. \2\
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\2\ ``Combat Exposure and Mental Health: the Long-Term Effects
Among Vietnam and Gulf War Veterans,'' Daniel M. Gade, Ph.D. and
Jeffrey B. Wenger, Ph.D. Institute for Veterans and Military Families,
Research Brief, released May 4, 2012.
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Non-VA Mental Health Services Available
Humana serves Veterans in VISNs 8, 16, 20, and 23 through Project
HERO, and provides care to Veterans living in four out of the five
pilot sites for Project ARCH which includes Farmville, VA; Pratt, KS;
Flagstaff, AZ; and Billings MT. For both of these pilot programs,
Humana provides access to a competitively priced network of physicians,
institutions, and ancillary providers to supplement the VA healthcare
system while adhering to high quality and access to care standards.
Currently, we have the authority to provide mental healthcare to
Veterans living in any of the VISNs participating in HERO, but our
authority to provide such care is limited to Pratt, KS under Project
ARCH. Our robust network of mental health providers is comprised of
4,539 for HERO and 7 for the ARCH site at Pratt, KS. The geographic
distribution of these providers is such that Veterans can easily access
them by traveling an average of 14 miles for their care. VA's
utilization of these two programs for mental health referrals has been
low. For example, since Project HERO's inception in October 2007, we
have received a total of 1,096 mental health referrals through 30 April
2012. We began implementing Project ARCH in Pratt, KS on 28 August 2011
and to date, have received zero mental health referrals.
There is abundant research that point to the mental health staffing
shortage in our healthcare system. Thus, VA will likely face
recruitment and retention challenges for the newly announced 1,600
mental health providers. There is certain to be delays in identifying
qualified providers, and even when VA is able to do so, the bureaucracy
of the Federal personnel system will further delay the on-boarding of
the new hires. This could mean years before all 1,600 providers are
deployed in the VA healthcare system and available to treat Veterans.
VA should assess existing resources that can be deployed quickly. This
includes an assessment of the existing contracts that VA has in place
with community partners such as Projects HERO and ARCH, and tapping
these underutilized resources to provide timely mental healthcare for
Veterans. VA can also re-examine the pilot program's eligibility
criteria and the definition for the pilot sites, especially with ARCH,
which Congress intended to be a VISN-wide program. In addition, VA
should examine its current mental health workforce to determine ways to
best maximize the productivity and efficiency of the staff, which
requires proper metrics and incentives.
An informed decision on the proper staffing levels is only possible
if VA identifies and maximizes underutilized non-VA and VA resources.
Humana has a proven service model and stands ready to assist VA in
delivering to Veterans quality mental health services in a timely
manner. Humana Veterans has existing capacity to handle additional
mental health referrals under Projects ARCH and HERO and is committed
to further expanding our network, if needed, to properly accommodate
the referrals from VA.
Conclusion
VA must not miss an opportunity to implement real care coordination
of mental health and other services.
Improving the mental health and well-being of our Veterans is
certainly a daunting task; however, our society cannot and must not
fail the men and women who bravely served this Nation. No single entity
has the capacity to fully address the mental health needs of our
Veterans. This is a national problem and a local community problem. VA
cannot do this alone just as the communities across the Nation cannot
do it alone. Instead, it will require collaborative partnerships and
care coordination among all mental health assets. VA can begin by
assessing the partnerships it has in place under existing contracts and
programs such as HERO and ARCH. In addition, PCCC is an opportunity for
the VA to mobilize networks of mental health providers in the
communities where Veterans live. Rather than excluding mental health
and other services inherent in a care coordination program from
proposed PCCC model, VA should rethink their approach and infuse strong
care coordination elements into the program design to include medical
surgical, laboratory, mental health, and health & wellness elements. We
look forward to continuing and enhancing our collaboration with VA to
bring excellent mental health services to our Nation's heroes.
Thank you, Mr. Chairman, for the opportunity to submit this
statement for the record.
Thomas J. Berger, Ph.D., Executive Director, Veterans Health
Council, Vietnam Veterans of America
Chairman Miller, Ranking Member Filner and distinguished members of
the House Veterans' Affairs Committee, on behalf of President John
Rowan, our Board of Directors, and our membership, Vietnam Veterans of
America (VVA) thanks you for the opportunity to present our statement
for the record on ``VA Mental Health Care Staffing: Ensuring Quality
and Quantity''.
As has been already reported by various sources, the Inspector
General (IG) report of April 23, 2012, concluded that the VA does not
have a reliable or accurate method of determining whether they are
providing veterans timely access to mental healthcare services and that
the VA is unable to make informed decisions on how to improve the
provision of mental healthcare to veteran patients due to the lack of
meaningful access data. VVA finds this absolutely unacceptable
Veterans Health Administration policy requires that all first-time
patients requesting mental health services receive an initial
evaluation within 24 hours, and a comprehensive diagnostic appointment
within two weeks. For years now, VHA officials have claimed that 95
percent of its new patients were seen in that time frame. But the
recent IG report called those calculations confused and inaccurate. By
IG researchers' count, fewer than half of those patients were seen
within the 14-day requirement. The average wait for a full evaluation
among the rest was 50 days.
The report also sharply criticized VHA staffers for not following
proper scheduling procedures, further confusing the data collection.
For new patients, scheduling clerks frequently stated they used the
next available appointment slot as the desired appointment date for new
patients, thereby showing deceptively short wait times. For established
patients, medical providers scheduled return appointments based on
known availability, rather than the patient's clinical need. The report
found that the V.A.'s system for measuring waiting times for
evaluations ``had no real value'' because it measured how long it took
the department to conduct the evaluation, not how long the patient
waited to receive it. As a result, the report said, even if a patient
waited weeks for an appointment, the V.A. could say there was zero
waiting time if it completed the evaluation on the same day it was
conducted.
Although IG investigators also blamed some of the long wait times
on shortages in mental health staff throughout the department and noted
that from 2005 to 2010 mental health services increased their staff by
46 percent. However, according to the report ``VHA's mental healthcare
service staff still did not believe they had enough staff to handle the
increased workload and consistently see patients within 14 days of the
desired dates.'' These flaws in the VA's appointment system has for
example, led to an average wait time of 28 days for patients at the
Milwaukee VA Medical Center and over 80 days at the Spokane VA center
in Washington state. And in several extreme cases reported in the
media, lack of immediate access to mental health services has resulted
in veteran suicides.
Although the IG recommended, among other things, that the VA revise
its method of measuring waiting times and analyze its staffing levels
to ensure that it is able to abide by its own policies, it remains
unclear as to how this will be accomplished so that VA facility and
VISN directors can no longer ``game'' the system. Under Secretary for
Health, Dr. Robert A. Petzel, said in a letter to the IG that the VA
generally agreed with the recommendations and that it would initiate a
timeliness review of its entire medical system, not just the four
regions analyzed by the inspector general. Thus VVA is forced to ask
the questions: Precisely how will this be accomplished so as to finally
end this and other ``gaming the system'' practices that we know are
used in many (if not most) clinics around the country, and exactly what
productivity and performance measures will be utilized to determine
whether the VA's measurements and analyses are real and correct?
Furthermore, in July 2011, the Senate Committee on Veterans'
Affairs requested VA to conduct a survey that among other questions,
asked mental health professionals whether their medical center had
adequate mental health staff to meet current veteran demands for care;
71 percent responded their medical center did not have adequate numbers
of mental health staff. Now in May 2012 we hear of VA's plan to hire an
additional 1,900 mental health staff. VVA asks if there is or will be a
staffing analysis to determine if mental health staff vacancies
represent a systemic issue impeding the VA's ability to meet mental
health timeliness goals, and if so, will the VA develop a transparent
but accurate action plan to correct the impediments.
Clearly the VA mental health scheduling and staffing systems needs
a complete major overhaul.
VVA agrees with a statement from the Chair of the Senate Veteran
Affairs Committee who said earlier this spring: ``Getting our veterans
timely mental-healthcare can quite frankly often be the difference
between life and death.'' VVA also hopes that this HVAC Committee will
directly oversee VA's efforts to do so, and we offer our assistance.
Again, thank you for the opportunity to offer a statement for the
record on this important veterans' issue.