[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


       PRESCRIPTION MISMANAGEMENT AND THE RISK OF VETERAN SUICIDE

=======================================================================

                                HEARING

                               BEFORE THE
                               
              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, JUNE 10, 2015

                               __________

                           Serial No. 114-25

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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                    COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN M. KUSTER, New Hampshire, 
DAVID P. ROE, Tennessee                  Ranking Member
DAN BENISHEK, Michigan               BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas                KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana             TIMOTHY J. WALZ, Minnesota

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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unintentional errors or omissions. Such occurrences are inherent in the 
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further refined.
                            
                            C O N T E N T S

                              ----------                              

                        Wednesday, June 10, 2015

                                                                   Page

Prescription Mismanagement and the Risk of Veteran Suicide.......     1

                           OPENING STATEMENTS

Mike Coffman, Chairman...........................................     1
Ann Kuster, Ranking Member.......................................     2

                               WITNESSES

Carolyn Clancy, M.D., Interim Under Secretary for Health, 
  Department of Veterans Affairs.................................     7
    Prepared Statement...........................................    33

    Accompanied by:

        Mr. Michael Valentino, Chief Consultant, Pharmacy 
            Benefits Management Service, Veterans Health 
            Administration

    And

        Mr. Harold Kudler, M.D., Chief Consultant, Mental Health 
            Services, Veterans Health Administration

Mr. Randall Williamson, Director, Healthcare Issues, Government 
  Accountability Office..........................................    10
    Prepared Statement...........................................    48

Ms. Jacqueline Maffucci, Ph.D., Research Director, Iraq and 
  Afghanistan Veterans of America................................    11
    Prepared Statement...........................................    63

                        STATEMENT FOR THE RECORD

The American Legion..............................................    67
Deliverable......................................................    73

 
       PRESCRIPTION MISMANAGEMENT AND THE RISK OF VETERAN SUICIDE

                              ----------                              


                        Wednesday, June 10, 2015

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                   Washington, D.C.
    The subcommittee met, pursuant to call at 10:30 a.m., in 
Room 334, Cannon House Office Building, Hon. Mike Coffman 
[chairman of the subcommittee] presiding.
    Present:  Representatives Coffman, Lamborn, Roe, Benishek, 
Heulskamp, Kuster, O'Rourke, Rice, and Walz.
    Also Present: Representative Miller.

           OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN

    Mr. Coffman. Good morning. This hearing will come to order. 
I want to welcome everyone to today's hearing titled 
Prescription Mismanagement and the Risk of Veteran Suicide.
    Before we begin, I would like to ask unanimous consent that 
a statement from The American Legion be entered into the 
hearing record. Hearing no objection, so ordered.
    This hearing will examine the relationship between veterans 
prescribed medications as a result of their mental health and 
the increased suicide rate among veterans.
    In a report issued in November 2014, which included in part 
evidence uncovered by the O&I Subcommittee, GAO examined VA's 
data on veterans with major depressive disorder including the 
extent to which they were prescribed medications, the extent to 
which they received proper care, and whether VA monitored that 
care, and the information VA requires VAMCs to collect on 
veteran suicides.
    It is now clear that VA is not even aware of the population 
of veterans with major depressive disorder due to inappropriate 
coding by VA physicians. As a result, VA cannot determine if 
veterans are receiving care consistent with the clinical 
practice guidelines.
    These guidelines are crucial to the treatment of mental 
disorders as they are designed to provide the maximum relief 
from the debilitating symptoms associated with mental health. 
It is imperative that our veterans receive the proper care and 
follow-up when receiving mental healthcare, especially when 
they are being prescribed various medications.
    What has also become clear is that VA is receiving and 
reporting inaccurate and inconsistent data regarding veteran 
suicides. This severely impacts and limits the department's 
ability to accurately evaluate its suicide prevention efforts 
and identify trends in veteran suicides.
    Not only did the committee conduct a hearing in 2010 on 
this same issue, but since then, there have been countless 
media stories of veterans being over-medicated or experiencing 
adverse drug reactions and not receiving the proper care, the 
proper follow-up, or the proper monitoring, and the all too 
common result of suicide.
    One story told of a veteran who went into a hospital 
seeking care, but after being, quote, unquote, lost in the 
system ended up dying by suicide right in the facility. We will 
also hear other similarly tragic stories today that highlight 
the tremendous problems occurring with VA for years and 
continuing today with regard to treatment of veterans with 
mental health concerns, adequate oversight of treatment 
programs, and more importantly the actions taken to ensure 
veterans who are prescribed countless medications receive 
proper follow-up.
    Currently VA has approximately ten different programs 
dealing with prescription medication and suicide prevention 
issues, but it does not appear that any of these programs 
interact with one another. No one is talking to anyone else. 
How can we ensure that the veterans are getting the proper 
care, the proper follow-up, and the proper advice if the right 
hand doesn't know what the left hand is doing?
    I think it is more appropriate to say based on the 
statistics from the GAO report and the numerous media stories 
that VA is just throwing out a bunch of different ideas and 
programs hoping one of them will stick and they can claim they 
have solved the problem. This is unacceptable. We need to know 
exactly what VA is doing to change this pattern and what is it 
doing to improve protection of veterans.
    What is a real way forward? Who will be held accountable 
for mistakes that have already been made and have cost veterans 
their lives? Who will stand up and take responsibility for 
making a change? It is time for answers. It is time for change.
    With that, I now yield to Ranking Member Kuster for any 
opening remarks she may have.

         OPENING STATEMENT OF RANKING MEMBER ANN KUSTER

    Ms. Kuster. Thank you, Mr. Chairman.
    And good morning to our panel. Thank you for being with us.
    This morning, we are addressing a complex healthcare policy 
issue affecting veterans and over 100 million American adults. 
The statistics on veterans experiencing chronic pain are 
staggering. Over 50 percent of all veterans enrolled and 
receiving care at VA medical facilities experience chronic 
pain, with over a half a million veterans managing pain with 
prescribed opioids.
    As a Nation and certainly in my district and throughout the 
northeast, we face what can only be described as an opioid 
abuse epidemic. The Centers for Disease Control and Prevention 
has termed opioid abuse the worst drug addiction epidemic in 
the country's history, killing more people than heroin and 
crack cocaine.
    In addition to the issue of pain management and the 
problems of addiction, we must remember that many veterans who 
experience chronic pain also suffer from mental health 
disorders such as posttraumatic stress and traumatic brain 
injury. Therefore, it is vital that the VA has in place the 
proper oversight mechanisms to monitor the safe use of opioids 
for managing veterans' pain.
    I am particularly concerned about veterans at risk of self-
medication and addiction being prescribed opioids for pain 
management. We know from multiple inspector general and GAO 
reports that the VA has struggled to properly monitor 
prescribed opioids and the mental health of its patients. And I 
am concerned that a potential deadly mix of opioid use, mental 
health disorders, and lack of oversight is contributing to our 
high rate of veteran suicide.
    The newest Drug Enforcement Agency regulations that require 
veterans to see a clinician monthly for a refill of opioid pain 
medication creates an additional burden on veterans who have 
difficulty accessing care at VA medical facilities, leaving 
some veterans to suffer from extreme pain and experience opioid 
withdrawal symptoms when they are unable to schedule an 
appointment to refill.
    This hearing provides us with the opportunity to begin to 
seriously examine whether the benefits of managing veterans' 
pain with opioids is outweighed by the risk and side effects 
experienced by veterans and the VA healthcare system's struggle 
to properly monitor opioid use.
    During this hearing, I would like to hear from our 
witnesses how we can better address safe and effective 
treatment of veterans while ensuring that care management is 
not forgotten.
    I would like to discuss whether a higher level of informed 
consent is needed to ensure veterans and their families 
understand the risks and side effects before choosing to manage 
pain with opioids and whether the VA is properly coordinating 
mental health and suicide prevention programs with VA medical 
facility clinicians and employees responsible for monitoring 
patient opioid use.
    I am also interested in alternative pain management and as 
I get to my comments later, I will talk about what is happening 
at the White River Junction VA in bringing down the rate of 
opioid prescriptions and how we can help get ourselves out of 
this problem, out of this cycle and address the veterans, to 
serve their needs without putting them and their families at 
risk.
    And, finally, I would like to discuss what is being done to 
reduce long-term opioid use and treat the underlying conditions 
causing chronic pain so that veterans are able to live a better 
quality of life.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    I will introduce our witnesses in just one moment, but I 
ask that the witnesses stand and raise their right hand.
    [Witnesses sworn.]
    Mr. Coffman. Please be seated.
    I would like to recognize the Honorable Jeff Miller, 
Chairman of the full Veterans' Affairs Committee, who has 
joined us on the dais.
    Welcome, Chairman Miller. You have the floor.
    Mr. Miller. Thank you very much, Mr. Chairman.
    To the Ranking Member, Ms. Kuster, thank you for the good 
work that this subcommittee has been doing over the last 
several years.
    If I might, instead of giving a typical opening statement, 
I want to ask Ms. Clancy a couple questions because I need to 
move on to another appointment.
    And I believe, Dr. Clancy, that you have been made aware 
that I am going to be asking a couple of questions, albeit a 
little bit out of order. And I want to talk specifically about 
Bradley Stone.
    We know that he was seen by his VA psychiatrist a week 
prior to his commission of multiple murders and subsequently 
dying of suicide. He was on many, many prescription drugs and 
had alerted VA, as I understand it, to mental health and 
physical difficulties in the weeks leading up to the incident.
    But it appears that VA said he showed no signs of suicidal 
or homicidal ideations. And I would like to know how did VA 
come to that conclusion that the veteran was okay, and I say 
that in quotes, when he was reporting all of these feelings 
prior to the incident.
    Dr. Clancy. In general, people would come to that 
conclusion by asking the veteran a series of questions about 
were they having thoughts of harming themselves and so forth to 
get some assessment of suicide risk. So my conclusion, if the 
clinician said, would be that the veteran answered, gave 
negative responses to them.
    Mr. Miller. Okay. On the 24th of April of this year, I 
asked the department if it would confirm whether or not they 
had provided the full committee with all of the files related 
to Bradley Stone. To date, I have not received a response. So, 
again, I ask you, has VA provided this committee with all of 
the files on Bradley Stone?
    Dr. Clancy. I had been told that VA had provided the 
committee with the files with some redactions and had also 
provided--offered an in-camera review. And the redactions were 
about Social Security numbers and some information that was 
about sensitive details about the living family members of 
Bradley Stone and, again, offered to discuss that with the 
committee in camera.
    Mr. Miller. And, again, as I have stated in every single 
letter that I have sent to the department requesting 
information, an in-camera review is not acceptable. That may be 
what you want to provide us, but that is not at all acceptable. 
And so, you know, the staff has informed you and the department 
that I was going to ask particular questions.
    So, again, I ask you, has all of the information--and I 
would go back to I sent the secretary a letter on April 24th 
where I referred to Ms. Diana Rubens, Director of the Regional 
Office, on April 22nd saying that the Philadelphia Regional 
Office had provided everything related to Mr. Stone's file. Her 
response was unequivocally yes.
    And so I am taking from your comment today then everything 
that she provided to the central office, the central office has 
now provided to this committee?
    Dr. Clancy. Since I'm under oath, I'm going to be very 
careful. I don't--I can't speak for what Diana Rubens is 
telling you. I have been informed directly by our lawyers that 
we have provided this committee with all the records with the 
redactions that I mentioned before, again, Social Security 
numbers and some sensitive details about the living family 
members of Mr. Stone.
    Mr. Miller. Okay. I want to for the record, Mr. Chairman 
and Dr. Clancy, I know for a fact that VA has withheld hundreds 
of pages related to the Bradley Stone file. And so with that, I 
would say that we have requested all the documents every way we 
know how.
    So I will ask you one more time, can I expect the 
department to deliver the complete records by the end of this 
week?
    Dr. Clancy. I will take that back and I will verify what 
I've been told that we have given this committee everything 
except for redactions as I noted earlier.
    Mr. Miller. Okay. I can assure you it is not redacted. It 
is missing, completely missing.
    Dr. Clancy. I will bring that message back.
    Mr. Miller. We also expect you to deliver the behavioral 
health autopsy unredacted by the end of the week. And I have 
told VA and I will reiterate it again an in-camera review is 
not acceptable.
    And I ask will you commit that all the documents that I 
have requested will be provided by the end of this week?
    Dr. Clancy. The behavioral health autopsy is a unique 
feature of what we do at VA healthcare for veterans. Rather 
than having a private limited to the people at the facility, 
root cause analysis or deep dive of what happens when a veteran 
takes his or her own life, this is something that we have 
centralized so that we can learn across the system what kinds 
of factors might have precipitated the suicide, what could we 
have done differently or better, and it also involves a 
conversation with the family members of that veteran, none of 
whom have been told that we would be thoughtfully sharing their 
details with members of the committee.
    And we think that it will have a chilling effect on family 
members sharing sensitive details and are very, very 
uncomfortable with sharing the behavioral health autopsy.
    Mr. Miller. Thank you very much for that educational 
opportunity.
    I refer to you again the fact that we are the legislative 
branch. You are the executive branch. We have complete and 
constitutional oversight over the department and unredacted 
information or anything that is done within your department 
that you choose to withhold, we will subpoena it if necessary.
    Can I expect to have this information delivered by Friday?
    Dr. Clancy. I will take that back, Mr. Chairman.
    Mr. Miller. Thank you very much.
    And also, I would also like to add on a positive note I was 
in Cincinnati yesterday. I was in Dayton the day before. I want 
to thank you for the good job that we see being done at the 
facilities there. There has been a great change in Dayton in 
specifics. And I enjoyed the opportunity to spend a couple of 
hours with the people in Cincinnati.
    We do focus on a lot of the negative and the press likes to 
focus on that as well, but I want to commend you on some of the 
great things and I would hope that some of the good things 
specifically at Cincinnati would be shared throughout VHA and 
the rest of the department.
    Thank you very much.
    Dr. Clancy. Well, if I might for one second, Mr. Chairman, 
first thank you very much for that. I know how hard those 
people work.
    Cincinnati is actually the hub of expertise in intensive 
care for our system, so they actually provide remote assistance 
to----
    Mr. Miller. I had a chance to view it.
    Dr. Clancy. Did you?
    Mr. Miller. I sure did.
    Dr. Clancy. It's great. It really is.
    Mr. Miller. Thank you very much.
    Mr. Coffman. One point, Dr. Clancy. The VA has turned over 
behavioral health autopsies to this committee before.
    And so, Ranking Member Kuster.
    Ms. Kuster. Yes. I just wanted to say for the record as a 
healthcare attorney who has worked in this area for quite a 
long period of time in the realm of quality assurance and what 
the purpose of this type of quality assurance is about when you 
go back and look, it is intended for physicians and the medical 
team to grow and learn from these experiences.
    And I am concerned at the impression that might be left 
with veterans and their families, particularly the family 
members that have been through the trauma of a suicide, that 
this information would be treated confidentially because these 
hearings, as we know, are televised. It is a very public 
setting.
    And I think we should get to the bottom, but I don't want 
to do anything that would have a chilling effect on families 
that are sharing the most personal aspects. We already have 
such a strong stigma around mental health and about people 
seeking treatment. And I would be extremely concerned if we 
left the impression today that we are in some way digging into 
private affairs.
    If there is information about living family members that is 
not relevant, it could be extremely personal. And I guess I 
just don't understand why we couldn't do that in a private 
setting or in a redacted way, why this committee would be 
trying to determine--and I am not speaking as to if you believe 
there are documents that have not been provided. That is a 
separate matter.
    But I know that under our statutes in the state, 
confidential information in this quality assurance process is 
confidential and it is not to be shared. And the purpose of 
that is so that people will come forward. So that is my only 
comment.
    Mr. Coffman. Mr. Chairman.
    Mr. Miller. Thank you very much, and I appreciate the 
expertise that you bring to this committee and to the 
subcommittee.
    And you can rest assured, and I think you know that what we 
are trying to do is to hold people accountable. We are not 
trying to release any information that is personally 
identifiable. This is also a murder situation. It is a suicide 
which is very difficult, but a murder suicide.
    And so I believe that while the VA is going through and 
doing this and attempting to find out where things may have 
broken down, the fact is we have gotten this information before 
from other incidents. This one is particularly grievous because 
of the murders that took place.
    And I remind you that we are a federal body, not a state 
body. We are bound by the United States Constitution of which 
we are given oversight of the executive branch and we are not 
bound by many of the laws, the HIPAA laws and other information 
to receive that information for us to be able to do our 
oversight in this. And it is not political.
    Again, we are trying to get to the bottom of a very tragic 
event and we are trying to partner with the VA as well. And 
right now they are not being as open as they should be. There 
are documents that are clearly missing from the file, documents 
that I believe are damning documents and would put VA in a very 
negative light.
    I understand that. But you can't remove those documents 
from the file just because it makes you look bad. And that is 
what we are trying to getting at at this point.
    But, again, I thank every member of this subcommittee for 
the job that you have been doing and look forward to continuing 
the good works.
    But thank you, Ms. Kuster.
    Mr. Coffman. Thank you, Mr. Chairman.
    I ask that all other members waive their opening remarks as 
per the committee's custom. Hearing no objection, so ordered.
    With that, I would now like to introduce our panel. On the 
panel, we have Dr. Carolyn Clancy, Interim Under Secretary for 
Health for the Department of Veterans Affairs; Mr. Michael 
Valentino, Chief Consultant, Pharmacy Benefits Management 
Service, Veterans Health Administration; Dr. Harold Kudler, 
Chief Consultant, Mental Health Services, Veterans Health 
Administration; Mr. Randall Williamson, Director of GAO's 
Health Care Team; and Dr. Jacqueline Maffucci, Research 
Director for the Iraq and Afghanistan Veterans of America.
    Dr. Clancy, you are now recognized for five minutes.

   STATEMENTS OF CAROLYN CLANCY, INTERIM UNDER SECRETARY FOR 
  HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY 
    MICHAEL VALENTINO, CHIEF CONSULTANT, PHARMACY BENEFITS 
   MANAGEMENT SERVICE, VETERANS HEALTH ADMINISTRATION, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS, and HAROLD KUDLER, CHIEF 
      CONSULTANT, MENTAL HEALTH SERVICES, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                  STATEMENT OF CAROLYN CLANCY

    Dr. Clancy. Good morning, Mr. Chairman Coffman, Ranking 
Member Kuster, members of the committee. Thank you for the 
opportunity to discuss the overuse of medication in the 
provision of mental healthcare to veterans, particularly for 
those at risk of suicide.
    One of our most important priorities at VA is to keep our 
veteran patients free from harm at all times. I am deeply 
saddened by the tragic outcome involving a veteran. So to 
families here today or watching this hearing who've lost a 
loved one, I want to express my sorrow and regret for your 
loss. I appreciate your sharing your experiences with us and 
will--we will honor your loved ones by learning from those 
experiences and improving care for veterans in the future.
    We acknowledge up front that we have more work to do to 
reduce opioid use, meeting the increasing demands for mental 
healthcare, and prevent suicides. And we've taken significant 
actions to improve these areas in order to better serve 
veterans.
    As Ranking Member Kuster said, chronic pain is a national 
public health problem. It affects about a third of the Nation's 
adult population and about half of veterans from recent 
conflicts.
    As a result, a number of veterans and Americans rely on 
opioids for pain control and they can be effective for a while 
until the side effects become quite worrisome. And often mixed 
with other drugs, they can have additional adverse, unintended 
effects.
    As you noted, Mr. Chairman, we've adopted a number of 
initiatives and tools to advance our goal of safe and effective 
pain management, making data about rates and doses of opioids 
as well as the other medications a veteran is taking visible at 
the network facility and most recently at the individual 
clinician level.
    Starting this July 1, we will be expanding on a very 
successful pilot of an approach called academic detailing which 
essentially consists of one-on-one coaching for every single 
clinician prescriber in our system.
    And in addition to information about effective use of 
medications, it also--this approach also works with clinicians 
to have the difficult conversations with veterans to help them 
try other alternatives for pain management and so forth.
    I think it's important to note that many of the veterans we 
serve come to us as they're transitioning from military service 
on opioids and other medications and abrupt discontinuation is 
not possible or actually practical. But we have to continue to 
taper these doses.
    We've seen some successes and as you might expect, those 
with the least amount of problems have tended to do better than 
those who are experiencing more severe pain.
    Suicide among veterans is very complex and tragic. Those of 
us who have lost a loved one to suicide know the deep and 
lasting pain. We've worked diligently with our scientific 
partners to understand suicides among those veterans receiving 
VA care and among all veterans across the Nation.
    We know that treatment works. We've identified many 
positive outcomes for veterans who are receiving our care. For 
example, the rate of repeat attempts at suicide among veterans 
who have attempted to take their own lives has declined quite a 
bit for veterans enrolled in our system.
    Between 1999 and 2010, the suicide rate among middle-aged 
male veterans who use our system fell by 31 percent, at the 
same time that the suicide rate for middle-aged men who are not 
veterans or who are veterans who don't use our system actually 
rose during that time period.
    The rate of suicide among women veterans is higher than 
other women in the general public, but women veterans who use 
our system actually are less likely to die from suicide when 
compared to other women veterans.
    As you know, our research has allowed us to estimate that 
about 22 veterans die by suicide every day. What's less well-
known is that 17 of those 22 do not receive treatment for care 
within the VA system. And I worry that some of the 17 are 
actually seen in our system and are fearful about raising 
mental health concerns because of concerns about the stigma or 
privacy.
    Suicide prevention efforts have to extend to veterans who 
may not seek assistance. And any veteran who needs help can 
come to any point of entry of care in our system and will be 
seen that day.
    We've also increased targeted outreach efforts to veterans 
in communities throughout the country and we've made it easier 
for anyone to call the veterans crisis line. And in response to 
many suggestions from stakeholders, in the very near future, 
you'll be able to do that when you call one of our facilities 
directly. You won't have to hang up and call the line. You can 
just hit a number on the phone and that will directly transfer 
you.
    I really want to express my appreciation to the Congress 
for the Clay Hunt Act and its passage which will expand our 
capabilities to help veterans. So thank you for that.
    The importance of mental health treatments I don't think 
can be overstated. About 20 years ago in this country, we 
simply did not recognize how important a challenge mental 
healthcare is for all Americans.
    At VA, we have embraced the problems that veterans from 
returning conflicts brought to us, whether that's various 
mental health problems, posttraumatic stress, traumatic brain 
injuries, and so forth. And in doing so, we have had to blaze 
some trails.
    We have had to go ahead of what is going on in the rest of 
U.S. healthcare where utilization of mental health has been 
pretty dramatically curtailed or utilization controlled over 
the years. So that meant that we have had to work with public 
and private science partners to build the basic science, the 
epidemiological data, and population health expertise.
    We have learned a lot. We've made significant gains and 
seen the successes of treating mental health problems, but we 
have so much to do to dispel the stigma linked to mental health 
issues.
    You know, it wasn't that long ago that cancer inspired that 
kind of whispering. People didn't talk about it out loud 
because of fears and misinformation. And, frankly, we hope with 
your help and the help of many partners that soon we'll be able 
to eliminate that fear and misinformation associated with 
seeking mental healthcare. And in the meantime, we're focusing 
on creating an atmosphere of trust and privacy.
    I want to just close by saying that we're committed to 
improving our existing programs, taking every available action 
to create new opportunities, and most importantly improving the 
quality of life for veterans. We're compassionately committed 
to serve those who have served. We're proud to have this honor 
and privilege.
    And we're prepared to answer your questions and look 
forward to working with you until we get this right. Thank you.

    [The prepared statement of Carolyn Clancy appears in the 
Appendix]

    Mr. Coffman. Thank you, Dr. Clancy.
    Mr. Williamson, you are now recognized for five minutes.

                STATEMENT OF RANDALL WILLIAMSON

    Mr. Williamson. Good morning, Mr. Chairman and Ranking 
Member Kuster. I am pleased to be here today to discuss our 
November 2014 report on VHA's efforts to monitor veterans with 
major depressive disorder referred to as MDD who were 
prescribed one or more antidepressants.
    MDD is a major risk factor for suicide among veterans. It 
is a particularly debilitating mental illness often associated 
with severe depression and reduced quality of life. Also, I 
will discuss certain aspects of VHA's suicide prevention 
program.
    Specifically I will discuss the incidences of MDD among 
veterans treated by VA, the extent that VAMC clinicians 
prescribe antidepressants to veterans with MDD and monitor 
anti-depressant use, and data VAMCs are collecting and 
reporting on veteran suicides to inform VHA's suicide 
prevention efforts.
    VHA data show that about ten percent of the veterans 
receiving VA healthcare were diagnosed with MDD and 94 percent 
of those veterans with MDD were prescribed one or more 
antidepressants. However, the estimate of veterans with MDD may 
be low because in reviewing a sample of medical records from 
selected VAMCs, we found that VAMCs did not always correctly 
report and record confirmed MDD diagnosis among veterans.
    At six VAMCs, we reviewed a sample of veterans with MDD 
that were prescribed one or more antidepressants and found that 
they did not always receive recommended care for three 
important recommendations in the clinical practice guideline 
referred to as CPG that VA has--VHA has established to guide 
its clinicians in treating MDD.
    For example, although the CPG recommends that a veteran's 
depressive symptoms be assessed using a standardized assessment 
tool at four to six weeks after initiation of antidepressant 
treatment, we found that for 26 of the 30 veterans in our 
sample VA clinicians did not use this assessment tool at or 
used it within the specified time frame.
    While not mandatory for VAMC clinicians, CPG 
recommendations are based on evidence-based data from clinical 
trials, research, and other proven and reliable sources and are 
meant to enhance outcomes for veterans with MDD.
    Moreover, VHA does not have a process at any level to 
systematically monitor the extent that VAMC clinicians deviate 
from CPG recommendations. With little, if any, visibility over 
whether the care provided is consistent with the CPG, VA is 
unable to ensure that deviations from recommended care are 
identified and evaluated and whether appropriate actions are 
taken to mitigate potential significant risk to veterans.
    Finally, we found that demographic and clinical data in 
VA's--VA--VAMCs collect on veteran suicides to better inform 
VHA's suicide prevention program were often incomplete and 
inaccurate.
    For example, as part of VA's behavioral health autopsy 
program, which I'll refer to as BHAP, VAMCs collect data on 
veteran suicides such as date of death, number of mental health 
visits, and last VA contact. We examined 63 BHAP reports from 
five VAMCs and found that about two-thirds of them contained 
inaccurate and incomplete information.
    Moreover, this situation is further exacerbated because 
BHAP reports prepared by VAMCs are generally not reviewed at 
any level within VHA for accuracy, completeness, or 
consistency.
    Lack of accurate and complete BHAP data limit opportunities 
to learn from past veteran suicides and ultimately diminish 
efforts to develop effective methods and approaches to enhance 
suicide prevention activities and reduce veteran suicides.
    VA has made good progress in addressing the six--six 
recommendations to improve weaknesses we noted in our report. 
In the six months since our report was issued, one 
recommendation has been fully implemented and several others 
are very close to being fully implemented.
    More globally, this work illustrates once again a 
continuing pattern of VHA's noncompliance with its own policies 
and established procedures, unclear guidance, inaccurate data, 
and poor oversight. These are among the same factors that led 
GAO to include VHA on its high-risk list.
    Until VA instills a culture throughout the organization 
that holds its staff and managers truly accountable for 
effectively performing their responsibilities, appropriately 
overseeing outcomes, and achieving a recognized standard of 
excellence, VA--VHA will continue to fall short of performing 
the highest quality and cost-effective care to our Nation's 
veterans.
    This concludes my opening remarks.

    [The prepared statement of Randall Williamson appears in 
the Appendix]

    Mr. Coffman. Thank you, Mr. Williamson, for your remarks.
    Dr. Maffucci, did I say that right?
    Ms. Maffucci. Yes, you did. Thank you.
    Mr. Coffman. Thank you.
    And you are now recognized for five minutes.

                STATEMENT OF JACQUELINE MAFFUCCI

    Ms. Maffucci. Chairman Coffman, Ranking Member Kuster, and 
distinguished members of the subcommittee, on behalf of Iraq 
and Afghanistan Veterans of America and our nearly 400,000 
members and supporters, thank you for the opportunity to share 
our views and recommendations on prescription management and 
the potential risk of veteran suicide.
    In 2014, IAVA launched its campaign to combat suicide. In 
February with your help, we celebrated the signing of the Clay 
Hunt SAV Act into law. This was a first step on a long road to 
address the challenges of combating suicide among our 
servicemembers and veterans.
    The issue that we're here to talk about today is complex 
because it encompasses two topics, providing care for veterans 
seeking relief from chronic pain, mental injuries, and other 
conditions, and recognizing the potential for misuse and abuse 
of these powerful drugs. And while these drugs are extremely 
powerful, they can also be extremely effective for a veteran 
who has not found relief elsewhere.
    A 2011 report estimates that chronic pain affects 
approximately 100 million American adults and this number is 
growing. Given the last 14 years of conflict and the very 
physical daily demands on our troops, we've seen a similar 
trend among servicemembers and veterans. Over 60 percent the 
Iraq and Afghanistan veterans seeking VA medical care seek care 
for musculoskeletal ailments and this is the most common 
category for disability compensation. Nearly 60 percent seek 
care for mental injury.
    Within IAVA's own community, two of three respondents to 
our member survey reported experiencing chronic pain as a 
result of their service. One in five reported using 
prescription opioid medications, one in three using anti-
anxiety or antidepressant medications.
    Among this newest generation of veterans, medical 
advancements have allowed for higher survival rates from 
complex injuries, but this also increases the likelihood for 
lifelong impacts of nerve and skeletal damage. Treatment of 
pain in these instances can be even more complex because co-
occurrence with other conditions like depression, anxiety, PTSD 
or TBI may limit treatment options.
    For clinicians, assessing pain and devising a management 
strategy can be very difficult as well, particularly given that 
knowledge in this field is still growing. Primary care 
physicians who see the bulk of patients with chronic pain 
report that they feel under-prepared to treat these patients 
due to lack of training. This includes VHA providers who were 
surveyed in 2013.
    Adding to the challenge are studies showing that untreated 
pain can actually put an individual at higher risk for suicide 
and, yet, we also know that prescription medications can result 
in strong addictions and provide a means for suicide attempts.
    The VA reports that over half of all nonfatal suicide 
events among veterans results from over--overdose or 
intentional poisoning. This highlights the challenges that 
clinicians face when treating patients with complex injuries 
and demonstrates the importance of comprehensive, integrated 
pain management.
    While the VA has moved the needle forward investing in 
research on pain, publishing an evidence-based clinical 
practice guideline, implementing an opioid safety initiative, 
and introducing a stepped case pain management system, more 
remains to be done.
    With approximately 22 veterans dying by suicide every day 
and more attempting suicide, reducing instances of over-
medication and limiting access to powerful prescription 
medications must be included in a comprehensive approach to 
addressing this issue.
    A recent study showed that while patients receiving opioid 
therapy are at an increased risk for attempting suicide, 
following some of the VA's clinical practice guidelines reduced 
this significantly. This shows the critical need not only for 
these guidelines, but full implementation of those guidelines.
    VA's 2009 directive on pain management which outlines the 
stepped care approach to pain expired in October of 2014. While 
it expired in date only and the policy remains active, IAVA is 
discouraged that updating this important policy has not been 
prioritized. We urge the VA to prioritize this and--and fully 
implement it at all VA facilities.
    IAVA would also like to emphasize the importance of 
minimizing the risk of overdose and over-medication through 
formulary take-back programs and prescription drug monitoring 
programs.
    Last year, an important change to DEA regulation expanded 
authorization for drug drop-off sites. This change gave VA the 
ability to stand up drug take-back programs in their hospitals 
and this is critical to limiting the possibility of misuse and 
abuse of powerful--powerful prescription drugs, yet no action 
has been taken.
    And while the VA is working to fully implement its 
participation in state prescription drug monitoring programs, 
full implementation remains to be seen and we urge the VA to--
to prioritize this as well.
    Too often we hear the stories of veterans who are 
prescribed what seems like an--an assortment of anti-psychotic 
drugs and/or opioids with very little oversight or follow-up 
and, yet, we also hear stories of veterans with enormous pain 
and doctors who won't consider their request for a stronger 
medication to manage this pain. These are tough challenges and 
IAVA remains committed to working with the VA and Congress to 
address them.
    Again, thank you for the opportunity to offer our views on 
this important topic. We look forward to continuing to work 
with each of you, your staff, and this committee in this 
critical year ahead. Thank you for your time and attention.

    [The prepared statement of Jacqueline Maffucci appears in 
the Appendix]

    Mr. Coffman. Thank you, Doctor. I deeply appreciate your 
testimony.
    Thanks to the witnesses.
    Dr. Clancy, according to a GAO report, VA deviated from 
recommended guidelines in most all of the 30 veterans' cases 
reviewed by not assessing antidepressant treatment properly.
    In your opinion, is policy simply ignored or is there just 
a lack of oversight by leadership?
    Dr. Clancy. So first I want to say that we regard the GAO 
recommendations, feedback as very important, a gift, if you 
will, to help us get better. I'm not sure that any guideline 
written on planet Earth should be followed a hundred percent of 
the time. Many doctors think of them as tools, not rules, 
because there will be patients with unique circumstances that 
don't fit perfectly.
    In terms of the follow-up assessment, I think that is 
important and we need to do a better job. We will be looking to 
see whether that is a feature of the fact that we had--we're 
having access problems and it was hard to get people back in or 
whether we weren't just on the ball. But that is a very 
important feature.
    Mr. Coffman. Dr. Clancy, in our case reviews, we found 
veterans who died of drug toxicity who reported hallucinations 
and subsequently died by suicide and reported homicidal 
thoughts.
    Are these the improved outcomes you are referring to?
    Dr. Clancy. No, they're not, Mr. Chairman.
    Mr. Coffman. Dr. Clancy, in response to the GAO report, VA 
noted that it would conduct chart reviews and develop a plan to 
determine and address the factors contributing to coding 
variances. This was to be completed by March 2015.
    Has this been completed?
    Dr. Clancy. It is in progress. We are not completed yet. I 
will also add to that that in addition to that, I have been 
meeting inspired both by the GAO report and other feedback with 
Dr. Kudler and a couple of the other national mental health 
leaders in our system to try to figure out who are the veterans 
who we think are struggling the most with mental health 
disorders that we should be targeting to make sure that they 
are getting the best possible care.
    Mr. Coffman. Thank you, Dr. Clancy.
    When do you think that report is going to be done?
    Dr. Clancy. I would have to double check on when we 
committed to having the recommendations done.
    Mr. Coffman. VA has stated it would examine associations 
between treatment practices and indicators of recovery or 
adverse outcomes for veterans being treated with 
antidepressants. The target date of completion was also March 
2015.
    Has this been completed?
    Dr. Clancy. I believe that it has. I'd have to double check 
my notes here. Here we are.
    Mr. Coffman. Well, can you get a copy of it to the 
committee?
    Dr. Clancy. Yes, absolutely. We'll submit that.
    Mr. Coffman. And roughly 63 percent of the behavioral 
health autopsies reviewed by GAO, critical data was missing.
    Is this inaccurate reporting based on incompetence or is it 
to intentionally keep central office in the dark?
    Dr. Clancy. I have no reason whatsoever to suspect it's to 
keep central office in the dark. As I understand it, this 
program was transitioned from doing root cause analyses at 
individual facilities to a centralized repository about two 
years ago.
    And as you might expect, training reviewers and people who 
are doing the interviews and collecting the data, to collect 
that data consistently and accurately took some time and, 
frankly, some iteration, excuse me, to make sure that we were 
getting it right.
    Dr. Kudler, do you want to add to that?
    Dr. Kudler. Yes. At the time the GAO was--oh, pardon me. At 
the time the GAO was conducting this study, the behavioral 
health autopsy program was just being launched. The forms were 
new. They were in need of refinement. They've been continuously 
refined as has the training of the suicide prevention 
coordinators, 300 of them across the country at over 150 
facilities who fill them out.
    There were questions about, well, what data goes where and 
how do you count this or where do you go with that. That's now 
been addressed through training and upgrading of our manuals. 
We're now reviewing all of these centrally at the national 
level.
    We've also created software that crosswalks these to 
another suicide prevention tracking system, the SPAN system, so 
that we can make sure we're accurately looking at these from 
multiple perspectives.
    So the system is continuously improving and it's progressed 
a great deal since the original report. And we will continue--
continue to work on it.
    Mr. Coffman. Dr. Clancy, this subcommittee has requested 
the behavioral health autopsies for numerous veterans who have 
died by suicide and in all cases except one of Kalisha Holmes, 
VA has stated that this information is confidential, 
privileged, et cetera, so it cannot be released to us.
    If this is true, why was the report for Ms. Holmes released 
to the committee?
    Dr. Clancy. I would have to take that question for the 
record. I would say in general, the behavioral health autopsy 
reports--I think the Ranking Member Kuster described this more 
clearly than I could. This is part of quality assurance where 
you want the most forthright kind of input and observations. 
And if people think that this is going to be disclosed, we will 
not get input that is that forthright.
    Mr. Coffman. Well, I think we are very concerned about the 
fate of our veterans and this subcommittee and the committee as 
a whole has an oversight responsibility for your operation. And 
we can't do that oversight operation and making policy that is 
best for our veterans if you don't fulfill your obligation and 
submit that information when requested to the Congress.
    Ranking Member Kuster.
    Ms. Kuster. Thank you very much, Mr. Chair.
    And thank you to all of our witnesses and particularly Dr. 
Maffucci.
    I really appreciate you being here and sharing with us the 
recent experience of the veterans returning from, as you 
mentioned, 14 years of conflict and that the injuries are much 
more complex. I mean, the good news is people are surviving, 
but the difficulty is that, as you say, they have chronic 
lifelong issues.
    I want to focus in on how we move forward. I share the 
concerns that have been expressed about the data and making 
sure that we are getting at the heart of the issue here. But I 
am very interested.
    As I mentioned, I had a meeting with the team up at White 
River Junction facility and there is some cutting-edge 
research, and I will talk to the chair about perhaps bringing 
in some witnesses to share that, but particularly the opioid 
safety initiative. And a couple of different things and 
whichever is the appropriate witness.
    One is getting at the heart of what is causing the pain. My 
husband has chronic pain and many, many years of back pain and 
various medications and come to find out what he needed was a 
hip replacement. It wasn't about his back at all. And now he 
lives pain free with yoga and stretching and exercise and such.
    So I would like to find out what is being done to get at 
the crux of what is causing the pain. Secondly, setting a goal 
of reducing opioid use and working with practitioners to bring 
down the opioid use and particularly emphasizing patient 
education, close monitoring.
    They talked about actual drug testing because in our area, 
selling these opioids on the market, what happens sometimes is 
people will not use the medication themself and they can 
determine that through frequent drug testing which, as you can 
imagine, is not popular with the patients but necessary, and 
then alternative medicine, acupuncture. I mentioned yoga, 
massage, exercise.
    So if you could comment on this opioid safety initiative. 
How far has that gone? How widely has it been--is it in use and 
what can we do to help move that forward?
    Dr. Clancy. So thank you. Those are all terrific questions. 
I'm going to start and then turn to Mr. Valentino.
    Like the case with depression, we do have a clinical 
practice guideline that we developed with colleagues from the 
Department of Defense on the management of chronic pain. That 
was published in 2010. It will--as of September of this year, 
it will be updated which is about the frequency you'd want to 
update these guidelines. And we will be having input from 
veterans and family members.
    The guideline does include urine drug testing periodically. 
And we have, as I mentioned probably too quickly in my opening 
statement, made in a series of steps that I would--the umbrella 
of which I would refer to as the opioid safety initiative made 
data about prescribing patterns at the network level, the 
facility level, and most recently at the individual clinician 
level available and visible so that clinicians can actually see 
what has this patient been on over time, what other drugs are 
they on and so forth.
    Getting to the root of the problem I think is incredibly 
important. I'd be happy to submit for the record to brief 
anyone any time about some of the exciting research we have in 
process because I think it's very important.
    I think there's a lot we need to learn in two areas. One is 
what are the predictors of veterans who or anyone who's likely 
to use opioids for a short time and go down the path of using 
them on a regular basis because if we knew then, that's where 
we would target a lot of efforts.
    The second is which veterans are most likely to respond to 
alternative treatments, to non-narcotic medications and so 
forth. We--as I said, we have some research going on in that 
area and have a lot more to learn.
    Mike, do you want to add to that?
    Mr. Valentino. Yes. Thank you.
    So this--the opioid safety program is just shy of two years 
old. And we've had to build it from--from the ground up. And as 
Dr. Clancy mentioned, it's been very iterative. So initially we 
focused on this data collection aggregation to identify 
outlier--potential outlier VISNs. So we focused on those, asked 
for corrective action plans.
    The next iteration was to continue to focus on VISNs, but 
drill down to VA facilities which we did identify outliers, 
asked for corrective action plans. We know this is working 
because 17 medical centers originally identified have now 
fallen off the list.
    We are poised right now at this moment and we--we've built 
the tools and we're--we're validating them for accuracy to 
drill down to the individual provider and patient level. This 
is very complex as you might guess. Someone may show up in data 
as an outlier, but maybe they're a pain management specialist. 
Maybe they treat cancer pain. Maybe there are other situations 
where you would expect this.
    So we have to make sure we get it right so there's 
confidence in the tool, but we've had really, really good 
results. I'll just name--I'll just go through some of the 
metrics.
    Since we began, we have 110,000 fewer patients receiving 
any kind of opioid short-term or long-term; 34,000 patients 
receiving opioids and benzodiazepines together which is a known 
risk; 75,000 more patients have had a urine drug screen who are 
long-term opioids, as you mentioned, because that is definitely 
an opportunity for--for diversion and we want to make sure 
patients are taking it.
    We have 92,000 fewer patients on long-term opioid therapy 
which we define as longer than 90 days. We also have begun to 
look at the totality of opioid, the opioid burden. So there are 
many opioid drugs, but you have to sort of boil those down to a 
common denominator, morphine equivalent daily doses. And we now 
have----
    Ms. Kuster. Mr. Valentino, I am sorry. My time is up. I am 
very interested----
    Mr. Valentino. Okay.
    Ms. Kuster [continuing]. In what you have to say, but my 
colleagues need their turn as well. So thank you so much and we 
can take that on the record.
    Mr. Coffman. Mr. Lamborn, Colorado.
    And let's see if we can not try and run the clock out on 
some of these answers.
    Mr. Lamborn. Well, I would like to thank the chairman for 
bringing this important issue to light.
    Unfortunately, it comes too late for one of my Colorado 
Springs families. I would like to tell you the story of Noah, a 
former marine who served with honor in Iraq in 2009 and 
Afghanistan in 2011. I won't use his last name, but his parents 
have offered the use of his picture, so if I could just show 
you Noah's picture.
    After leaving the marine corps, Noah began work on a 
business degree at the University of Colorado at Colorado 
Springs and started his own online business based out of 
Colorado Springs.
    Noah comes from a military family, his dad having honorably 
served for 23 years. Noah chose to put off college so he could 
serve this great Nation. Unfortunately, his parents are 
appalled by the care that their son didn't receive from the VA. 
They believe their son would still be alive had he received 
better care.
    Noah was diagnosed with PTSD and received a 50 percent 
disability due to PTSD. On April 2nd of this year, he went to 
the Colorado Springs VA clinic where medical notes from his 
visit state that he had suicidal thoughts or suicidal ideation 
specifically. Noah was prescribed a psychotropic drug, 
Venlafaxine, and sent on his way.
    Now, we don't know at this time what this drug did or 
didn't do, but we know this. He was not referred for suicide 
prevention. He was not offered counseling and there was no 
follow-up from the VA. He went missing the evening of May 4th 
and was found dead from an apparent suicide May 12th of this 
year, a month ago.
    As you can imagine, his family is devastated. They are 
asking a lot of serious questions, so, Dr. Clancy, I would like 
to ask you several questions on their behalf.
    Why was their son who had been documented with having 
suicidal thoughts or ideation not referred to suicide 
prevention? Why wasn't there follow-up from the VA and why 
wasn't he offered counseling?
    Dr. Clancy. I will look into this personally, Mr. 
Congressman. That's heartbreaking. I can't even imagine what 
this--I can imagine, but I know it's horrendous what his family 
is going through. The picture was worth many, many words as 
someone who did so much for this country. And I will look into 
that and get back to you on these and to the family.
    Mr. Lamborn. Would one of the other witnesses have any 
response to my questions, to the family's questions?
    Dr. Kudler. You know, as a psychiatrist, as somebody who's 
treated veterans in clinics for 30 years, it's hard to 
understand the report that we're given and, yet, these seem to 
be the facts that are available. We have to look into it.
    My first thought is that I want to make sure this family 
has been reached out to directly and that we have a chance to 
collect this information. As I say, we've created a system. A 
system can be cold and inhuman, but we need to have a real sit 
down with them and understand everything that happened from 
their point of view, questions that they have which may torture 
them, and we will work with them to do that.
    Mr. Lamborn. Okay. Thank you both.
    Mr. Chairman, thank you for having this hearing and I yield 
back the balance of my time.
    Mr. Coffman. Mr. O'Rourke, Texas.
    Mr. O'Rourke. Thank you.
    Dr. Clancy, a question to which I would like to receive a 
quick, direct answer. We are touting reduced prescriptions of 
opioids as though perhaps that in itself is success.
    What I would like to know are the consequences. I have 
veterans that show up to my town hall meetings saying that 
their prescriptions were cut off without notice, without 
transition, without ramping down.
    How many of those who are no longer receiving prescriptions 
from the VA are now using heroin or other street drugs?
    Dr. Clancy. We can't know that without--with the 
information that we have. It is something we worry about 
constantly. So----
    Mr. O'Rourke. Let me tell you another problem. This is just 
hopefully helpful feedback for you from El Paso. Others who 
have prescriptions are required to renew those prescriptions 
after a monthly visit with their prescriber. They are unable to 
get the appointment in El Paso to see the prescriber, so they 
cannot get the prescription renewed. So they go without or they 
go with something that they shouldn't have that perhaps they 
buy on the street. And at a minimum, they are suffering. And in 
some cases, I would connect that suffering to suicides that we 
see in El Paso.
    I would also like to give you the following feedback. As I 
shared with you when I met with you on Monday, the May 15th 
access report from the VA shows that El Paso is ranked 157 out 
of 158 for mental healthcare access. We have 115 mental 
healthcare positions approved for El Paso. Only 87 of those are 
filled, leaving a 24 percent vacancy rate.
    Your predecessor, when we would relay anecdotal information 
that I was hearing from veterans, told me we were seeing 
everybody within 14 days. As you know, we did our own survey 
and El Paso found that more than one-third of veterans could 
not get a mental healthcare appointment, not in 14 days, not in 
a month, just not ever.
    That situation, because we are surveying the veterans again 
right now and we are receiving the responses back, has not 
improved in the year that we have had new leadership there. 
This should be for you a five-alarm fire.
    I have met with the widows and the mothers of suicides in 
El Paso far too often and I am continuing to do that. And I 
just did the last time that I was home in El Paso.
    As you know, for whatever reason, the VA has been unable to 
solve this issue and to treat it as a priority that it should 
be and to turn around El Paso. I am glad to hear that there are 
good things happening in other parts of the country, but 
everything that I do and view is through the prism of the 
veterans that I serve in El Paso.
    You know that we have a proposal from the community in El 
Paso to address this. I want your commitment that you are going 
to work with us because the community has come forward in the 
vacuum of VA leadership and action and will and resources to do 
the right thing.
    I will do whatever it takes to work with you and your team 
and the secretary to get this implemented, but this is a crisis 
that has deadly repercussions for the veterans that we all 
serve in El Paso.
    And I want to make sure because we didn't take it seriously 
over the last year because our statistics and our vacancy and 
our position relative to mental health access is actually worse 
than it was a year go, I want your commitment that you are 
going to work with me to resolve this, that it is a crisis for 
you, that it is urgent for you, and that we are going to turn 
this around.
    Dr. Clancy. You have my full unwavering commitment. We were 
very impressed with your reaching out and bringing in various 
members of the El Paso community to work with us. And I want to 
thank you for your support of our employees during what was a 
different kind of tragedy at the El Paso facility several 
months ago, something that cut to the heart of clinicians 
across the country, but particularly to those serving veterans 
in El Paso. You have my full commitment.
    Mr. O'Rourke. Thank you.
    I yield back.
    [Disturbance in hearing room.]
    Mr. Coffman. All right, sir. I am sorry. You are out of 
order. You are out of order. Thank you.
    Dr. Benishek, Michigan.
    Dr. Benishek. Thank you, Mr. Chairman.
    Well, I want to associate myself with the comments of Mr. 
O'Rourke for one thing and that is I have seen this as well is 
that the goal seems to be cutting down the amount of narcotics. 
And the same circumstances happen in my district, too, where 
people have just had their prescriptions cut off with no 
alternative treatment. Figure it out. It has been a real 
problem.
    There are a couple of specifics I want to get to after that 
and that is something Dr. Kudler said and then something Mr. 
Williamson said. And Mr. Williamson said there is not that 
much--there doesn't seem to be that much follow-up on this, the 
behavioral health autopsy program or we are learning moving 
forward.
    Can you remind me what you said in your testimony, Mr. 
Williamson, because it seemed like----
    Mr. Williamson. We were talking about----
    Dr. Benishek [continuing]. You were contradicting what Dr. 
Kudler said.
    Mr. Williamson. I was talking about oversight. VA conducts 
very little over the suicide prevention of that program at the 
local or the national level to see whether data were accurate 
and complete.
    Dr. Benishek. Right, right. Now, Dr. Kudler, you said that 
you are doing oversight and Mr. Williamson said the GAO says 
you are not. So what is exactly going on?
    Dr. Kudler. The difference is the two years that have 
passed since this report was written. I'm not questioning the 
report at all. In fact, I find the report helpful as a real 
spur to do more.
    Dr. Benishek. All right.
    Dr. Kudler. At this point, we are making a difference in 
this. We've developed programs to address----
    Dr. Benishek. Could you show me the results of the 
oversight that you have done in the last two years? Could you 
get that to me, you know, within a reasonable period of time, 
like a month?
    Mr. Williamson. That's--that's not quite the way it is, I 
think. I think there is still--to respond to our 
recommendations on oversight, I don't think VA has completed 
those yet. It's not the two or three-year lag at all. I think 
what we're talking about there have been some changes made. 
There's now a box checked on the--on the behavioral autopsy 
report that indicates that oversight has been done, but we know 
that hasn't----
    Dr. Benishek. That is all there is is a box you are saying, 
right?
    Mr. Williamson. Well, that's one of the things. And--and 
they--they are revising guidelines and so on. They are making 
progress. I'm not going to--but it's not been completed to our 
understanding.
    Dr. Benishek. I am not going to give you another chance, 
Dr. Kudler. Sorry.
    But, Dr. Clancy, you said something in your testimony that 
was very important to me and that is this seems so simple, but 
the fact is that people who have an idea that they want to hurt 
themselves have to hang up and dial another 800 number when 
they are calling into the VA. And you spontaneously said that 
you are going to have that fixed and be able to just, you know, 
hit a key and make that work.
    So what I want to know is when. Can you give me a date when 
that all happens that I can call the number and see if it is 
actually working?
    Dr. Clancy. Absolute----
    Dr. Benishek. When is that going to happen?
    Dr. Clancy. Absolutely by November or December. One of the 
things that we have been working very closely with the 
veterans' crisis line----
    Dr. Benishek. Great. No.
    Dr. Clancy. We just want to make sure----
    Dr. Benishek. I don't want you to go on about what 
happened.
    Dr. Clancy [continuing]. That we don't overstress that 
system when we do it.
    Dr. Benishek. I just want to have a date so that if it is 
not there by November or December----
    Dr. Clancy. Yes.
    Dr. Benishek [continuing]. Because I completely agree with 
the guy that stood up here in the back and was out of order in 
that, you know, it is just great to keep hearing that you are 
going to all do work, but from where I sit, you know, the 
actual accomplishment of the job does not seem to be happening.
    So I just----
    Dr. Clancy. No, I hear that.
    Dr. Benishek [continuing]. I will be back to talk to you in 
January and hopefully that I have called those places and there 
actually is a number I can hit because, I mean, I got people 
calling me all the time.
    Dr. Clancy. I'll be checking before you will.
    Dr. Benishek. This is ridiculous.
    Dr. Clancy. But, yes.
    Dr. Benishek. All right. With that, I think I will yield 
back the remainder of my time. Thank you, Mr. Chairman.
    Mr. Coffman. Thank you, Dr. Benishek.
    Mr. Walz of Minnesota.
    Mr. Walz. Thank you to the chairman.
    And thank you all for being here today.
    And I, too, would like to hit on this, the OSI that was 
implemented in Minneapolis. And we followed this closely since 
October 2013 and we are getting the results. But I think my 
colleagues, I would associate with them.
    And I know this is nothing new to all of you that we saw a 
dramatic increase in calls to our office after it was 
implemented which I think probably is somewhat expected, but I 
think the lack of maybe being there or the alternative. And I 
say this very clearly. This issue of mental health parity, 
mental health treatment certainly is societal-wide.
    I am very proud of the work that this committee has 
started, a small first step on Clay Hunt, but it is going to be 
the broader issue.
    And on the opiate issue, this Nation has vacillated back 
and forth from over-prescribing to under-prescribing and trying 
to find this as the research gets it. So I hear that.
    I guess my concern and the frustration, and you hear 
authentic frustration from veterans, whether it be here or all 
the time, this pain management thing is a tough one, tough, 
tough, tough. It is tough and I always say this, but I think it 
is important for context. I represent the Mayo Clinic area, so 
these are folks dealing with this also on a very big issue.
    But I was very proud back in 2008. One of the first bills I 
was able to move through was the Military Pain Care Act and 
Veterans Pain Care Act. And out of that came the VHA's pain 
directive 2009-053. And what it was is we put together through 
IOM the stepped care pain model which is the old standard, the 
best practice; is that correct?
    Dr. Clancy. Yes.
    Mr. Walz. Okay. And I won't go through all of it that is 
here, but what I would say is is that it had a five-year span 
on it. I wanted to go further, but this is the nature of how we 
do legislation. It expired in 2014 before it was fully 
implemented. It did not get reauthorized.
    But when we were out in Toma on this issue, Dr. Clancy, you 
responded, and this was on March 30th, that the VA doesn't need 
us to do it, that you can put it in yourself. And I said that 
is wonderful. Let's do it. And I followed up with a written 
letter and I don't expect to be a high-maintenance person, but 
I have heard nothing on my specific question.
    So the frustration lies in this was seven years ago, we 
were dealing with pain management. Seven years ago, we 
implemented best practices. Seven years ago, the VA started but 
didn't fully implement it. Eight months ago, it expired. Three 
months ago, I asked about it.
    And I hate the exchanges that we continue to have. I hate 
the pattern of communication that we now have because it does 
not bode well for our veterans. It does not fit. In fact, it is 
very irritating.
    So I don't set you up to get up because I wanted to start 
and preface this that I understand the challenge of this issue. 
I understand the deep societal issues. I understand the 
positives we are making and the pluses and minuses. The 
frustration lies more in that this might not have been the fix, 
but why didn't we do it? Why aren't we?
    Dr. Clancy. It has been done. It is still being reviewed 
internally. And I will be honest and say this is an issue that 
the GAO highlighted in putting us on their high-risk list. And 
we have got to get better at the process and updating of our 
policies and directives. But the pain directive has been 
updated. All policies----
    Mr. Walz. Who knows that?
    Dr. Clancy. Yes?
    Mr. Walz. Who knows that? Would the author of the bill not 
be someone who would need to know that?
    Dr. Clancy. Well, we're going to tell you as soon as we 
have reviewed it and made sure that we have gotten consensus 
and we haven't missed any details. And I apologize. I have not 
personally seen your letter, but I will make sure that I do see 
it before the day is over.
    Mr. Walz. Part of this is, and I go back to that, and, 
again, I don't expect to be high man, you got other priorities 
to get on here, but this is one of the issues we have struggled 
with is this very thing. Our job is tasked to do this.
    We think we had a pretty good--not us. We built a great 
coalition from private companies like Boston Scientific to 
working with your talented people in this. We got a good piece 
of legislation on it. We are trying to communicate to implement 
it and we are left in a no man's land where we don't know what 
to think.
    I don't like going out and hammering on you that we haven't 
heard from it yet, but this is important stuff. And there are 
some things and I encourage my colleagues to look at this. The 
things I hear the ranking member asking to put in, she is 
intuitively clicking into this. That is in the stepped care 
pain management. The things that you are hearing from Dr. 
Benishek are in the stepped care. And if we just get it out 
there, get it implemented, make it best practices, make it SOP, 
it would be there.
    So, again, I encourage you in many cases if you are doing 
something right, let us know and talk about it, communicate 
with us, see us as partners in helping our veterans, so the 
frustration you hear both here and out in our districts is 
reduced. So we will look forward to the follow-up.
    And I yield back.
    Mr. Coffman. Thank you, Mr. Walz.
    Dr. Roe, Tennessee.
    Dr. Roe. Thank you, Mr. Chairman.
    And just a couple of things. One on data collection. And 
certainly when you draw or produce inadequate data, you draw 
inadequate results. And the results may not be accurate at all. 
And it is extremely important in healthcare to get the data 
right because we are going to draw conclusions based on this 
many patients did this and this many patients did that while 
the outcome--I mean, I have been involved in those clinical 
studies for years.
    And when you put BS in, you get BS out. And so that is sort 
of what it looks like has happened right here. And that is 
being a little crude, but that is absolutely what it looks like 
you have done.
    And Mr. Williamson has pointed out, I mean, you have got 
half of the BHAP templates were incomplete or inaccurate. You 
draw bad conclusions from that. You can't help but do it. So I 
think until you get the data right, you are never going to 
know. You are going to have one--and, Dr. Clancy, you are 
right. What works for one patient may not work for another.
    And the ranking member certainly has pointed out there are 
many alternative therapies and what works. And Dr. Murphy whom 
I am sure you know continually complains about when he is at 
DoD and has a patient stable and then they are separated from 
the military and they go to the VA, there is a different 
formulary there, so they then stop all of what he has taken 
forever to get the patient stable on and they are now on 
something else.
    So I think that is something that needs to be addressed. He 
was very adamant about that he sees it a lot since he is still 
in clinical practice.
    And I, too, with Dr. Benishek want to associate myself. I 
think the outburst that you heard was just frustration from 
probably a veteran who has either tried to get in or couldn't. 
And Mr. O'Rourke has every right to be frustrated when he has 
people lined up outside his office talking about not being able 
to get in the VA.
    And let me share why that is frustrating to me. I have been 
here six years and change on this committee and we have 
increased the budget 74 percent. It is not money. It is 
management. And it is not the amount of money that we are 
spending on our veterans. There is plenty of money out there to 
spend. And I don't understand why the system isn't functioning 
better.
    Any comments on that because, Mr. Williamson, I think you 
pointed out in your testimony poor oversight? Why is that? No 
accountability. What happens to someone when we find out they 
are just not following it? Apparently nothing. So I know there 
are outcomes. You mentioned all of those things.
    Mr. Williamson.
    Mr. Williamson. So your question is directed at oversight?
    Dr. Roe. Yes, sir.
    Mr. Williamson. Yes. There's a lot of reasons why oversight 
doesn't happen. And VA does not have the data perform to 
rigorous oversight.
    I don't think there's any willful motive on VA's part. I 
think it's just that oversight is missing especially at the 
local level. At that level, accountability is missing; 
supervisors are not holding employees accountable for doing 
their jobs correctly.
    Dr. Roe. But that seems basic to doing your job to me. I 
mean, to hold someone accountable for their job, I mean, that 
is not rocket science. You are not doing your job, so what 
happens when you don't do your job? Do you lose your job or 
what happens?
    Mr. Williamson. I'm not sure I'm the right one to answer 
that, but in an idealistic world, I would think you would lose 
your job if you are not performing. We should be held 
accountable for the quality of the work that we do. When we 
don't do it well, we get feedback. First of all, we should be 
given expectations, then we get feedback and hopefully 
corrective action after that. And that's basically business 
101--it's common.
    Dr. Clancy. So, Dr. Roe, if I might, I want to say that to 
you and your colleagues we share your frustration. And I want 
to salute my colleague, Dr. Kudler, who is working with others 
to try, yes, so when people who don't do their job should be 
held accountable if, in fact, we have given them the resources 
and the capacity to do that job. You can't hold somebody 
accountable if there are no appointments and no ability to see 
a patient in follow-up.
    Dr. Roe. But Mr. O'Rourke pointed out that there are 20 
something people, jobs available right now. We claim we have a 
job problem.
    Dr. Clancy. Yes.
    Dr. Roe. There are 24 people that need a job in El Paso, 
Texas and there is money there to fund it. So why aren't those 
positions filled?
    Dr. Clancy. We have tried a lot of varieties of ways to 
recruit people. Mr. O'Rourke came in with a group of partners 
from the community. And I think I'm very much looking forward 
and he has my full commitment to looking at that proposal to 
see how we can be working----
    Dr. Roe. And VA is not making----
    Dr. Clancy [continuing]. With them more effectively.
    Dr. Roe [continuing]. It hard for those veterans to leave 
that system and go to these private practitioners. It is with 
the veteran's choice card or with a non-VA care because we find 
that sometimes. It is just so hard with all the rules they have 
to get, it takes forever for someone to get an appointment.
    And one last thing. I know my time is expired. But how long 
does it take to change a phone number to get--why does it take 
six months to have some--when you call--and I know how 
frustrated I get when I call. Punch two for this and three for 
that. It makes me want to throw my phone away.
    How hard is it to do when someone is contemplating suicide 
to have a phone change to where they go straight to a person, a 
human being----
    Dr. Clancy. We wanted to make----
    Dr. Roe [continuing]. On the other end?
    Dr. Clancy. We want to make sure that we don't overstress 
the people who are taking the calls, one of whom recently took 
their own life. As you can imagine, that is a very, very 
stressful job. So that's the reason we're just testing it first 
in about 20 different facilities this summer. And we'll then 
roll it out full steam this fall.
    Dr. Roe. That may be stressful and I am very sorry for that 
family, but it is very stressful on the other end. That is why 
they are making the call.
    Dr. Clancy. No, I understand that completely. And we--we 
want to make sure that when you do hit that one number or 
whatever the number will be that, in fact, it connects you 
directly to a counselor because the only thing worse than not 
having it is doing it then.
    And I do have to say that the issue of transitioning 
servicemembers over to VA, they continue on the drugs that they 
were getting in the service. We've gone over this with Dr. 
Woodson at the Defense----
    Dr. Roe. I will ask Dr. Murphy today again when I see him 
on the House floor. He is under a different impression. So I 
will have him check.
    Dr. Clancy. Well, and I would be happy to follow-up with 
him as well because if we've missed something in our surveys of 
veterans, we want to know about that and fix it.
    Mr. Coffman. Ms. Rice, New York.
    Ms. Rice. Thank you, Mr. Chairman.
    I mean, I hate to say that maybe the stress for the poor 
operators comes from the fact that they know that they are not 
going to have the support from the VA in getting the callers 
the help that they need.
    I would like to take a minute to recognize the work that is 
being done in my home state in a VISN that covers the Bronx and 
Manhattan. They specifically reject the prescribe first, 
diagnose later treatment philosophy that I think is all too 
often adopted by the VA. They have taken again what shouldn't 
be a revolutionary approach to pain management, but it is. They 
actually believe that the first thing you do is diagnose the 
patient before developing a path of treatment. And instead of 
prescribing opiates as the default treatment for veterans 
suffering from pain--and I understand that doctors when a 
patient comes and presents with real pain, you want to take 
away the pain. I get that that is the doctor's mode of 
reaction.
    But this facility is using alternative approaches such as 
acupuncture and exercises to relieve pain. And what we have 
seen is veterans who undergo these treatments experience a 
relief from pain without the harmful effects of addictive 
narcotics. The Bronx VA's outstanding approach to pain 
treatment should become the norm at all VA facilities 
nationwide.
    My question is to you, Dr. Clancy. What is the VA's version 
to alternative forms of treatment like meditation, acupuncture, 
and exercise?
    Dr. Clancy. First of all, let me say I completely share 
your enthusiasm for what I believe it's VISN 3 is doing.
    Ms. Rice. Yes.
    Dr. Clancy. And I have spoken to those folks. It's 
wonderful. And we have many thousands of veterans actually 
using alternative forms of therapy. So there is no aversion 
whatsoever.
    For veterans who are already getting opiates like other 
Americans and some of whom come to us from active duty on those 
same medications, the path forward is going to be different. 
It's not starting from day one. So I love what they're doing in 
New York.
    And I have spoken with many veterans and have actually 
begun to think about how we might use their stories to help 
those who are struggling to get off opioids and try 
alternatives. Many of the veterans who take opioids would like 
not to, but they'd like to kind of wake up and it would all be 
okay. The journey there is not so easy.
    So we actually have to----
    Ms. Rice. Because we have a system here that you know 
works. And I think it was one of my colleagues who told the 
story about Noah and clearly he was just prescribed drugs. He 
was not given any follow-up, any alternative, any, you know, 
therapy, anything like that.
    The doctor who is in charge of VISN 3, Dr. Klingbeil, she 
made a statement that I thought was very accurate. She said 
that to be on opiates is to be trapped in a cycle of poor 
function and poor pain control. And that is what we need to get 
away from.
    And I am just imploring you. It is not rocket science. They 
get it right there. Just export it throughout the rest of the 
country.
    One other thing that I wanted to talk about is a bill that 
I happen to be a proud cosponsor of that is put forth by our 
colleague, Ron Kind from Wisconsin. It is H.R. 1628, the 
Veterans Pain Management Improvement Act, which would establish 
a pain management board within each VISN to better handle 
treatment plans for patients with complex clinical pain. They 
would incorporate doctors, patients, family members into the 
decision-making process for a veteran's course of treatment.
    Has the VHA taken the ideas in this bill under advisement?
    Dr. Clancy. Yes. Representative Kind asked us for our 
comments and I told him he had my personal full thread of 
support which may be different than the department's support. 
But I can't think of anyone who would--I can't think of any 
reason we would not support that fully.
    It was really inspired by that that in updating our 
clinical practice guideline I wanted to make sure that we had 
input from veterans and families in doing just that. And I told 
him that. I think that's--because as heartbreaking as some of 
the experiences of the veterans are are the experiences of 
families who raise their hands and said I'm worried about my 
son, daughter, spouse, whatever, and didn't feel----
    Ms. Rice. It is a family issue. It is not even just a 
serviceperson issue. It is----
    Dr. Clancy. Yes.
    Ms. Rice [continuing]. An entire family issue. And I don't 
think that we want to be a Nation that says to our brave men 
and women who fight for us----
    Dr. Clancy. I agree.
    Ms. Rice [continuing]. And come back so damaged and so 
injured that we are going to do our best to keep you in a 
catatonic state for the rest of your life as a pain management 
therapy. That just cannot be where we come down on this.
    So I am begging you to do everything that you can to look 
at what they are doing in VISN 3 and export it throughout the 
rest of the country. It is not rocket science.
    Thank you very much, Mr. Chairman.
    Mr. Coffman. Thank you.
    I think if I was going to sum up this hearing with the 
Veterans Health Administration, it would simply be that drugs 
are a shortcut. They are a shortcut to doing the right thing. 
They are a shortcut to doing the therapies that are really 
required to treat our veterans both mentally and physically in 
terms of management and in terms of those suffering from 
depressive disorders. And I think that that is disconcerting 
and it is unfair and hurtful to the men and women who have made 
tremendous sacrifices for this country in uniform.
    And one question that I have is, how many physiologists or 
rehabilitation physicians does the Veterans Administration 
have, Dr. Clancy?
    Dr. Clancy. I would have to take that for the record, Mr. 
Chairman.
    Mr. Coffman. Well, I've got the number of about 40.
    Dr. Clancy. And I'll get back to you.
    Mr. Coffman. I've got the number of about 40. So, I mean, 
therein lies part of the problem. Those are the people central 
when it comes to pain management and, yet, we are shortchanging 
that because, again, the easy thing to do is to drug somebody, 
drug them not to feel pain, drug them to get them up in the 
morning, drug them so they can go to sleep at night.
    And I think when we look at the suicide rates of our 
veterans, that is reflective of what the Veterans 
Administration is doing in terms of having drug reliant 
therapies again as a shortcut for doing the right thing.
    Dr. Maffucci----
    Dr. Maffucci.
    Mr. Coffman. Maffucci. Okay. I got it right now?
    Dr. Maffucci. Yes.
    Mr. Coffman. And are you a veteran yourself?
    Dr. Maffucci. I am not. I'm a neuroscientist by training 
and prior to IAVA worked for the Pentagon on behavioral health 
issues with the Army Suicide Prevention Task Force and other--
other programs.
    Mr. Coffman. Well, I want to thank you for your work on 
behalf of the men and women who served this country.
    What is your view about--I mean, do you believe that, in 
fact, the over-prescription of drugs is a shortcut?
    Dr. Maffucci. I think this is a really complex question to 
ask because if you look at the history of--of clinician 
education, medications have always kind of been at the 
forefront, particularly with pain management.
    As a neuroscientist, I can tell you the research is still 
very young in understanding how pain manifests, how it 
manifests in individuals. Every individual experiences it 
differently. And because of that, we also don't have a lot of 
great treatment options.
    However, having said that, there is a lot of research 
coming out right now that really supports this idea of 
integrated management of pain using alternative and 
complementary medicines. There is--there are some--spinal cord 
stimulation is a new technology that's out there.
    And IAVA actually has a member veteran who was addicted to 
opioids, was a chronic pain sufferer and was able to get off of 
those drugs and through spinal cord stimulation and through 
alternative practices lives a much better life now as a result.
    But these are all very new technologies. Doctors don't know 
about them. They're not using them. And so clinician education 
is so, so critical to redefining how clinicians look at pain 
management.
    Mr. Coffman. Well, I think you would agree, though, that 
drugs should not be the first course of action? They should be 
the last course of action?
    Dr. Maffucci. Absolutely. I think drugs are--drugs are one 
option of many and they might be necessary, but they shouldn't 
be the--the end all be all. They need to be a part of a 
comprehensive plan.
    Mr. Coffman. Mr. Williamson, how would you view in terms of 
the principal modalities or treatment, whether for 
psychotherapy or for pain management? From what we are seeing 
here in terms of testimony, it seems to be kind of the first 
and preferred method of treatment tends to be drug therapy.
    Mr. Williamson. Well, I'm not a clinician and I'm really 
not qualified to answer that. But GAO will be looking of the 
opioid program, later this year. So I'll be much more educated 
after we finish with that study.
    Mr. Coffman. Well, that is not comforting. We were prepared 
here to know.
    Dr. Kudler, what do you think?
    Dr. Kudler. I'm really glad you asked that question.
    Mr. Coffman. Yes
    Dr. Kudler. No.
    Mr. Coffman. Let's----
    Dr. Kudler. No, no. The bottom line----
    Mr. Coffman [continuing]. Not run the clock here.
    Dr. Kudler. The bottom line is this. Whether it's pain or 
depression, it takes an integrated approach just as Dr. 
Maffucci was saying. And different patients need to start in 
different places. There are patients who will say I can't talk 
about this. I won't talk about this. And the medication will 
make that possible in the depression case.
    In a pain case, there are people who absolutely need not to 
go where they mean to go into opiates or come off them, but 
they believe this is all that would ever work for me. So we 
need to start where the--where the patient is, where the 
veteran is and use a mixture.
    With my patients, I've always said, look, I have a lot of 
different tools, talk therapies and medication. This is the 
good and the bad about each of them. What makes sense to you 
and, by the way, we can do both. And in most cases, we end up 
doing both, but often the stepped way.
    Mr. Coffman. Dr. Clancy, in an OIG report from 2013, it was 
recommended that VA ensure that facilities take action to 
improve post-discharge follow-up for mental health patients, 
particularly those who are identified as high risk for suicide.
    What is being done to ensure that this process is being 
followed?
    Dr. Kudler. A few years ago, VA put out as a performance 
measure that veterans must be seen in person or at least by 
phone in the first seven days after leaving a psychiatric 
hospital. And this is based on statistics that show this is the 
most vulnerable time. Actually, the first two weeks, the most 
vulnerable time for a suicide attempt, especially after 
treatment of depression or admission for suicide activity.
    We've been monitoring this. We are not perfect in this, but 
we have--we--we are--I--I can't give you the number now. I can 
provide it later. We are now at a point where all across the 
Nation, we're tracking this. We have automatic alerts. We have 
teams that do this work with people. And we've taken it miles 
further. I wish I could give you the exact number right now. I 
can provide it.
    Mr. Coffman. You know what is amazing is from what we are 
hearing on the ground and from what we are hearing in this 
committee, it is a world apart. And if for what we are hearing 
in this committee were true, we wouldn't be here today having 
this discussion.
    Ranking Member Kuster.
    Dr. Clancy. Well, Mr. Chairman, if I might, we're not 
saying everything is fine and I acknowledged that at the 
outset. What I did want to tell you is that we are committed to 
getting it right. This is tough work and we have a lot to 
improve on. And we very much welcome your support and help.
    Mr. Coffman. Very hard to get it right if you are not 
acknowledging the depth of the problem.
    Ranking Member Kuster.
    Ms. Kuster. Thank you very much. Thank you, Mr. Chair.
    And thank you to our committee, to our panel for coming 
forward and all the comments from the committee.
    I just want to follow-up on where we go from here in terms 
of sharing best practices. We have now heard Dr. Maffucci. I 
really appreciate again your commentary and your expertise in 
this area and to the team from the VA. We have heard about VISN 
1. I talked about some examples in White River Junction.
    How do these best practices get shared and the research 
that is underway, how do we move forward with this to make sure 
that more veterans and their families will be served by this 
and in particular the clinician education because I think we 
have got to change some of the parameters and some of the, you 
know, sort of go-to answers that some of the clinicians have? 
Where do we go from here with this and how can this committee 
best stay on top of that and continue to work with the VA to 
make sure that we are serving these veterans all across the 
country?
    And I will bring El Paso up. Obviously one of the 
challenges is that this involves a very case management 
intensive approach. And you are right. The worst case scenario 
is just to cancel somebody's medication without follow-up 
because as we all know, that is why people are turning to 
heroin in the streets.
    So how do we get this right and how do we get it right 
across the board in the VA and what is the follow-up?
    Dr. Clancy. So what I might suggest is that you invite us 
back for a briefing and we would give you a follow-up. You pick 
the frequency, a couple of months, three months.
    And I did want to--didn't get a chance to say before to 
Congressman O'Rourke that I do have people monitoring for this 
abrupt discontinuation of medications. And I'm really worried 
about it when people change providers, right? If we're sending 
out a message that says we want to see fewer veterans on 
opioids, it's much, much easier when someone changes providers 
to just say no. That is absolutely not acceptable and that is 
no definition of success here. So I wanted to be very, very 
clear on this point.
    Some of these challenges are areas where U.S. medicine is 
struggling in general. Chronic pain in particular and for 
mental health, we've had to blaze some trails. There is no 
clear-cut blood test that one can do like a blood sugar or 
blood pressure, whatever, to double check on the diagnosis or 
assessment.
    It depends a lot on the use of standardized questions in 
some cases. And this we are working very hard on right now. We 
are changing how we schedule appointments and simplifying it so 
that it is much easier to get veterans in for that follow-up 
assessment.
    But you should hold us accountable and I would look forward 
to showing you where we've been and where we're going. In no 
way do I not want to say that we have problems to solve. We do. 
We own them and we're stepping up to them and look forward to 
your support.
    Where you can help is helping to work with us on reducing 
stigma. I mean, this remains a huge, huge problem. And also, I 
think sending a sense that you are supporting the efforts to 
get better care for clinicians--I mean, for veterans.
    One of our challenges is that a lot of young people are not 
choosing to go into these fields and that is the ultimate 
recruitment problem is that if they're not--we have terrific 
incentives thanks to the Clay Hunt Act, in terms of debt 
reduction thanks to the Veterans Choice Act and so forth. And 
those are great tools, but someone has to actually make the 
decision to go down that path.
    Ms. Kuster. Thank you very much.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    And, Dr. Clancy, I want to stress again the need for you to 
turn over documents when requested by Congress. And your 
failure to do so makes our job very difficult.
    Mr. O'Rourke, Texas.
    Mr. O'Rourke. And, Dr. Clancy, thank you for addressing the 
El Paso issue and the larger issue within the VA to ensure that 
you are monitoring those veterans who are going to be coming 
off of opiates. But, again, the feedback stands because I am 
hearing it directly from veterans that that is apparently not 
happening in El Paso.
    And I think we both must conclude that for every veteran 
who takes the time to come down to a town hall meeting despite 
whatever they are going through to tell their congressman that 
they are having this problem in front of 200 other veterans and 
is admitting that they are receiving opiates and now are doing 
without that there are many others that that person represents 
who have just given up and says why should I bother.
    So we have got a problem in El Paso, perhaps nationally in 
terms of ramping people down or finding an alternate therapy to 
pair with their cessation of opiates.
    I would like you to respond to something that we have heard 
the secretary say and read about in the press that he has got 
28,000 positions to fill in the VHA. It is something that Under 
Secretary Sloan Gibson reiterated three weeks ago, four weeks 
ago in a hearing here.
    And then when the ranking member and I and some other 
Members of Congress and the Senate were in your command and 
control center on the 8th Floor a few weeks back, we heard that 
that number was actually not 28,000. It was 50,000 positions to 
be filled at the VHA.
    Could you confirm that number and could you tell me how you 
are prioritizing those hires? And obviously I am getting to if 
we have a crisis in mental health and we are treating all hires 
the same, we have a problem. If you are prioritizing mental 
health, here is a chance to tell this committee and the public 
at large.
    Dr. Clancy. So I did not hear the number 50,000, so I'm 
going to have to check on that and get back to you directly I 
think would probably be the easiest way to say that. With 
300,000 employees sorting out normal turnover which is 
somewhere around seven or eight percent across all the 
disciplines from, you know, what we're--areas where we're 
trying to fill is a little bit challenging.
    We have identified five areas that are the highest 
priority, physicians, nurses, mental health professionals, 
physician assistants, and I'm blocking on the fifth one, but 
mental health professionals is clearly on that list. And, in 
fact, we have been way ahead of the curve compared to the rest 
of the country in terms of hiring mental health professionals 
from multiple disciplines. They work as teams. We've got them 
in primary care as well as working in mental health clinics and 
so forth.
    Trying to do everything to make it almost impossible to 
seek assistance and get it. If you actually do get care from 
one of our facilities, we have a long way to go. I was simply 
commenting on the overall pipeline problem.
    The other area where we are beginning--where we do a lot 
now but I think could do much more is in tele-mental health. So 
Big Spring, Texas which isn't that far from you in Texas terms, 
you know, they tried very, very hard to recruit psychiatrists 
and had a problem and recently recruited one from Wisconsin who 
is not moving. It--that individual is providing all virtual 
care.
    So we're working with them to try to figure out how to make 
that business process work as smoothly as possible. Many 
veterans prefer that. They find it a bit less confrontational.
    Mr. O'Rourke. And I appreciate that. And as I yield my 
time, I will just conclude. You have asked for an additional 
briefing or hearing to follow-up. I hope that when you come 
back, you come back with a plan for El Paso or any under-served 
community. And you say you know what, we are paying 
psychiatrists and psychologists and therapists and social 
workers and counselors X. I am going to pay them X plus 20 
percent to get them to El Paso or that under-served community 
and then to retain them once they are there because you have a 
huge problem with retention as well, and that is a suggestion, 
or some other plan that really treats this as the crisis that 
it is versus the, you know, we are making this a priority. We 
are going to do this, that, and the other.
    I need dollars on the table, specific offers, deals that 
will get that psychiatrist or mental health professional there 
in the first place and then keep them there after. So I hope to 
hear specifics next time.
    So appreciate your answers to our questions today.
    And, Mr. Chair and Ranking Member, thank you for holding 
this hearing. Really important. Thanks.
    Mr. Coffman. Ranking Member Kuster.
    Ms. Kuster. Thank you, Mr. Chair.
    And just briefly I want to follow-up for my colleague that 
we will do a follow-up hearing and not only on the types of 
pain management and techniques that do seem to be working but 
in particular, I would like to include tele-mental health. And 
maybe we could even do a short demonstration, but just for you 
that that might be an alternative in this crisis situation that 
you have. I want to make sure that we stay on top of this so 
that our colleague, his region gets served.
    Thank you.
    Mr. Coffman. Thank you, Ranking Member Kuster.
    Our thanks to the witnesses. You are now excused.
    Today we have had a chance to hear about problems that 
exist within the Department of Veterans Affairs with regard to 
prescription management and veteran suicides. This hearing was 
necessary to accomplish a number of items, to demonstrate the 
lack of care and follow-up for veterans prescribed medications 
for mental disorders, to demonstrate the inaccuracies and 
discrepancies in the data collected by VA regarding veteran 
suicides and those diagnosed with mental disorders and, three, 
to allow VA to inform this subcommittee what it plans to do to 
improve these glaring deficiencies in order to ensure veterans 
are receiving the care they deserve.
    I ask unanimous consent that all members have five 
legislative days to revise and extend their remarks and include 
extraneous materials. Without objection, so ordered.
    I would like to once again thank all of our witnesses and 
audience members for joining in today's conversation.
    With that, this hearing is adjourned.
    [Whereupon, at 12:12 p.m., the subcommittee was adjourned.]

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