[Senate Hearing 114-521]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 114-521

               VA MENTAL HEALTH: ENSURING ACCESS TO CARE

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

                                 HEARING

                                BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 28, 2015

                               __________

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

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                            October 28, 2015
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from 
  Connecticut....................................................     2
Rounds, Hon. Mike, U.S. Senator from South Dakota................    36
Tester, Hon. Jon, U.S. Senator from Montana......................    38
Moran, Hon. Jerry, U.S. Senator from Kansas......................    40
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    42
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    43
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    46
Boozman, Hon. John, U.S. Senator from Arkansas...................    65

                               WITNESSES

Karnaze, Nicholas, U.S. Marine Corps Veteran.....................     3
    Prepared statement...........................................     4
Maiers, Dean S., U.S. Navy Veteran...............................     7
    Prepared statement...........................................     7
Butler, Roscoe G., Deputy Director, National Veterans Affairs and 
  Rehabilitation Division, The American Legion...................     8
    Prepared statement...........................................     9
Maffucci, Jacqueline, Ph.D., Research Director, Iraq and 
  Afghanistan Veterans of America................................    13
    Prepared statement...........................................    14
Draper, Debra A., Ph.D., Director, Health Care, U.S. Government 
  Accountability Office..........................................    16
    Prepared statement...........................................    18
Kudler, Harold, M.D., Chief Consultant for Mental Health 
  Services, Veterans Health Administration, U.S. Department of 
  Veterans Affairs; accompanied by David Carroll, Ph.D., 
  Executive Director, Mental Health Operations; and Michael 
  Davies, M.D., Executive Director, Access and Clinical 
  Administration Program.........................................    49
    Prepared statement...........................................    51
    Response to posthearing questions submitted by:
      Hon. Richard Blumenthal....................................    67
      Hon. Bill Cassidy..........................................    72

                                APPENDIX

Murray, Hon. Patty, Chairman, U.S. Senator from Washington; 
  prepared statement.............................................    77

 
                   VA MENTAL HEALTH: ENSURING ACCESS
                                TO CARE

                              ----------                              


                      WEDNESDAY, OCTOBER 28, 2015

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:31 p.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Cassidy, Rounds, 
Tillis, Sullivan, Blumenthal, Murray, Brown, Tester, Hirono, 
and Manchin.

           OPENING STATEMENT OF HON. JOHNNY ISAKSON, 
              CHAIRMAN, U.S. SENATOR FROM GEORGIA

    Chairman Isakson. First of all, I would like to call this 
meeting of the Senate Veterans' Affairs Committee to order, and 
I appreciate everybody's attendance today. I particularly 
appreciate our visitors who are testifying, and I will 
introduce them in just a second.
    This is a critical hearing for the VA Committee. You are 
all familiar with the GAO report regarding suicide prevention 
and suicides in the Veterans Administration. I called the first 
hearing on preventing suicide in the Veterans Administration or 
Veterans Benefit Services in August 2013 in Atlanta, Georgia, 
because we had had an inordinate number of suicides in the 
Atlanta area during that period of time. To Leslie Wiggins' 
credit, who is the Director of the Clairmont Hospital in 
Atlanta, a number of things were done to address that subject 
and greatly reduce, although not totally eliminate, which is a 
very difficult thing to do, the number of suicides that took 
place. But, we got our arms around the problem.
    I particularly am glad that GAO has focused on the problems 
that we do have so we can focus on the solutions we must have. 
As I told a member of the media a few minutes ago outside, 
failure is not an option, as far as I am concerned. The lives 
of every one of these veterans is important. They risked that 
life for all of us and our safety and our security overseas. We 
have got to make sure they have the comfort and the care and 
the accessibility to mental health coverage so they do not take 
their life while they are here at home. That requires a VA that 
is responsive, a hotline that works, and a program to make sure 
that veterans can get services when they need them on a timely 
basis, not a week or two later on.
    I am delighted that all of you chose to come and 
participate today. I appreciate your being here.
    With that said, I will introduce the Ranking Member, 
Senator Blumenthal.

         OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, 
         RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thanks, Mr. Chairman, and thank you for 
having this hearing on a topic that is supremely important. 
There is no topic, in my view, that is more important than 
mental health for our veterans.
    As in the civilian world, mental health is often 
overlooked, given less attention than it should be, an 
invisible condition that needs to be treated with the same 
urgency and immediacy as any physical condition would be. In 
the case of our veterans, it is an invisible wound of war for 
many and has been often disregarded and neglected until 
recently.
    To its credit, our military now is much more focused on it, 
particularly when it affects our men and women in uniform 
engaged in combat, and the same sensitivity and attention have 
to be given by the VA and our civilian society, not enough that 
our insurance laws provide parity and require parity in 
coverage. All too often, incidentally, that law is neglected 
and overlooked--a separate topic. But, for our military men and 
women, for our veterans, mental health is as absolutely vital 
as an arm, a leg, any physical part of the body, and it 
deserves the same kind of world class, first class health care.
    The GAO report that has been issued and is involved in 
today's hearing certainly documents failures and neglect that 
need to be remedied, and that is the topic that brings us here 
today, what more we can and should do right away, not at some 
distant point in the future, but literally right away.
    Thank you, Mr. Chairman, for having this hearing. I look 
forward to hearing and learning as we listen to this testimony, 
but also acting on it as soon as possible. Thank you.
    Chairman Isakson. Thank you, Senator Blumenthal.
    I am pleased to introduce our first panel, to which each 
will have 5 minutes for their testimony and then we will do a 
round of questioning by the Committee members and then go to 
our second panel. We thank you for being here.
    First is Nick Karnaze, U.S. Marine Corps veteran. We 
appreciate your being here today and thanks for bringing Lauren 
along. Lauren used to work for me a long time ago and she is a 
great lady. I appreciate it.
    Dean Maiers, U.S. Navy veteran. Thank you for being here. I 
married into a Navy family, so I am kind of biased towards the 
Navy. We are glad you are here.
    Mr. Maiers. Thank you, sir.
    Chairman Isakson. Roscoe Butler--and Roscoe, you are always 
with us and we appreciate your being here all the time--the 
Deputy Director of Health Care for The American Legion.
    Dr. Jackie Maffucci, Research Director of Iraq and 
Afghanistan Veterans of America.
    Dr. Debra A. Draper, Director of Health Team, the 
Government Accountability Office.
    We are delighted that all of you are here. We will start 
with Nick for your testimony, up to about 5 minutes each.

                STATEMENT OF NICHOLAS KARNAZE, 
                   U.S. MARINE CORPS VETERAN

    Mr. Karnaze. Mr. Chairman, Members of the Committee, thank 
you for inviting me here today. It is an honor to be able to 
share my story with you.
    My name is Nicholas Karnaze. I served about seven-and-a-
half years in the Marine Corps, both as an intelligence officer 
and as a special operations officer. I have multiple combat 
deployments to Afghanistan. I am a graduate of the U.S. Naval 
Academy and recently completed a veteran program at the 
Stanford Graduate School of Business.
    This is an issue that is near and dear to my heart. I am 
testifying from the perspective of a veteran who receives all 
of his health care through the VA.
    Many men and women are suffering, as we all well know, from 
the mental wounds sustained in combat. A lot of them are 
fearful of coming forward and asking for help because of the 
stigma associated with it or the impact it could have on their 
employment. For those that do have the courage to step forward 
and ask for help, many are met with a lengthy administrative 
process to gain access to the care that they are asking for and 
desperately need.
    In my personal experience, it took me about a year to get 
into the VA system upon separation from the Marine Corps. Once 
I was actually in the VA system, the physical care received was 
fantastic.
    Late last year, in the fall of 2014, I was having some 
issues with concentration and just the ability to get work 
done, work that I was compassionate about. I reached out to my 
primary care physician to get a referral to a mental health 
specialist. It took me about a month to get that appointment. 
My first meeting with her was about an hour long, and at the 
end she asked if I was open to taking medication, because while 
I did not feel depressed, my inability to concentrate could be 
a sign of depression.
    Wanting to get my head right, getting back and wanting to 
get back in the game, I agreed. She put me on an 
antidepressant. We agreed to meet 2 months later and she let me 
know that it would probably take a few weeks to a month for the 
drug to start working.
    Several weeks into taking that medication, I actually began 
to feel depressed. I was in a very, very dark place. It was not 
me. It was not normal. I knew it was not normal. I reached back 
out to the VA to see my doctor again. She could not see me for 
another 30 days or thereabouts. So, on my own, I decided to 
stop taking the medication.
    Shortly after I stopped, I was back at my baseline. I 
started feeling better. Things were good. I went back and I met 
with her and she said I had made the right choice by stopping 
the medication, that my body just did not metabolize it 
properly.
    I told her that I would like to speak to a psychologist and 
maybe get some cognitive therapy, something like that, just 
because, for me, I was defining a good year by attending more 
weddings than funerals. I was losing a lot of friends in combat 
and I had some guilt associated with that. She said that was a 
great idea, but she could not provide that cognitive therapy 
for me. That was my last interaction with a mental health care 
professional within the VA.
    Just this week, I reached back out. I receive my care 
through the clinic at Fort Belvoir. They have one phone number 
listed on the Web site. I called that. It went to a recording 
and gave me another phone number to dial to be referred or to 
ask for a referral. I called that number, and after waiting for 
about 15 minutes, I decided to select the option of pressing 
one to leave a message and have the representative contact me 
when someone became available. I left my phone number. I left a 
voice message explaining that I needed to meet with my primary 
care physician, that I was in search of some mental health 
care, and to please give me a call back.
    Today, I have yet to receive a call back from my clinic. At 
this time, I am still waiting to at least get an appointment.
    I am not the only one in this position. I posted about this 
on Facebook, that I was going to be speaking before you, sir, 
and the response that I received was amazing. I received so 
many e-mails, and I forwarded them along to your staff. I 
included some of them in my written testimony, as well.
    Some of my friends have actually given up hope. My friend, 
Nathan Lewis, he actually went through his private health care 
provider with the aid of his employer to receive mental health 
care. His wife asked him to do so because his issues were 
putting a strain on their marriage.
    I and many veterans like me do not have that luxury. I am a 
small business owner, and unfortunately, at this time, I cannot 
afford private health care. Hopefully, that will change, but 
right now, I am still very much in that startup mode.
    A lot of people want help. They need help. As a leader of 
Marines, I feel it my responsibility to help with that.
    I truly believe that when we get the right access to care 
in a timely manner, we will find that we are going to see a 
reduction in veteran suicides and we are going to have 
healthier and happier families.
    I am an open book. There is no question off limits for me, 
I am open and welcome to any questions you might have that 
might help in this matter. Thank you.
    [The prepared statement of Mr. Karnaze follows:]
  Prepared Statement of Nicholas Karnaze, U.S. Marine (Retired), and 
                      founder of Stubble & 'Stache
    Mr. Chairman and Members of the Committee: Thank you for the 
invitation to be here today; it is an honor to be able to share my 
experiences with you. My name is Nicholas Karnaze, and I served 7.5 
years in the United States Marine Corps both as an intelligence officer 
and as a special operations officer. I served two combat deployments in 
Afghanistan, and I have a disability rating with the VA. Because of 
this, I receive all of my health care through the VA. I am a graduate 
of the United States Naval Academy, and recently received a certificate 
from the Stanford University Graduate School of Business.
    I am testifying today from the perspective of a veteran with 
service-connected disabilities who has attempted to receive mental 
health treatment from the VA. As a leader of Marines, I feel it is my 
duty to share my personal experiences with you so that, together, we 
can ensure the men and women who honorably served our Nation receive 
the mental health care that they deserve.
    Many men and women are suffering in silence from the mental wounds 
they sustained during their time in the military. Most know they need 
help, but some are fearful to ask out of concern that any mention of 
``mental health'' will have an adverse effect on their government 
security clearance, and ultimately, their jobs. For those who have 
mustered the courage to reach out, most are confronted with a lengthy 
and discouraging administrative process in order to gain access to 
mental health care. There are extremes in mental health--for example if 
a person is about to commit suicide--but the majority of people seeking 
treatment have not reached that point.
    Often, veterans who are actively seeking help are in the stage in 
which they experience the feeling that something is not right. While 
they may know something is wrong, they are not on the verge of suicide, 
so contacting the VA's widely publicized Veterans Crisis Line seems 
excessive. So what options do we veterans have in this situation?
    Upon leaving active duty, it took me over a year to gain access to 
the VA healthcare system. Once in the system, the actual physical care 
I received was fantastic. But, it's the time and process necessary to 
ultimately receive the care is where the issues lie.
    In the fall of 2014 I expressed an interest to meet with a mental 
health care professional to discuss some issues I'd been having with 
concentration and memory. Upon referral to a psychiatrist, it took over 
a month before I was finally able to meet with the doctor. During our 
hour-long initial meeting, she asked if I was opposed to taking 
medication, mentioning that while I do not feel depressed, my inability 
to concentrate could be a symptom of depression. Eager to ``get my head 
right,'' I said I had no problem trying medication. She then prescribed 
me an antidepressant, and we agreed to meet several months later to 
assess my progress. She noted that it could take from several weeks to 
a month before I noticed a change in my mood.
    Two weeks into taking the medication, I began to feel depressed, 
beyond my initial issue with memory and concentration. Cold, lonely 
depression took its hold. I felt hopeless. At first I thought I was 
just having a really bad day, but these feelings persisted. I knew 
something was wrong. This was not me. I attempted to call the VA to 
talk with the psychiatrist, but she could not see me for about 30 days. 
I could not live like this for 30 days. I decided to stop taking the 
medication. Shortly after I stopped taking the drug, my mood began to 
improve and I was soon back to my original baseline. When I was able to 
see the doctor again, she said that I had made the right choice in 
stopping the medication. She asked if I wanted to try a different drug. 
I declined. I told her I'd like to try cognitive therapy. She said that 
was a good idea, but could not provide that for me. I was not referred 
to a psychologist. I left the clinic and that was the last interaction 
I've had with a VA mental health professional.
    My experience in which the VA deferred to pharmaceutical treatment 
instead of psychological treatment is not unique. On August 26, 2014, 
Adam Looney took his own life. Adam was a Marine Corps veteran and 
brother of my friend Kate Looney, also a Marine Corps veteran. Up until 
his death, Adam was receiving mental health treatment from the VA in 
Columbia, MO. According to Kate, the ``VA's approach was basically to 
try every psychiatric medication without really taking the time to 
counsel the root issue. He used to hate going because it was a long 
drive and a long wait. I brought him a few times, and he was never in 
there long. It seemed they were always changing his meds, losing 
paperwork and switching his counselor.''
                           current situation
    I receive my health care through the VA Community Based Outpatient 
Clinic at the Ft. Belvoir Community Hospital. Still interested in 
meeting with a psychologist, I recently attempted to contact my clinic 
for a referral. The only way I've found to do this is through the one 
phone number listed on the clinic's Web site. The phone number links to 
an audio recording that lists another phone number to call for 
referrals. After calling that number, I was on hold for about 15 
minutes before I decided to select the option of having a 
representative call me back when one became available. To date, no 
representative has called me back nor responded to the voice message I 
left requesting help earlier this week.
    From a mental perspective, I feel very fortunate. No matter how bad 
things get, I always have a slight feeling that everything will be OK, 
that I just need to keep pushing forward. This feeling has been with me 
through my most difficult days on the battlefield and during my darkest 
times at home. Because of it, I have always been able to keep moving. 
But I know not everyone has this internal voice. When a person reaches 
out for help, especially mental health help, they are extremely 
vulnerable. Not having someone pick up on the other end, someone you 
have been told will help, is crushing. When you are suffering from a 
mental wound, you will not have the emotional energy to keep asking for 
help if your first calls go unanswered.
    After learning I'd be testifying before you today, I posted on 
Facebook asking my friends about their experiences with mental health 
care from the VA. The responses I received were overwhelming. Alisa 
Beasley emailed me the following:

        I was medically retired from the Army 28 April 2014. I was just 
        barely holding on mentally, that is how I felt. I saw my 
        primary care provider by May and referred to Mental Health that 
        same day! Then I saw a psychologist in July. Then nothing. I 
        was supposed to be receiving follow up visits and every time I 
        called the Mental Health number it just beeped like it was 
        disconnected. I was so frustrated, and on top of that the VA 
        had sent me a letter stating my benefits would be cut due to 
        two missed appointments for psychiatry and neurology. I didn't 
        miss either of these appointments, they were never rescheduled 
        like I called and asked for. I could literally feel my world 
        crumbling. I had gone through a really tough divorce, he wasn't 
        letting me see my kids * * * I felt like what's the point. I'm 
        done. I was having panic attacks and nightmares and depression. 
        I called and called and there was never an answer from the VA 
        mental health building. It took me calling the patient 
        advocate. By this time I was a sobbing mess and crying and 
        shaking and felt like my world was crashing. She was kind 
        enough to tell me it looks like they literally just dropped me 
        completely off the mental health log. She was able to get me an 
        appointment for February 2015, this call took place in 
        November 2014. I didn't see a psychiatrist to talk about 
        possibility of meds till sometime after June 2015.

        This is not the worst-case scenario from the VA and mental 
        health, but this is my story. This can not continue, others are 
        far worse off and need the help they ask for RIGHT NOW not 
        months or even days later. Why is there not a program set up 
        that's 24/7 hours where the Vet can come into the VA mental 
        health building and be treated at that moment. I am going to 
        school now so I hopefully can help another Vet with PTSD. I 
        would like to work with in the VA, efficiently. They cannot 
        continue on this path they are living up to the motto most vets 
        live by now ``The VA giving Vets a second chance to die for 
        their country.''
        The saddest part is it is the truth.
            Sincerely,
                                             Alisa Hurkman,
                                                  Ret. US Army Vet.

    Like Alisa, I too have had the VA threaten to cancel my benefits 
for missing an appointment. The problem is that I knew I wasn't able to 
make the appointment and actively reached out to the VA, but could not 
get through to an actual person. So, I left a voicemail with my 
appointment details and that I needed to reschedule. I never heard 
anything until I received a letter reprimanding me for missing an 
appointment.
    There's a common thread here: the need to be able to efficiently 
gain access to the right care in a timely and thorough manner. Nathan 
Lewis, a former Marine Corps Officer, shared this with me:

        After my transition from the Corps my wife suggested I seek 
        help for my challenges related to my two tours in Iraq. I 
        reached out to the local VA hospital and asked for support. I 
        waited months for their response. After three or so months I 
        contacted them again. I was given a list of items I had to 
        complete. It was an admin exercise and I decided to seek help 
        through the assistance of my private sector employer.

    But what about those who cannot go outside of the VA for care? As a 
small business owner, I cannot afford private healthcare at this time. 
I am aware of several amazing psychologists in the DC area, but I 
simply cannot afford to pay for treatment out of pocket.
    In conclusion, as a veteran seeking mental health treatment from 
the VA, my biggest issue is gaining timely access to the right type of 
treatment. For me, the barrier to this is on the VA's administrative 
side; gaining access to the right providers. I truly believe that 
streamlining this process and providing veterans with the appropriate 
mental health care will result in stronger families and dramatically 
reduce veteran unemployment and the tragic suicides that are plaguing 
the veteran community.

    Mr. Chairman and Members of the Committee, I wish to thank you for 
this opportunity to present my perspective today.

    Chairman Isakson. Thank you, Nick.
    Mr. Maiers.

         STATEMENT OF DEAN S. MAIERS, U.S. NAVY VETERAN

    Mr. Maiers. Good afternoon. My name is Dean Maiers. I am an 
OEF/OIF disabled veteran. I served in the Navy. I would like to 
take some time and explain to you about how my peer support 
specialist has been extremely helpful.
    Pretty much when I got out of the military, just like this 
gentleman to my right said, I had a rough time accepting that I 
was not right, and it took me numerous years in order to get to 
the VA and get help. They put me through this program at the 
Errera Center where all your doctors and peer support 
specialists are in one building. Ever since I have been going 
there, my life has changed tenfold.
    When I got out of the military. I tried to kill myself 
twice. I lost my wife, my children, my job. I was homeless for 
3 years. This is very important to me, because our fellow 
veterans really need this help, and if it was not for the VA, I 
probably would be dead. I have all the thanks and gratitude to 
the VA, their staff there, and everybody here that has been so 
helpful.
    Every single veteran coming home deserves this program. 
Every State in this great country needs to have this program 
implemented. Some veterans, like myself, have too much pride to 
admit there is something wrong, after it took me 8 years to do 
it.
    Just the fact of knowing that someone is there for you when 
you need it, or even if you do need it, and I am--I am sorry. I 
am a little nervous.
    Chairman Isakson. You take all the time you need to take.
    Mr. Maiers. Basically, I went through some trials and 
tribulations. I had a very, very rough time when I got out, and 
I am so grateful for this program and this country, that they 
are taking care of me now, and it just means the world to me.
    I thank you so much for this opportunity and your time. I 
hope that has been somewhat helpful. Anything I could do to 
help my brothers and sisters in arms to get the treatment they 
need and deserve. Thank you very much.
    [The prepared statement of Mr. Maiers follows:]
            hearing testimony of dean s. maiers, usn retired
    My name is Dean Maiers and I am an OIF/OEF disabled veteran. I 
would like to take some time and explain how my peer support specialist 
has been extremely helpful.
    I had a very rough time adapting when I got out of the Navy. I 
pretty much lost everything that was important to me, my wife, 
children, employment everything seemed hopeless.
    Then I found this program. It changed my life in so many ways. 
Ernest Johnson and the Comprehensive Work Therapy program at the Errera 
Center in West Haven have been a blessing to be honest. He also 
introduced me to several other social workers and other programs that 
have helped me tremendously, by getting me the right support team, and 
doctors to get me back on track. If it wasn't for my peer support 
specialist, the program I am in and all the people who are there 
whenever you need them, I would never have gotten back on track. It 
gave me a sort of relief knowing that they are always there when I need 
them.
    Every single veteran coming home deserves a peer support 
specialist. Every state in this great country needs to have this 
program implemented. Some veterans like myself not too long ago might 
have too much pride to admit there is something wrong it took me 8 
years of failing at everything to give it a try - and now my life has 
improved in every way possible.
    Just the fact of knowing that someone is there for you if or when 
you need them is a great relief. I am happy to elaborate if you have 
any further questions for me today.

    Thank you so much for this opportunity and your time. I hope this 
has been somewhat helpful. Anything I can do to help my brothers and 
sisters in arms to get the treatment they need and deserve.

    Chairman Isakson. We thank you for your testimony and your 
service to the country.
    Mr. Maiers. Thank you.
    Chairman Isakson. Mr. Butler.

   STATEMENT OF ROSCOE G. BUTLER, DEPUTY DIRECTOR, NATIONAL 
  VETERANS AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN 
                             LEGION

    Mr. Butler. Good afternoon. Everyone in this room knows the 
highest cost of failing to provide mental health care to 
veterans is losing the life of one of our Nation's defenders to 
suicide. Even the more mundane stakes are sobering.
    Setting aside those who take their own lives, veterans who 
struggle with untreated mental illness suffer daily with deep 
and lasting impact to their life, their work, and the lives of 
everyone that they hold dear. This is a crisis with deep and 
lasting impact to every facet of life and to every entire 
community.
    That is why ensuring veterans get the right mental health 
care is and has been a top priority of The American Legion. We 
are leading the engagement at every level, from VA and DOD 
officials to veterans and their families in every community. We 
hold summits. We regularly survey veterans. We are deeply 
committed to speaking to the folks who are fighting this battle 
in the trenches to make sure we are providing the voices of 
those fighters who it comes to look for solutions.
    Chairman Isakson, Ranking Member Blumenthal, and 
distinguished Members of the Committee, on behalf of our newly 
elected National Commander, Dale Barnett, and over two million 
members of The American Legion, we thank you for the 
opportunity to testify about ensuring access to mental health 
care for our Nation's veterans.
    The American Legion has conducted detailed examinations of 
the VA Health Care System for over a decade and as part of our 
System Worth Saving Task Force. In 2013, we compiled ``The War 
Within,'' a detailed study of veterans and their experiences 
with treatment for PTSD and TBI. We followed that up with a 
survey of veterans' mental health treatment in 2014 and a 
follow-up survey this fall that are analyzing for patterns as 
VA adapts their care and treatments.
    The survey indicated concerns from veterans about over-
medications and a lack of complementary and alternative 
treatment options, such as art therapy, companion dogs, equine 
therapy, hyperbaric oxygen treatment, and many more options.
    In response to VA's pledge to increase access to those 
sorts of treatment, by speaking to our members and traveling to 
VA facilities as part of our System Worth Saving Task Force, 
has indicated that access to those type of treatments which 
could be beneficial to treating veterans and mental health 
conditions varies greatly from location to location. This level 
of inconsistency is troubling. In fact, one of the more serious 
problems plaguing the system is not a lack of proper ideals, 
but inconsistent application of VA guidance.
    When we talk to veterans across the country about how well 
VA implemented a mental health care summit initiative, the 
responses varied widely. A veteran in Chicago had an 
outstanding experience with their summit at the Jesse Brown 
VAMC. The veteran described positive network experiences and a 
strong level of interaction between VA and the veterans in the 
community and the applicable stakeholders.
    Conversely, a veteran from Seattle had the opposite 
experience. That veteran experienced summit meetings full of 
bureaucratic obstacles, mired in a lack of constructive 
progress, and ultimately was driven to abandon participation, 
feeling the whole mess was counterproductive.
    VA must improve their consistency. No matter how well 
intended their policies, if they cannot execute them evenly 
across the country and forge connections with the veterans they 
serve, they will drive veterans away from beneficial care for 
their mental health disorders. That must be a consistent and 
welcoming environment for veterans if VA is going to treat 
their disorders.
    The veterans who provide anecdotal accounts to The American 
Legion are indicative of larger patterns that even more 
systemic examinations have revealed. The independent studies of 
VA health care delivery mandated by the Choice Act found the 
same problems, troubling inconsistencies in terms of results 
across VA.
    Thank you again, Mr. Chairman, Ranking Member Blumenthal, 
for ensuring the Committee's attentions stay focused on the 
critical issues of veterans' mental health care. I appreciate 
the opportunity to present The American Legion's experience on 
this topic and views and look forward to any questions you may 
have.
    [The prepared statement of Mr. Butler follows:]
   Prepared Statement of Roscoe G. Butler, Deputy Director, National 
   Veterans Affairs and Rehabilitation Division, The American Legion
    Chairman Isakson, Ranking Member Blumenthal and distinguished 
Members of the Committee, on behalf of National Commander Dale Barnett 
and The American Legion; the country's largest patriotic wartime 
service organization for veterans, comprising of over 2 million members 
and serving every man and woman who has worn the uniform for this 
country; we thank you for the opportunity to testify and for taking on 
one of the most serious challenges facing America's veterans, that is 
``VA Mental Health: Ensuring Access to Care.''
    The mental health of our Nation's veterans is something that The 
American Legion takes very seriously. One of The American Legion's 
legislative priorities for the 114th Congress is to ensure Congress and 
the Department of Veterans Affairs (VA) provide help for veterans 
struggling with mental health issues and brain injuries and that they 
dedicate extensive resources to study the devastating effects of Post 
Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). The 
American Legion believes that additional resources and alternative 
treatments must be provided as options for veterans and servicemembers 
in need of treatment for brain injuries and mental stress.
    The American Legion has helped drive the focus on unprecedented 
numbers of veterans returning home from Operation Iraqi Freedom (OIF), 
Operation Enduring Freedom (OEF), and Operation New Dawn (OND) with 
PTSD and TBI which have been known as the signature wounds of these 
conflicts. To address this problem, The American Legion convened a TBI 
and PTSD committee in 2010, to investigate Department of Defense (DOD) 
and VA existing medical science and procedures, as well as alternative 
methods for treating servicemembers and veterans suffering with PTSD 
and TBI as a result of their combat service.\1\ In addition to the TBI 
and PTSD Committee, The American Legion's System Worth Saving Task 
Force, established in 2003, assesses the quality and timeliness of 
veterans health care within the VA healthcare system, of which mental 
health care is a critical component to the overall evaluation.
---------------------------------------------------------------------------
    \1\ The American Legion TBI and PTSD Committee Report: The War 
Within: Sept 2013
---------------------------------------------------------------------------
    On August 31, 2012, President Obama signed Executive Order (EO) 
Number 13625: Improving Access to Mental Health Services for Veterans, 
Servicemembers, and Military Families directing the Departments of 
Defense (DOD), Veterans Affairs (VA), and Health and Human Services 
(HHS), in coordination with other Federal agencies, to take the 
necessary steps to ensure that veterans, servicemembers and their 
families receive the mental health and substance use services and 
support they need.
    These steps include strengthening suicide prevention efforts across 
the military services and in the veteran community; enhancing access to 
mental health care by building partnerships between VA and community 
providers; increasing the number of VA mental health providers serving 
our veterans; and promoting mental health research and development of 
more effective treatment methodologies.\2\
---------------------------------------------------------------------------
    \2\ Interagency Task Force on Military and Veterans Mental Health: 
2013 Annual Report
---------------------------------------------------------------------------
    The American Legion applauds VA for the work the department has 
been engaged in to meet the objectives of the President's Executive 
order, but much work still needs to be accomplished. The American 
Legion urges Congress to ensure VA has the funding needed to deliver 
comprehensive mental health services and to continue to provide the 
necessary oversight to ensure our Nation veterans receive timely and 
appropriate mental health services.\3\
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    \3\ American Legion Resolution No. 155: Aug. 2014
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                   va mental health hiring initiative
    Staffing shortages within VA leadership, physicians, and medical 
specialists within the Veterans Health Administration (VHA) remain a 
top concern of The American Legion. Since 2003, The American Legion's 
primary healthcare evaluation tool ``System Worth Saving'' (SWS) 
Program has tracked and reported staffing shortages at every VA medical 
facility visited across the country. The 2014 SWS report found that 
several VA medical centers continue to struggle with filling critical 
positions within the VA healthcare system.\4\
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    \4\ American Legion System Worth Saving Report: 2014
---------------------------------------------------------------------------
    In the Spring of 2013, VA attempted to address the increasing 
numbers of veterans seeking mental health care by announcing the hiring 
of an additional 1,600 mental health clinical providers and over 800 
peer support specialists. VA reported they have exceeded the 
President's 2012 Executive Order requirements and believe they are on 
the way to improving veterans access to mental health services. Yet 
problems with mental health scheduling clearly still exist, as VA's 
Office of the Inspector General (OIG) found in a June 2015 study of 
mental health care in Augusta, Maine.\5\ VA's continued struggles are 
indicative of how the lack of available mental health providers can 
contribute to long wait times for patients. Despite VA efforts in 2014 
to hire an additional 1,600 mental health-care providers, time has 
shown that VA's effort to address the lack of mental health providers 
still remains a serious problem.
---------------------------------------------------------------------------
    \5\ VA-OIG Report no. 14-05158-377 Mismanagement of Mental Health 
Consults and Other Access to Care Concerns--VA Maine Healthcare System 
Augusta, Maine June 17, 2015
---------------------------------------------------------------------------
    On January 30, 2015, the OIG released a report entitled ``Veterans 
Health Administration's Occupational Staffing Shortages'' as required 
by Section 301 of the Veterans Choice and Accountability Act (VACAA) of 
2014. The OIG report determined one of the occupations of critical need 
within VHA for Fiscal Years 2011 through 2015 for staffing shortages 
were psychologists.\6\
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    \6\ VAOIG Report ``OIG Determination of Veterans Health 
Administration Occupational Staffing Shortages'': Jan 2015
---------------------------------------------------------------------------
    When The American Legion's System Worth Saving team travelled 
across the country, medical center staff continues to inform our team 
that they continue to struggle with recruiting mental health 
professionals. For example, during a September 1, 2015, SWS site visit 
one medical center \7\ identified the following mental health 
vacancies:

    \7\ SWS Site visit, Baltimore, MD, September 1, 2015
---------------------------------------------------------------------------
     14 mental health psychiatrists,
     7 mental health psychologists,
     15 mental health social workers,
     1.5 mental health peer support specialists,
     and 1 neuro-psychologist totaling 38.5 mental health 
vacancies in a single medical center.

    On average, a position may be vacant anywhere from 90 days to six 
months before the position is filled resulting in a significant delay 
in veterans receiving treatment for their mental health conditions.
    The VA has a systematic problem with recruiting talented people to 
either run their medical centers or to provide front line health care 
to veterans. The Blue Ribbon Panel, created by VACAA to examine reform 
of the VA healthcare system, provided a presentation to the VA 
Commission on Care noting:

     39 percent of senior leadership teams at VA medical 
centers had at least one vacancy;
     43 percent of network directors are in a ``acting'' status 
resulting in a severe leadership problem with VHA.
     More than two-thirds of network directors, nurse 
executives are eligible for retirement, as are 47 percent of medical 
center directors.

    Leaders within the VA healthcare system have to be empowered and 
more needs to be done in order to grow new leadership.
    The American Legion calls on VA to establish a short and long range 
strategic plan to address their recruiting and retention problems. 
Whether the problem is pay disparity with the private sector or other 
disincentives to employment at VA, this needs to be examined and 
corrected. VHA needs to continue developing and implementing staffing 
models for critical need occupations, and work more comprehensively 
with community partners when struggling to fill critical shortages 
within VA's ranks.\8\
---------------------------------------------------------------------------
    \8\ The American Legion Resolution No. 101: Department of Veterans 
Affairs Recruitment and Retention: Sept. 2015
---------------------------------------------------------------------------
    VHA must find a way to fill these vacancies if they are serious 
about addressing the mental health needs of this nations veterans'. If 
VHA cannot fill the vacancies, then VHA must determine how they can 
better allocate the staff and resources they have to maximum effect. 
Solving the staffing problem requires both short term and long term 
solutions. In the short term, how can you treat the veterans who need 
care with the providers you have? In the long term, how can you recruit 
more providers, and if there are shortages of providers, how can VA 
help create more mental health professionals?
             community mental health provider pilot program
    On August 31, 2012, President Obama signed Executive Order (EO) 
13625: Improving Access to Mental Health Services for Veterans, 
Servicemembers, and Military Families. The goal of the Executive Order 
was to create a vast network of support that had the capabilities of 
providing quality and timely mental health care services for veterans, 
servicemembers, and their families. Section 3(a) of the EO directed VA 
to create partnerships with community providers to decrease veterans 
wait times and increase the geographical range for veterans accessing 
mental care treatments and services. Through this action, VA 
implemented 24 VA/Community Mental Health Clinics (CMHCs) pilot 
programs with community-based mental health and substance abuse 
providers across nine states and seven Veterans Integrated Service 
Networks (VISNs) to enhance veteran access to mental health care 
programs and services between VA and community mental health care 
providers.
    In June 2013, President Obama directed all 152 VA medical centers 
across the country to hold Community Mental Health Summits with 
community-based programs and organizations to support veterans and 
their families. These summits were established to promote awareness of 
mental health services, assist veterans to gain access to mental health 
community programs and services, and to build health communities for 
veterans and their families to participate in. Annual mental health 
summits are held at every VA medical center (VAMC) across the country. 
The VA's goal is to reach all veterans regardless of whether they are 
enrolled and receiving their health care through the VA.
    Communication within the veterans' community is essential. As The 
American Legion learned from over a dozen community town halls we 
facilitated under our Veterans Crisis Center program last year, getting 
veterans in touch with VA to talk about their challenges is a critical 
tool to solving some of VA healthcare challenges. Recognizing the 
importance of this initiative, The American Legion has been worked to 
track the experiences of our members with VA's Mental Health Summits.
    One veteran told us:

        ``A Mental Health Summit was held on September 10th at the 
        Jesse Brown VA Hospital in Chicago. It was moderated by a staff 
        psychologist from the hospital and was attended by many people 
        from various agencies and organizations. We heard from several 
        veterans about their experiences in the VA mental health system 
        and they were all positive. We also had a networking session 
        which was, in my opinion, very positive. I made several good, 
        new contacts that I will utilize in the future. Unfortunately, 
        I understand that not all experiences veterans have with the VA 
        mental health system are positive. But it was good to hear some 
        success stories and speak to the veterans about what they went 
        through.''

    Another veteran described their experience:

        ``I was asked to participate in a mental health focus group at 
        the Seattle VA. The purpose of the group was to provide 
        feedback to VA about promoting awareness, helping veterans gain 
        access etc. I missed the first meeting, attended the 2nd and 
        the 3rd and decided to not participate in the group. Our first 
        task was to adopt bylaws for our group, select a president and 
        a secretary. As I missed the first meeting the group had 
        already selected a leader for the meeting. Staff offered a 
        bylaws template at the previous meeting. The second meeting 
        consisted of taking turns reading the bylaws out loud. Third 
        meeting was even less constructive. Having served on the King 
        County board to end veteran homelessness, served on several 
        other boards in different capacities including President, and 
        being well connected to service organizations such as the 
        Legion, I felt that I had a lot to offer this group. However, 
        most of the group assembled did not have experience in running 
        organizations, access to technology to read documents between 
        meetings. I decided that spending 2\1/2\-3 hours driving round 
        trip to attend a one hour lunch meeting progressing at a pace I 
        deemed a snail would find slow a waste of my time. I was 
        Unimpressed in Seattle.''

    The disparity between these two experiences is representative of 
perhaps the biggest challenge VA faces in delivering healthcare--
inconsistency between locations. Where one veteran in the Midwest can 
have such a positive experience and another in the Pacific Northwest 
can have such a negative experience, it's indicative of a system that 
still has a ways to go to deliver consistent care and results. VA must 
work harder to achieve that consistency if mental health efforts are 
going to be effective.
    The American Legion is not alone in finding these inconsistencies. 
The recently completed Independent Assessment of VA healthcare, 
mandated by VACAA, has similarly illustrated the vast range of 
inconsistency across VA facilities in the implementation of programs. 
It is not necessarily that VA is not attempting to implement good 
policy, it is often that it is executed with disparate results 
depending on location. That is not a recipe for success.
                               conclusion
    Much of the problems VA faces in delivering effective mental health 
care revolve around two primary considerations--lack of staff and lack 
of consistency. The former is something VA and Congress have attempted 
to address with additional hiring, with mixed results. The latter is 
something that is completely within VA's realm of control. If they are 
to change their culture to be better focused on serving veterans, 
ensuring consistency needs to be at the top of the list of priorities 
for achieving that goal.
    The country's obligation to its Armed Forces and its veterans 
includes a responsibility for their care and treatment from wounds 
inflicted upon them while serving their country. The challenge raised 
by Traumatic Brain Injury and Post Traumatic Stress Disorder demands a 
dedicated, well coordinated, and flexible response that adapts care and 
treatment to an individual's needs, not the other way around.

    The American Legion thanks this Committee for their diligence and 
commitment to examining this critical issue facing our servicemembers 
and veterans as they struggle to access mental health care across the 
country. Questions concerning this testimony can be directed to Warren 
J. Goldstein, Assistant Director in The American Legion Legislative 
Division (202) 861-2700.

    Chairman Isakson. Thank you very much, Mr. Butler.
    Dr. Maffucci.

  STATEMENT OF JACQUELINE MAFFUCCI, Ph.D., RESEARCH DIRECTOR, 
            IRAQ AND AFGHANISTAN VETERANS OF AMERICA

    Ms. Maffucci. Chairman Isakson, Ranking Member Blumenthal, 
and the Committee members, on behalf of Iraq and Afghanistan 
Veterans of America and our more than 425,000 members, and as 
IAVA's Research Director and resident neuroscientist, I thank 
you for the opportunity to share our views today.
    In 2014, IAVA launched the Campaign to Combat Suicide, a 
result of our members continually identifying mental health and 
suicide as their number 1 issue. This campaign was centered 
around the principle that timely access to high quality mental 
health care is critical in the fight to combat veteran 
suicides.
    The signing of the Clay Hunt SAV Act into law was an 
important first step to addressing this and we thank you for 
your support on this legislation. But, there is still so much 
work to be done.
    Every year, IAVA surveys our members, and in our most 
recent survey, half of respondents reported having a mental 
health injury and about 60 percent of those were seeking care 
from the VA. Of those, over 70 percent reported satisfaction 
with that care, but an almost equal percentage reported 
challenges scheduling appointments.
    Bottom line: our members have told us that access to VA 
mental health care is a challenge, but once in the system, they 
are satisfied.
    No veteran should have to wait for mental health care once 
they take that difficult step to seek help. Clay Hunt was one 
of these veterans. Clay sought help at the VA, but was 
repeatedly frustrated by challenges in scheduling appointments 
and receiving consistent care. He was a Marine, a son, a friend 
to many, an advocate, and humanitarian. Yet, despite his 
proactive and open approach to seeking care, he lost hope and 
took his life on March 21, 2011. Access to care is critical.
    There is a shortage of mental health professionals in this 
country. The supply is waning while the demand is growing. The 
Secretary is working to recruit medical students into the VA 
and into mental health professions, and this is really 
important. However, there are barriers in place that make it 
difficult for the VA to hire and to retain these professionals. 
The Federal hiring process can be confusing and lengthy, and 
this can be a huge deterrent in attracting and identifying 
talent.
    A recent VA Inspector General report that looked at hiring 
and loss rates of VA psychologists and medical officers found 
that a significant percentage of the total gains from hiring 
was offset by losses. The VA needs to understand and address 
the reasons that these staff leave as well as how best to 
attract new talent.
    The VA also needs to continually assess and update its 
staffing models and hiring guidelines. There is an opportunity 
here for an innovative approach to predict local demand for 
mental health professionals using real time data. One of the 
biggest obstacles to this is the current scheduling system, 
which does not provide this type of data that can inform the VA 
of usage habits of veterans seeking VA mental health care. This 
is just one of the reasons why updating this outdated system 
and clarifying its policies is so important.
    As part of this, we also encourage the VA to get away from 
grouping mental health professionals as one category and focus 
on defining the needs for each discipline. Each have a unique 
skill set. Defining demand and establishing targeted hiring for 
these professions will help in filling gaps in access, and as 
these hiring initiatives occur, the need for additional 
resources is critical.
    Outside of staffing, there are three additional areas that 
warrant focus. Telemental health is one of these areas. VA 
should be commended for its telemental health program, which 
can fill gaps in communities that have critical provider 
shortages and potentially encourage more veterans to seek care. 
This program must continue to be developed, assessed, and 
expanded to ensure veterans have access to care.
    Vet centers continue to be a highly praised resource among 
IAVA's member population. We would like to see a comprehensive 
assessment of the role that Vet Centers play in supporting 
veteran mental health. It is a critical resource and fills a 
specific need, particularly for veterans who may be less 
inclined to seek services at VA health centers or seeking care 
with their family or are not eligible for VA health. We want to 
ensure that it is being fully utilized.
    Finally, the role of the community providers. The majority 
of veterans do not seek care at the VA. The care of this 
Nation's veterans is not the sole responsibility of the VA, but 
rather the community, and yet as community mental health 
providers are called upon to serve this population, a recent 
RAND report suggests they may not be well equipped to address 
these needs. Pilots such as the VA Community and Mental Health 
Partnership, or existing and successful programs like the Star 
Behavioral Health Program, can help to provide a framework for 
addressing the skills gap.
    All veterans deserve the very best our Nation can offer. We 
look forward to working with you and the administration to 
address these very real challenges. Thank you, and I am happy 
to take any questions.
    [The prepared statement of Ms. Maffucci follows:]
 Prepared Statement of Jacqueline Maffucci, Ph.D., Research Director, 
                Iraq and Afghanistan Veterans of America
    Chairman Isakson, Ranking Member Blumenthal and Distinguished 
Members of the Committee, on behalf of Iraq and Afghanistan Veterans of 
America (IAVA) and our more than 425,000 members and supporters, we 
would like to extend our gratitude for the opportunity to share our 
views on VA Mental Health: Ensuring Access to Care.
    In March 2014, IAVA launched the Campaign to Combat Suicide, a 
direct result of our members continually identifying mental health and 
suicide as the number one issue facing the newest generation of 
veterans. This campaign was centered around the principle that timely 
access to high quality mental health care is critical in the fight to 
combat veteran suicides. The signing of the Clay Hunt SAV Act into law 
was an important first step to addressing this. IAVA continues to work 
with Congress and the VA to fully implement this law, but there is 
still much work to be done.
    Every year IAVA surveys our members on their health experiences, 
among other issues. In our most recent survey, about half of IAVA's 
survey respondents reported having a mental health injury, and a little 
less than 60 percent were seeking care for these injuries from a VA 
provider. Over 70 percent of those using VA mental health care reported 
satisfaction with that care, but an almost equal percentage of 
respondents reported having some level of challenge scheduling VA 
mental health appointments. This is compared to only 31 percent of 
those using non-VA mental health care reporting scheduling challenges. 
Bottomline, our members have told us both through the survey and 
anecdotally that access to mental health care continues to be a 
challenge, but once in care, they are satisfied. No veteran should have 
to wait for mental health care once they take that difficult step to 
seek help. And this is where the topic of access becomes so very 
critical.
    Clay Hunt was one of these veterans. Clay sought help at the VA but 
was repeatedly frustrated by challenges in scheduling appointments and 
consistent care. He was a Marine who even after being injured signed up 
to deploy for a second time. Once he separated from the Marines, he 
became a veteran advocate, working with IAVA, and participated in 
humanitarian work with Team Rubicon. Despite his proactive and open 
approach to seeking mental health care, he lost hope and took his life 
on March 31, 2011. Access to care is critical.
    There is a shortage of mental health care professionals in this 
country. The supply is waning while the demand for mental health 
services is growing, as highlighted by Clay's story. Specific to the 
veteran community, almost 30 percent of new veterans treated at the VA 
have been diagnosed with Post-Traumatic Stress Disorder and 57 percent 
have some form of a mental health injury. The demand among the new 
generation of veterans will likely continue to grow as more troops come 
home and those already home continue transition to civilian life. And 
we cannot discount potential growth in demand among all veterans. The 
nation must be prepared to care for these veterans for decades to come, 
both in and out of the VA.
    The Secretary and this Administration are working to encourage 
medical students into mental health professions, and this must continue 
to grow the field. However, there are barriers already in place that 
make it difficult for the VA to both hire and retain these 
professionals. The application process and the lengthy wait time to be 
hired into the Federal Government can be a huge deterrent in attracting 
talented professionals. A recent VA Office of Inspector General Report 
\1\ looked specifically at hiring and loss rates of VA psychologists, 
determined to be a critical needs occupation. The report found that a 
significant percentage of the total gains from hiring was offset by 
losses. Given the amount of training and the continued demand for these 
professionals, the VA must understand and address the reasons that 
these staff leave.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs Office of the Inspector General. 
OIG Determination of Veterans Health Administration's Occupational 
Staffing Shortages. September 01, 2015; Report 15-03063-511.
---------------------------------------------------------------------------
    The VA also needs to continually assess and update its use of 
staffing models and guidelines surrounding the hiring of these mental 
health specialities at the facility level. IAVA believes that there is 
an opportunity for an innovative approach to develop more predictive 
models of need that can better inform these staffing models. There are 
examples of this type of data driven approach to understanding 
characteristics of the veteran population already in process that could 
drive this concept, like the Veteran Data Project led by the Center for 
New American Securities.
    As the VA continues to focus on staffing models, it must also get 
away from grouping mental health professionals as one category when 
focusing on hiring initiatives, and more specifically focus on the 
needs for each discipline. Each have a unique skill set and the demand 
and targeted hiring for these must be determined in their own right.
    There are additional constraints that also must be considered. 
Paramount to all of these recommendations is the need for better data 
within the VA to define the current demand. This will come as the VA 
replaces its extremely outdated scheduling system, an initiative in 
place but not yet fully implemented. Additionally, as demand increases 
and additional staff are required, there is an impact on resources, 
including facility space.
    Outside of these recommendations, there are three additional areas 
that warrant focus to address access to care:

    1) Telemental health: The VA should be commended for its work in 
introducing and developing its telemental health program. IAVA sees 
this initiative as one that is able to fill the gaps in communities 
that have critical shortages in mental health professionals. We look 
forward to working with the VA to continue to continue to develop, 
assess and expand this program to ensure that it is providing high 
quality mental health care to veterans particularly in areas that are 
geographically isolated and/or experiencing severe mental health 
staffing shortages in the community and the VA.
    2) Vet Centers: Since 2003, the VA has expanded the number of Vet 
Centers, and currently 300 exist. Vet Centers continue to be a highly 
praised resource among IAVA's member population. They fill a specific 
need among the veteran population, including serving family members, 
hosting later hours and serving the veteran population regardless of 
discharge status. IAVA would like to see a comprehensive assessment of 
the role the Vet Centers play, the demand for these services and a 
determination of whether the current number of Vet Centers is 
addressing that demand. We feel that this is a critical resource, 
particularly to veterans who may not be inclined to seek services at 
the VA health centers.
    3) The Role of Community Providers: Approximately 60 percent of new 
veterans, and less than 40 percent of the entire veteran population, is 
seeking care at the VA. The care of this Nation's veterans is not the 
sole responsibility of the VA, but rather the community at large. And 
yet, as community providers are called upon to serve this population, a 
recent RAND report \2\ suggests that community providers might not be 
well equipped to address the needs of veterans and their families, 
specifically in understanding high quality treatments for PTSD and 
other mental health injuries. Pilots such as the VA/Community Mental 
Health Partnership can help to provide a framework for how public-
private partnerships can address this skills gap.
---------------------------------------------------------------------------
    \2\ Tanielian, Terri, Coreen Farris, Caroline Batka, Carrie M. 
Farmer, Eric Robinson, Charles C. Engel, Michael Robbins and Lisa H. 
Jaycox. Ready to Serve: Community-Based Provider Capacity to Deliver 
Culturally Competent, Quality Mental Health Care to Veterans and Their 
Families. Santa Monica, CA: RAND Corporation, 2014.

    At IAVA, we believe our members, and all veterans, deserve the very 
best our Nation can offer when it comes to fulfilling the promises made 
to them upon entry into the military. There is no doubt every Member of 
this Committee has the best interests of our veterans at heart. We look 
forward to continuing to work with you and the Administration as 
partners in trying to address these very real challenges with 
innovative and scalable solutions.
    Thank you for your time and attention. IAVA is happy to answer any 
questions you may have.

    Chairman Isakson. Thank you very much.
    Dr. Draper.

  STATEMENT OF DEBRA A. DRAPER, PH.D., DIRECTOR, HEALTH CARE, 
             U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Draper. Chairman Isakson, Ranking Member Blumenthal, 
and Members of the Committee, I appreciate the opportunity to 
be here today to discuss veterans' access to VA mental health 
care.
    My testimony today is based on a report released today, and 
my comments focus mainly on the timeliness of mental health 
care and VHA's oversight.
    Of the 100 medical records for veterans new to VA mental 
health care that we reviewed, 86 percent received their initial 
appointment for a full mental health evaluation within 30 days 
of their preferred date. However, this does not reflect the 
whole story.
    We found that VHA has conflicting policies regarding how 
long it should take a veteran to receive a full mental health 
evaluation. One policy says 14 days while the other says 30 
days. VHA has not provided guidance on which policy should be 
followed, which has caused confusion, making it difficult to 
ensure timely access to mental health care, particularly given 
the increasing demand for care.
    We also found that VHA's wait time calculations do not 
always reflect the overall time veterans waited for care 
because these calculations do not account for the period of 
time prior to establishing the veteran's preferred date, which 
can be quite lengthy.
    VHA disagreed with our overall wait time calculations, 
which calculated wait time from the initial request for care 
until the veteran was seen, stating that these calculations did 
not capture situations that were out of their control, such as 
when a veteran wants to delay care. While this is sometimes 
true, we found instances where requests or referrals for care 
made prior to the establishment of the preferred date were 
mismanaged or lost in the system. Gaining a better 
understanding of veterans' overall wait time experiences 
provides an important opportunity for VHA to identify and make 
needed improvements.
    Additionally, we found that veterans who receive a full 
mental health evaluation may experience additional delays in 
receiving treatment specific to their mental health condition. 
While VHA disagreed with our findings, stating that the full 
mental health evaluation should be considered the start of a 
veteran's treatment, the wide variation we found in the amount 
of time between a veteran receiving this evaluation and their 
next appointment presents an additional opportunity for VHA to 
improve veterans' experiences accessing care.
    VHA monitors access to mental health care, but the lack of 
clear policies contributes to unreliable wait time data and 
hinders oversight. We found that mental health wait time data 
may not be comparable over time because VHA has changed 
definitions used to calculate certain measures. VHA has not 
clearly communicated the definitions used or changes made, 
which has created confusion and limits the reliability and 
usefulness of the data.
    We also found that wait time data may not be comparable 
between medical centers. For example, one of the medical 
centers we visited referred about a third of veterans seeking 
mental health care to an open access clinic, which is a type of 
walk-in clinic, rather than scheduling an appointment. These 
veterans were tracked using a manually maintained list. Follow-
up was inconsistent, and nearly half of those on the list never 
presented for care. This finding is especially troubling given 
VHA's past problems with maintaining lists outside of the 
scheduling system.
    We recommended that VHA issue clarifying guidance on its 
access policies, definitions used to calculate wait times, and 
how open access appointments are to be managed. We also 
reiterated our prior recommendation, which calls for VHA to 
take actions to improve the reliability of its wait time 
measures.
    Very briefly, we also looked at VHA's recent mental health 
hiring efforts as well as a pilot program to help expand 
capacity through the use of community providers. We found that 
while local improvements to mental health care access were 
reported due to the recent hiring efforts, a number of 
challenges were also noted, such as the inability to keep pace 
with the increasing demand for care.
    We also found that in 2013, as the result of an Executive 
Order, ten VA medical centers established partnerships with 
community providers to improve access to mental health care. A 
limited number of mental health care appointments resulted from 
these partnerships, about 2 percent of the total appointments 
provided by the participating medical centers.
    The bottom line is that work is needed to improve veterans' 
experiences accessing mental health care. Given the 
vulnerabilities of veterans seeking mental health care, 
veterans who may be at risk of serious if not life-threatening 
events, ensuring their timely access to care is critical.
    Mr. Chairman, this concludes my opening remarks. I am happy 
to answer any questions.
    [The prepared statement of Ms. Draper follows:]
     Prepared Statement of Debra A. Draper, Director, Health Care, 
                 U.S. Government Accountability Office

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Chairman Isakson. We will take a round of 5-minute 
questions for each Member, and I will begin.
    Dr. Draper, the VA's representative, Dr. Kudler, is going 
to testify after this panel, but in reading his testimony with 
regard to open access appointments, he says, and I quote, ``The 
combination of current policy and training constitutes clear 
guidance on how to manage and schedule open access 
appointments.''
    In the report, open access is discussed quite frequently 
and is a misleading, in some cases, process in terms of the 
actual timeliness of veterans being served. Can you comment on 
that?
    Ms. Draper. Yes. We actually found two medical centers that 
were using open access appointments. One facility--there were 
access audits that were done following the Phoenix issues, and 
one of those facilities, through that access audit, they were 
told that they could no longer use the open access appointments 
without also scheduling appointments. They just could not refer 
someone to a clinic without scheduling an appointment.
    The second medical center that we visited, they were not 
told that, and they would do a telephone triage. A mental 
health nurse would do a triage with the veteran seeking mental 
health care, and at that point, they were referred to an open 
access clinic, which is a type of walk-in clinic, but they have 
actually had a triage through a mental health provider, a 
nurse. It was not the same as a walk-in clinic. VHA did tell us 
that they provided training, but that is not what we observed 
in the field. We did not observe the type of walk-in clinic 
that they were referring to.
    Chairman Isakson. An open----
    Ms. Draper. This was basically a list that people were put 
on. This manual list that maintained outside of the scheduling 
system, where the policy says that those veterans should have 
been scheduled for an appointment.
    Chairman Isakson. Given the problems we had at Phoenix and 
other areas on appointments and masked, m-a-s-k-e-d, use of 
lists to show appointments being made in a timely fashion when 
they really were not, this would have contributed to that. Am I 
not right?
    Ms. Draper. It has, and actually, the medical center that 
was doing this told us that they did this to reduce their ``no 
show'' rates, so----
    Chairman Isakson. I found that to be one of the most 
disturbing parts of the report, because the last thing we need 
to do in the VA health services is continue or do anything that 
perpetuates the memory of what happened in Phoenix in terms of 
the manipulation of data. So, whatever is reported to us needs 
to be an accurate reflection of the timeliness of service 
veterans are getting.
    Ms. Draper. Absolutely. We found that you really cannot 
compare the data between medical centers because of issues like 
that. My question would be, are there other facilities that we 
did not visit that are also using the open access appointments 
without scheduling an appointment.
    Chairman Isakson. Well, the reason we are conducting this 
hearing today is to get the word out far and wide that we are 
very concerned about the timeliness of service to our veterans 
persuing mental health and want to make sure they get the most 
timely service they can with the very best processes they can.
    Mr. Maiers, thank you for your testimony.
    Mr. Maiers. Thank you, sir.
    Chairman Isakson. In your testimony, and we appreciate your 
emotion, because I know you care much----
    Mr. Maiers. I apologize about that. To be honest, I did not 
mean to get that emotional about it. I am trying to stay strong 
here, you know.
    Chairman Isakson. I cry at weddings and funerals, too, so 
do not worry about that.
    Mr. Maiers. I hear you, sir.
    Chairman Isakson. Your testimony was very compelling, and 
your services that you receive from the VA, you were 
complimentary of those services, correct?
    Mr. Maiers. Yes, sir.
    Chairman Isakson. How long did it take you between the time 
you knew you had a mental health challenge and you were able to 
get your appointment scheduled with the VA?
    Mr. Maiers. Well, like I said before, it did take me a 
while to admit that I had a problem, but the program that was 
in place--I think I spoke to my psychiatrist and then 2 weeks 
later, I was referred to this outside place called the Errera 
Center. It is kind of like a subdivision of the VA where, 
basically, all your doctors--your primary care, your mental 
health, your comprehensive work therapist, your peer support 
specialist--are all in one building. So, instead of waiting at 
the VA for hours upon end for one appointment, you can knock 
out all your appointments in 1 day at one place.
    If it was not for this, I do not know, honestly, where I 
would be right now, sir. They have gone leaps and bounds with 
improving my mental health since the day I admitted I had a 
problem.
    Chairman Isakson. What facility was that? What was the name 
of that facility?
    Mr. Maiers. The Errera Center.
    Chairman Isakson. The Errera Center.
    Mr. Maiers. In West Haven, Connecticut.
    Chairman Isakson. Thank you.
    Mr. Karnaze, thank you very much for your testimony. I 
think in your testimony, you said it took you about a year to 
get into the VA Health Care System, is that correct?
    Mr. Karnaze. Yes, sir, it did.
    Chairman Isakson. Is that a year from your severance with 
DOD going into veteran status?
    Mr. Karnaze. Yes, thereabouts.
    Chairman Isakson. Why did it take you a year?
    Mr. Karnaze. I do not know. After I started receiving 
health care here in DC--I used to live in North Carolina, which 
is where I started my paperwork, in the clinic there in 
Wilmington, NC. I moved up here and was receiving care in the 
DC office when I actually received a letter from North 
Carolina--I think it came from Greenville--asking if I was 
still interested in receiving health care benefits from the VA. 
I just ignored that letter because I already was.
    I am not sure, sir, why it took so long for me to get 
pulled into the system. I kind of feel like I had an unorthodox 
entry because I had some symptoms of TBI and they brought me 
in. I was not assigned a primary care physician first. I 
actually went to specialists and then kind of went backwards 
and was assigned a primary care physician.
    Chairman Isakson. Well, I am not going to abuse my 
Chairmanship and take extra time, but we will have a second 
round of questions. I want to delve a little bit further into 
that particular situation.
    Senator Blumenthal.
    Senator Blumenthal. Thank you, Mr. Chairman, and thank you 
for having this hearing.
    Thank you, Mr. Karnaze, Mr. Maiers, and Mr. Butler, for 
your service.
    Mr. Karnaze, I noticed in your testimony a reference to the 
fact--and I do not know whether you repeated it here--that the 
VA threatened to cutoff your benefits because you missed an 
appointment, is that correct?
    Mr. Karnaze. Yes, and there was an appointment that I could 
not make, so I called that number and there was no answer at 
the other end. I left a voice mail saying I have to cancel this 
appointment. This is my name. This is what I am being seen for. 
I cannot make it. I need to reschedule. I did not hear anything 
back.
    Shortly thereafter, maybe a week or two, I received a 
little postcard in the mail saying that I had missed a VA 
appointment and if I continued to miss appointments, I might 
lose my benefits.
    Senator Blumenthal. Are you familiar with that practice, 
Mr. Maiers?
    Mr. Maiers. Yes. I have gotten several of those letters 
myself. I mean, to be completely honest with you, it is hard 
working a full-time job and scheduling your time around the VA, 
because when you go in there, you do not have a choice of 
appointment. They say, Monday, 2:30, Monday, 3:30. You do not 
have a choice. If you physically cannot make this appointment, 
then there is nothing you can do about it. And for us to be 
held accountable for that, I really do not think it is fair.
    Senator Blumenthal. All the more reason for the VA not to 
threaten you with cutting off your benefits.
    Mr. Maiers. That is correct.
    Senator Blumenthal. If you were going to a psychiatrist and 
you missed an appointment and left a message on the voice 
machine, the last thing in the world you would expect is for 
that office to call you back and say, we may not see you 
anymore, or we will not see you anymore. Absolutely 
unacceptable.
    Mr. Maiers. I agree.
    Senator Blumenthal. I want to thank you, Mr. Maiers, for 
making the trip here. Just so the Committee knows, you drive 
for a living and you spent an additional 8 hours on the road to 
get here----
    Mr. Maiers. That is correct.
    Senator Blumenthal [continuing]. Overnight.
    Mr. Maiers. Yes, sir.
    Senator Blumenthal. We will forgive you if you nod off----
    Mr. Maiers. Yeah. I am not at 100 percent today.
    Senator Blumenthal [continuing]. Which is a temptation that 
many spectators feel----
    Mr. Maiers. I hear you.
    Senator Blumenthal [continuing]. Listening to Senators. 
[Laughter.]
    Mr. Maiers. I will try not to fall asleep on you, sir.
    Senator Blumenthal. Well, I want to thank you for being 
here. Thank you for your dad, Leroy's, service.
    Mr. Maiers. Thank you. I will let him know.
    Senator Blumenthal. And for your strength and courage to be 
here, as well as to Mr. Karnaze.
    On the Errera Center, which I have visited more times than 
I can count, as I understand it one of the programs available 
there is the peer program----
    Mr. Maiers. Yes.
    Senator Blumenthal [continuing]. The peer-to-peer, veteran 
helping veteran, program. I have just introduced legislation, 
with support from a number of my colleagues, to expand that 
program----
    Mr. Maiers. Good.
    Senator Blumenthal [continuing]. In effect, to overcome the 
stigma, alienation, sometimes shame that veterans may feel 
seeking mental health care.
    Mr. Maiers. Absolutely.
    Senator Blumenthal. It is against their culture, so to 
speak. I think you have been a beneficiary of the peer program. 
I wonder if you could tell the Committee a little bit about 
your experience.
    Mr. Maiers. Absolutely. I would be honored to. Basically, 
if I can just elaborate on what a peer support specialist is; 
it is a fellow veteran who, basically, takes the role of a--not 
so much a psychiatrist, but puts things into perspective for 
you that only somebody who has been there and gone through what 
you have gone through can understand and help you with. I have 
been through at least a half-a-dozen to ten psychiatrists 
through the VA and I felt was that it was all medicine, 
medicine, medicine, medicine, with no regard for the way I was 
thinking.
    Ever since I have been in the Errera Center, not only do I 
have a peer support specialist, I have a primary care 
physician, and maybe three psychologists. If one does not 
answer the phone, the other one will call me back in 5 minutes. 
I mean, what I have going on for me now has turned my life 
upside down meaning it is 100 percent better and it is all 
thanks to the Errera Center and the VA Health Care System and I 
would like to thank them for that.
    Senator Blumenthal. And the peer program----
    Mr. Maiers. Peer support specialists, absolutely.
    Senator Blumenthal [continuing]. That the Errera Center has 
helped to pioneer----
    Mr. Maiers. Yes. Absolutely.
    Senator Blumenthal. Laurie Harkness has been a tremendous 
force for good----
    Mr. Maiers. Yes.
    Senator Blumenthal [continuing]. In our veterans' 
community.
    Dr. Draper, my reaction on reading this GAO report is I am 
just more astonished and appalled that the VA has not done 
better, even after years of records and documentation and all 
the rest. There still seem to be excessive wait times, 
inconsistent reporting, inadequate data. Do you have an 
explanation? Is it a failure of will or resources? Would you 
give us your sort of from-the-heart assessment.
    Ms. Draper. Sure. I have been involved with the wait time 
work for probably 4 or 5 years now. I think that what we have 
seen, certainly, we see a greater awareness of the need to get 
wait times under control and a greater awareness of making sure 
that the information is accurate.
    However, we still see data reliability issues, and this 
goes back to unclear policies. A lot of schedulers enter the 
data correctly, but the issues that we saw were with the open 
access appointments. So, you cannot really compare data from 
across medical centers and the changes in the wait time 
calculations without providing sufficient definitions.
    All of that is not very comparable, and the system itself--
I think someone mentioned that the IT system does not support 
good scheduling practices. We had one facility tell us they go 
in and check every appointment that is made that day for mental 
health to make sure that it is done correctly. That is a gross 
inefficiency of time, where you have limited resources. That is 
not where people should be focusing their time. The system 
should support what they are doing.
    The policies, ambiguous policies and inadequate oversight 
are the reasons why we put VHA on the High-Risk List this past 
year. We still see some of the same issues.
    Senator Blumenthal. Thank you. Regrettably, my time has 
expired, but I hope to come back to this topic with you and GAO 
and a number of our witnesses and I thank you all for being 
here.
    Chairman Isakson. Senator Rounds.

        HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman.
    I am just curious. It seems strange that the VA would begin 
their process by announcing an appointment without first 
conferring with the individual to find out whether or not they 
could make it. Is that consistent across all of the offices or 
all of the different locations in the VA? Or, did I 
misunderstand the statement, that in some cases you are missing 
appointments because they give you the time and they date. They 
do not ask you whether or not you are available in the first 
place. Did I misunderstand?
    Mr. Maiers. Well, what they do is they offer you a couple 
of appointments, ask which can you make. If you cannot make 
either one of those appointments, then you are--I do not even 
know what word I would use--considered an unauthorized absence. 
You are not there for your appointment. I have received several 
letters that I have missed appointments, but I missed the 
appointments because I was in the hospital. So, how am I 
supposed to go to this appointment when I am in the emergency 
room? It is very stressful.
    It has gotten a lot better and I have the Errera Center to 
thank for that. I am no longer in the VA hospital. I am in the 
Errera Center moreso. So, it is a lot different now.
    Senator Rounds. Dr. Draper, did you find that in your 
reviews?
    Ms. Draper. Well, the scheduling policy calls for 
appointments to be set at what the veterans' preferred date is. 
However, I think there is a lot of confusion about how that 
gets operationalized at the local level, because sometimes it 
becomes, what the next available appointment is. This is really 
an artificial measure, because a veteran does not know what 
that means. So, you see this sort of tug-of-war between the 
scheduler and the veteran. They are pushing the preferred date, 
but that really does not make any sense to a veteran. There is 
still a lot of training and clarification of what all this 
means.
    Senator Rounds. Has implementation of the Choice Act 
increased access to mental health care?
    Ms. Draper. That was beyond the scope of our work, but we 
did look at the community pilot program for mental health and 
it did increase access somewhat. It was pretty limited, and 
there was a lot of confusion among the provider community with 
the many different programs that were going on, the PC-3, the 
Veterans Choice, this program, and they all pay different 
rates, as well. So, it was very confusing for people as to what 
the different programs were.
    Senator Rounds. I know we talked about it and there was a 
discussion about the ``no show'' rate. How does that play into 
this whole discussion? Is it a cascading effect where, number 
1, they are making appointments where, in many cases, the 
veteran is not going to be able to make it in the first place? 
The veteran did not get there and now they have a no show. So, 
now they are going to try a different approach, to push the 
issue. What is with the no-show rates? How are the no-show 
rates consistent between VA versus non-VA? Have you looked at 
any of that?
    Ms. Draper. Not in this particular engagement, but when we 
looked at wait times back in 2012, no show was a huge problem 
for VA. At that time, they did not really have a policy. It is 
called the missed opportunity rate, which includes veterans not 
showing up for care or a clinic canceling an appointment or a 
veteran canceling an appointment. So, all that gets factored 
in. It is really lost productivity for the provider.
    The clinic that we talked about, the open access clinic, 
that was one way they went and tried to resolve their no show 
issue. They did it incorrectly. It is hard to really understand 
what each medical center is doing.
    The policy says that they are supposed to get the veteran's 
preferred date and not supposed to schedule without the 
agreement of the veteran.
    Senator Rounds. What have we learned from it and is there a 
new implementation plan that is trying to achieve a better rate 
than what they have got today? Where are they at right now with 
it?
    Ms. Draper. Yeah, that is probably a good question for the 
VA witnesses that will come up next, but I can say they have 
done some training. Yet, the scheduler, that is a high-turnover 
position. The training is just required to be ongoing.
    Senator Rounds. Are there appropriate specialties available 
for the different needs? My first thought had been that a 
veteran would come in and they would be working with a 
specialist. What I am learning here is that there are multiple 
specialists that are involved with an individual. Could we talk 
a little bit about whether or not those specialists are 
available in the areas where they are needed, or do we have a 
missing link here somewhere in terms of the professionals, the 
trained professionals for the different things that a single 
veteran may need. For anyone who would like to answer.
    Ms. Maffucci. Sir, I can take a stab at that. Yes, each 
mental health professional has their own area of expertise and 
have their own relevance in providing care. I spoke a little 
bit to the staffing models, and the way the staffing models go, 
it is a ratio. There is a preferred ratio of the number of, for 
example, psychiatrists to X-number of veterans that are seeking 
care.
    The challenge is, at the local level, there is really not a 
dynamic system that can really qualify what the demand at the 
local level is, and often, it is left to the local medical 
centers to really determine that. But without the data to 
support it, our understanding is it can be really hard to get 
at that accurately to understand, how many psychiatrists do we 
really need? How many psychologists do we really need? How many 
social workers? And that is really where the data aspect comes 
in, in really defining a more dynamic way of determining the 
demand at the local level, but being led by the national VA.
    Senator Rounds. Thank you. My time has expired.
    Thank you, Mr. Chairman.
    Chairman Isakson. Senator Tester.

           HON. JON TESTER, U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman. Thank you for 
holding the hearing. I thank the Ranking Member, also.
    I want to thank the folks who provided the testimony. When 
our men and women go to war, go to battle, we see their 
courage. We see their sacrifices. When they come home, we never 
see the wounds that they have acquired when they were in 
battle, and I think the testimony here points that out more 
than ever.
    We do have a VA panel coming up. Nick, I will just tell 
you, I apologize. I mean, when you have mental health issues 
and you call somebody, the last thing you want to hear is a 
recording. We will take that up with the VA folks. We certainly 
do not want to be put off and put off, so I appreciate your 
testimony.
    Dean, I appreciate your service and I appreciate your 
passion. It is good to know that the Errera Center is helping 
you and moving you where you want to go. I think that is really 
important.
    I guess I am going to ask the first question for you, Dr. 
Maffucci. To what extent are you seeing the younger generation 
of veterans? Are they more likely to see mental health care 
when they need it, or are they like the previous generation of 
Vietnam veterans, or just tell me.
    Ms. Maffucci. Certainly, among our members, we are finding 
they absolutely are seeking care. Of the folks in our survey 
who responded that they had a mental health injury, three out 
of four were getting care, some outside the VA, more of them 
within the VA. It is really huge that we are seeing that among 
the younger generation. There are more conversations that are 
happening. There is a support system in place, a buddy system 
in place; and in having these conversations, we are seeing a 
higher demand.
    Senator Tester. OK. Roscoe, regarding The American Legion, 
you have got some veterans from previous conflicts. Is the 
stigma still there for them? Are they becoming more willing to 
go get mental health care, or do they still say, no, that is 
for somebody else?
    Mr. Butler. For the Vietnam veterans, they continue to rely 
on the Vet Centers. They still do not trust the VA system and 
they want to be separate from the system----
    Senator Tester. Right.
    Mr. Butler [continuing]. And that the Vet Centers maintain 
a separate system, so that they believe that the information 
they share with the Vet Centers remain confidential and 
entrusted by the Vet Centers.
    Senator Tester. Got you. Got you.
    Ms. Maffucci. Sir, if I may----
    Senator Tester. Go ahead.
    Ms. Maffucci [continuing]. Just add very quickly, stigma in 
the post-9/11 generation still does exist----
    Senator Tester. Yes.
    Ms. Maffucci [continuing]. And I want to make sure that we 
are clear about that. But, I think it is improving through the 
supports that they have established.
    Senator Tester. Well, we have got a long ways to go on the 
stigma----
    Ms. Maffucci. Absolutely.
    Senator Tester [continuing]. Which is why when somebody 
like these two fellows are willing to step up and say, I know I 
have a problem, that is a huge step and we owe them--we owe 
them better----
    Ms. Maffucci. Absolutely.
    Senator Tester [continuing]. And they ought not to have to 
go to a center to get that help, to be honest with you.
    Mr. Karnaze. Sir, if I may, I think one of the reasons why 
we are seeing more younger veterans look for help is because 
within the military itself, we are getting better at that.
    Senator Tester. Yes.
    Mr. Karnaze. I know in the special operations community, we 
do something called third location decompression, where on our 
way home from the war zone we have to stop for 3 days, a small 
group of the guys----
    Senator Tester. Yes.
    Mr. Karnaze [continuing]. And we have two required 
meetings. One is with a psychologist and one is with the 
chaplain.
    Senator Tester. Yes.
    Mr. Karnaze. That kind of makes it OK. So, we are leaving 
the military knowing, OK, something is not right. It is OK to 
ask for help. But, absolutely, the stigma is still there.
    Senator Tester. Yes, and that decompression is good. That 
is something we have worked on the DOD: to make sure that there 
is an education process going on, to learn what their benefits 
are, and to know that it is a big deal if they need to ask for 
help, because it is curable. We can fix it, like a broken arm; 
we need to look at it that way.
    Dr. Draper, you pulled 100 medical records. I just want to 
get an idea. Is that an adequate sample?
    Ms. Draper. Well, they were random--we took 20 each for the 
five facilities that we visited.
    Senator Tester. You just took them randomly out of the----
    Ms. Draper. We took a random sample of each facility. These 
were patients new to mental health care.
    Senator Tester. OK. When you looked at these, did you look 
at all to see if the problem was in staffing, inadequate 
staffing, or facilities, or----
    Ms. Draper. We tracked the date that the patient or the 
veteran initially requested care, then took it through when 
they first received their full mental health evaluation----
    Senator Tester. Right.
    Ms. Draper [continuing]. And the next appointment. Then, we 
also spoke with the facilities that we had these medical 
records. They confirmed that our reviews were accurate, and 
then we talked to them about their staffing needs.
    Senator Tester. What did they say about their staffing 
needs? Were they understaffed, or did they have extra staff?
    Ms. Draper. The facilities that we visited, their vacancy 
rates ranged anywhere from 9 to 28 percent in mental health.
    Senator Tester. Do you know how that compares with general 
practitioners?
    Ms. Draper. Yes. The vacancy rate for mental health is, I 
think it is 14 percent; and 16 percent for VA overall.
    Senator Tester. You are saying the vacancy rate is less in 
the mental health area than it is in the----
    Ms. Draper. It depends on--it ranges anywhere from 0 to 28 
percent for the facility. So, it varies by facility.
    Senator Tester. OK.
    Ms. Draper. Some of the rural areas have particularly 
difficult times recruiting mental health professionals.
    Senator Tester. OK. My time has expired.
    Thank you, Mr. Chairman.
    Chairman Isakson. Senator Moran.

           HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

    Senator Moran. Mr. Chairman, thank you very much. Thank you 
to those who are here to testify today. Thank you for your 
service to our Nation. You are once again serving our Nation by 
your testimony and I am grateful for it.
    Dr. Draper, you have been at the GAO for a while.
    Ms. Draper. Mm-hmm.
    Senator Moran. Do you care to put on the record how many 
years? [Laughter.]
    Ms. Draper. I have had two tours of duty, so in total, 8 
years.
    Senator Moran. In those 8 years, have you been involved in 
reviewing the operations of the Department of Veterans Affairs?
    Ms. Draper. I have been involved probably for the last 5 
years.
    Senator Moran. I want to use your experience in an 
institutional way, because what strikes me today as I sit here 
is, once again, this Committee--I previously served on the 
Veterans Committee in the House. We have veterans who come tell 
us the circumstances they find themselves in. We have GAO and 
OIG who come and give us reports. We have been doing this for a 
long time. What strikes me as I listened to the testimony here 
of this panel, and what I, to some degree, can expect from the 
Department of Veterans Affairs, I am going to hear something 
very similar to what I have heard on previous occasions about 
mental health or health care or benefits, and how the VA is or 
is not capable of meeting the needs of our veterans.
    My point of that conversation is, it seems to me, not much 
changes. As someone who has examined the Department of Veterans 
Affairs for the last 5 years, is that perception correct? What 
is it that we can do to get out of the cycle of inviting you to 
come and report on GAO studies? What is it that we can do to 
get out of the cycle of asking veterans how things are going 
and to have The American Legion, PVA, VFW and others in front 
of us telling us about their members and their experiences, 
then the Department of Veterans Affairs explaining what is 
going on? How do we get out of the cycle of hearing the same--
it is a different topic each time, but it is the same set of 
circumstances that veterans find themselves in?
    Ms. Draper. I would love to report something different. I 
know that we sound like a broken record sometimes, but there 
are common themes. Going back to the reasons we put VHA on the 
High-Risk List this past year, there are five common themes and 
we see them here again in this work. (1) Inadequate policies; 
(2) things play out differently at the local level, you have 
got a lot of variation among medical centers; (3) there is poor 
oversight; (4) data systems or information technology that does 
not support good practices; and (5) lack of training and 
resource allocation--identifying what the resource needs are 
and appropriately allocating those.
    One of the issues with agencies that are put on the High-
Risk List is that they are in need of major transformation, 
which I think is certainly true of VA, or VHA. VHA is what we 
put on the High-Risk List.
    Senator Moran. If I could paraphrase what I think you are 
telling me, which is those five circumstances are common 
throughout the VA regardless of what audit report you are 
preparing, what the topic is. Those failures continue to exist 
systemwide----
    Ms. Draper. I would say it is systemwide in VHA.
    Senator Moran. VHA, OK.
    Ms. Draper. Right.
    Senator Moran. Let me take you to my question again, which 
is, so what can we do--what can I do as a Member of Congress, 
what can this Committee of the U.S. Senate do, so that when we 
have a hearing 6 months from now, or a hearing a year from now, 
the conversation, the testimony is different than what we hear 
today?
    Ms. Draper. To get off the High-Risk List, it calls for the 
creation of a framework. There are specific criteria to get off 
the High-Risk List. I think that is a good place to start. 
There are five criteria which provide a good road map to help 
frame an action plan to get off the list. The independent 
assessment that was recently done, that also provides great 
information. The Commission on Care is going to be issuing a 
report. All that is information that can be funneled into a 
framework for transformation.
    Senator Moran. Finally--and perhaps it is the repetition of 
my questions--there are recommendations, there is a guide plan, 
a path to reverse the themes that caused you to have placed 
them on high-risk.
    Ms. Draper. Right.
    Senator Moran. Is there evidence that it is being pursued, 
the path to get off the high-risk category?
    Ms. Draper. We have not seen a lot of progress yet.
    Senator Moran. Mr. Chairman, thank you.
    Chairman Isakson. Thank you, Senator Moran.
    Senator Murray.

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

    Senator Murray. Mr. Chairman, thank you, and thank you to 
all of our witnesses. I share the frustration that I am hearing 
from all of you and Senator Moran. When I was Chairman of this 
Committee, we actually held several hearings on mental health 
care. We asked for several IG and GAO investigations. We 
demanded that the VA hire more providers and listen to the 
providers in the field about the barriers they were facing. We 
even passed into law reforms.
    It is really frustrating to be sitting here again today, 
and I am having a hard time understanding what really has 
changed since 2012. Why is it that the VA still does not have 
an accurate picture of wait times? We do not have a staffing 
model for mental health care at the VA that works and have an 
alarmingly high number of vacancies still? It is very 
frustrating, and I think something that we cannot just have a 
hearing on. We really need to work on this. I really appreciate 
having this hearing today.
    Dr. Draper, thank you to you and your team at GAO for the 
work you are doing on overseeing VA's mental health care 
facilities. I am very concerned about the findings. You said in 
your testimony that you found a medical center with a mental 
health vacancy rate as high as 28 percent, and as Mr. Butler 
mentioned, the Legion found, in a site visit to Baltimore, they 
had a 38.5 mental health vacancies.
    What is worse, you mentioned VA projects they will need 
another 12 percent increase in mental health staff on top of 
those current vacancies just to keep up the demand through 
2017. There is a major shortage of mental health care providers 
around the country already and VA is struggling to hire. So, I 
am very concerned about how the VA is going to be able to keep 
up.
    What can the VA do to get enough providers into the system 
to meet the increasing needs of our veterans?
    Dr. Draper.
    Ms. Draper. I can talk a little bit about this. I think 
that what we found is that some of the things that they are 
doing, they are offering hiring bonuses, retention bonuses. I 
will say, there are real concerns with the hiring process 
itself. It is a very lengthy process. What we heard from the 
medical centers that we visited is it sometimes takes up to a 
year to get a mental health professional on board. During that 
period of time, they often lose people to the private sector. 
We repeatedly heard about all the VA medical centers trying to 
recruit at the same time, so there is a lot of competition 
between the different facilities.
    So, there are a lot of challenges related to trying to get 
people on board. I think if some of those challenges are 
addressed, that may pave the way for some smoother transition 
of people into VA. The lengthy hiring process, we heard that 
across the board. Some of that depends on the sophistication of 
the individual facility. Some have more sophisticated human 
capital departments than others and it is a real struggle.
    Senator Murray. If a veteran cannot get into care, if they 
cannot get in for follow-up appointments, what is the chance 
they are going to stay in treatment or drop out?
    Ms. Draper. I will say that of the facilities we visited, 
there are some very dedicated mental health professionals. 
Thank goodness they are there, because I think the problems 
would be a lot worse, because they really work hard to try to 
make things work with what they have.
    We see things like they are spreading out appointments for 
longer periods of time. They are trying to convert space to put 
new people in. We have heard stories about converting closets 
into small offices, trying to do some sharing of space. So, 
there are a lot of things going on, but there is not a systemic 
or a systematic approach to how to counter these shortages.
    Senator Murray. OK. Mr. Butler, I wanted to ask you, in 
your testimony, you talked about feedback the Legion received 
from the Seattle VA community mental health summits. I was 
really concerned by that report. VA hospitals were actually 
directed to interact with patients in the community to improve 
communication and awareness of mental health services. Instead, 
it seems they kind of created pointless bureaucracy, and 
according to the report, managed to actually make the 
relationships worse. Tell me what you think the Puget Sound VA 
ought to be doing to improve communication and interaction with 
its veterans.
    Mr. Butler. Our experience varied across the country in 
terms of who responded to our questions. But in regard to the 
one service officer who shared that information, he felt that 
the summit was demeaning and it was not focused in terms of 
trying to draw the community partners together in terms of what 
can we do to serve veterans. But it was more talk down from the 
VA.
    I think what they need to do is to reach back out to the 
community and involve the community in such a way that the 
community feels that they are valued, that whatever they bring 
to the table and whatever they can offer, that the VA is being 
genuine and allow them to provide the opportunity to help the 
VA in that regard.
    Senator Murray. I would appreciate if you would ask your 
members in Washington State to get in touch with me. I would 
like to work with them and work on helping develop better 
relationships out there. So, if you could follow up with this, 
I would really appreciate it.
    Mr. Butler. Will do.
    Senator Murray. Thank you.
    Chairman Isakson. Thank you, Senator Murray.
    Senator Tillis.

       HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. Thank you, Mr. Chairman.
    First off, I would like to associate myself with the 
comments that have been made by Senator Murray, Senator Moran, 
and others about the concern with this continuing dialog. I 
have only been here 10 months and I am really becoming 
frustrated with the lack of progress. I cannot imagine those 
who have served much longer seeing basically the same thing.
    Some of these things speak to systemic problems that we do 
not seem to be getting at, and Chair, I have lost count. How 
long has it been since we have had a permanent IG in the VA?
    Chairman Isakson. A long time. How long has it been? 
Sixteen months.
    Senator Tillis. It seems to me that when you are looking at 
root causes to these sorts of problems, the sort of resources 
that will really focus on it, like the IG's office, like the 
work that Dr. Draper has done, we need to put every single 
resource that we can put on it as quickly as possible to get to 
some of the systemic problems.
    Mr. Butler, I wanted to talk to you about something. I 
apologize for being late. I had a conflict earlier. But, I 
happened to run into a veteran on a flight, sat next to a 
veteran and his wife on a flight from Charlotte up here to D.C. 
a couple of weeks ago, and he is 100 percent disabled, special 
operator, served for 15 years, and had overcome his own 
challenges with PTSD and has really found a calling by helping 
others. He is very well known. He is down in Mississippi.
    He had a veteran call him who knew he was in a crisis 
situation. It was a domestic situation with his wife. He called 
the VA for help. Now, this is an immediate crisis situation, 
and the feedback that he got from the VA, it would be 4 days 
before they could get back with him.
    In these crisis intervention scenarios, did he just call 
the wrong number, or are you reporting back from your members--
and anyone can respond to me--a personal experience where this 
is not just aberration, but something that we should seriously 
look into?
    Mr. Butler. I think that the person he spoke to was not 
trained in terms of the crisis intervention, the crisis 
hotline. Every facility has a crisis intervention team that 
should immediately put them in contact with the appropriate 
people that can--locally as well as at the crisis center--that 
can address their immediate needs and problems. I think that 
whichever facility he contacted, they need to provide some 
remedial training to their staff, because VA----
    Senator Tillis. There should have been an option.
    Mr. Butler. Right. There should have been an option.
    Senator Tillis. OK.
    Mr. Butler. They have an excellent crisis----
    Senator Tillis. Well, I think it got worse, because then 
when he called this veteran and he realized that he needed help 
and he wanted to remove him from that situation, this man 
carried him to a hospital, drove him several hours, and they 
waited in an emergency room setting from about 3 in the 
afternoon until about midnight before he was actually able to 
get to a point where he was first able to see somebody that 
could help him with the intervention. Is that just another 
breakdown in training or a systemic problem?
    Mr. Butler. I think that that is a systemic problem with 
that particular center, because that should never have 
happened.
    Senator Tillis. Now, I want to get back to Dr. Draper. Dr. 
Draper, on page six of your opening testimony, I want to get 
back to--I have got a lot of questions I could ask you all, and 
you all know that. I have not figured out how to work in the 
Camp Lejeune toxic substances comment into this----
    [Laughter.]
    Senator Tillis [continuing]. I just figured I will put it 
out there randomly. I will have the next panel to talk about 
with that.
    This graphic is interesting. Why is it not easy to define 
what a wait time is? To me, a wait time is when the veteran is 
waiting when he or she does not want to. It sounds like a part 
of the questions in your testimony about an objection to your 
methodology, well, it does not count the times when the veteran 
really wants to be seen later. Great. Solve for that and then 
figure out what the real wait time problem is. What am I 
missing?
    Ms. Draper. That is really an artificial measure as I 
mentioned in my opening remarks. You know, a veteran really 
does not know what it means to have a preferred date, and we 
found that the time between initial request and getting into, 
you know, establishing a preferred date, that is done at the 
time that they actually talk to a scheduler.
    Senator Tillis. I think with this chart you kind of set the 
context within which you should be able to define something 
where we can determine whether or not the VA is achieving 
acceptable wait times or not.
    The other question I had for you was why would the data be 
incompatible in your analysis between the VAMCs?
    Ms. Draper. The example of the two VA medical centers, or 
the one that had the open access appointments, they never 
really scheduled an appointment until the person actually 
showed up, even though they had talked to them. It may have 
been months before. When they actually show up, they show a 
zero wait time, so that is what gets recorded----
    Senator Tillis. And that happens in one and not another?
    Ms. Draper. It can happen for other reasons that way, but 
that was a good example of where you might see some zero wait 
times, which is not accurate. We had a case where someone on 
that list had called the VA and they were put on that list. A 
month later, they presented in the emergency room suicidal and 
they were admitted to an inpatient unit. It is not really a 
true wait time. There are other things, data entry errors. 
There are a lot of things where the data just are not 
comparable between facilities.
    The interesting thing is, we did 100 medical records, but 
that took a lot of work to do because this is a very 
complicated system to go through. What we know, one of the 
VISNs is currently doing something similar because they believe 
that that period of time is also important to identify 
problems. It is not consistently done throughout VA, and I 
think if the VA instituted doing audits in their facilities, 
such as what we did, they would find a lot of areas that 
potentially could be improved.
    Senator Tillis. Which, again, points back to how I started 
this conversation. The more people we have auditing the systems 
and the outcomes, the better off we are. The VA should welcome 
that as an additional resource, not as some perceived threat.
    Thank you, Mr. Chair.
    Chairman Isakson. Thank you, Senator Tillis.
    Senator Brown.

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

    Senator Brown. Thank you, Mr. Chairman.
    Mr. Karnaze, I want to understand your personal experience 
better. Senator Tester and I got on this Committee the same day 
in 2007, and everywhere I went in my State as I did roundtable 
after roundtable with veterans, some recently returned 
veterans, others that had been in the VA system and been 
treated generally pretty well, we have a number of VA centers, 
VA hospitals, and we have in my State probably 27 or 28 CBOCs 
now that serve veterans very well.
    But, I heard repeatedly, as you all are aware, that in 
those days, that if you were home on leave from Iraq and you 
went to the CBOC in Mansfield, my home town, or you went to a 
hospital in Dayton or Cleveland, they did not have your medical 
records. It has been a long-term battle to get DOD interested 
enough and to have the right interface between DOD and the VA. 
We still have not made the progress we should yet.
    I heard repeatedly from veterans, I remember at Cleveland 
State and at Youngstown State, there were veterans that were 
integrating into a classroom, veterans or soldiers that were 
infantry and they returned home and they are sitting next to an 
18-year-old suburban kid and the experiences were so different, 
all of that. But they also said that when they did not re-up, 
the DOD just said, see you, without talking nearly enough to 
the soldier or the Marine or the airman or woman about what VA 
benefits were. We see all those problems. I think they are 
improving. They are not there yet.
    I want to understand better with you, when you got out, 
when you came back, when you tried to get access to VA, you 
said it took a year before you could get in. What does that 
mean? They had none of your records? Tell me sort of your 
experience that way.
    Mr. Karnaze. I consider myself quite fortunate in that when 
I was leaving the Marine Corps in Camp Lejeune, there was 
actually a nonprofit aboard Camp Lejeune that would help soon-
to-be veterans get everything together and submit to the VA. I 
brought all my medical records to them. We went through it 
together. They helped me compile the second set of records for 
me to hold on to.
    Then, there was actually a VA center or small office aboard 
Camp Lejeune where I did my out-processing physical. I went 
through that whole out-processing physical, I guess, with them. 
They had all of my records and they set up all of the follow-on 
appointments for me to go through my screening process so they 
could determine what was service related and what was not. And 
then that just went off someplace.
    From that point, start the clock, I finally received a 
letter in the mail with my disability rating and saying that I 
now had coverage. During that time, I went to the local VA 
clinic in Wilmington, NC, because I was pretty sick. I had 
tried to get treatment and I ended up just leaving because they 
did not have anything in the system. Apparently at that point, 
I did not receive health care from the VA.
    When I moved here to D.C. is when I actually received the 
letter from the VA with everything like that. And then once I 
received that letter, I could be a bit aggressive, so I just 
started burning up the phone lines, calling the D.C. office 
here because I wanted some help with some of the concentration 
issues, and that is when they connected me.
    A very wonderful nurse--I forget her name--she took me in. 
She asked who my primary care physician was. I told her, I do 
not know. I do not have one. I do not know how to get one. She 
was, like, OK. Well, let us get this taken care of first. She 
connected me with neurology. We did a bunch of cognitive exams. 
That is why earlier when I said I kind of entered in an 
unorthodox fashion, I feel like I did, because I went through 
all these specialists before I finally received my primary care 
physician, who is down at Fort Belvoir.
    I am not sure how the process is supposed to work. I just 
know that is how it was with me, and a lot of that was me being 
highly aggressive on the phone, in a tactful manner, but until 
they finally responded.
    Senator Brown. People for a whole host of reasons are not 
as aggressive as you, because of the stigma, because their 
personality is not so outgoing as yours, for a whole host of 
reasons, if they are not as aggressive with you, what happens 
then? You said partly DOD. Is it all VA? What do we do to get 
people in the system, and if they want cognitive therapy, that 
they can make those choices with their provider to go in the 
right direction?
    Mr. Karnaze. I think, in some cases, they die on the vine. 
If they do not reach out, I think they are lost and they will 
not enter the VA system. And for the ones that do, I feel out-
processing--because at the time when you are leaving the 
military, you are pretty excited, or depending on the 
situation, maybe not so excited, and you are worried about your 
DD-214, right, free man, free woman. But, the out-processing 
class that you mentioned, my experience was very poor. It was 
just a few hours, a representative from the VA saying, hey, if 
you need a home loan, also, you get health care for 5 years as 
a post-9/11 veteran. Here is a pamphlet, and their phone number 
is in there. I was, like, cool. Roger that. Got it. All right. 
Let us go. And then you are, like, I do not know what to do.
    Senator Brown. That was VA or that was----
    Mr. Karnaze. That was a representative from the VA. We 
called it TAPS, the Transition Assistance Program. There was a 
group of us, all ranks, ages, shapes, and sizes at Camp Lejeune 
and we sat through this class. Most of the people fell asleep 
in the back of the room. The VA presented first, which I think 
was great, but again, it was a short, few hour presentation, 
and then we walked away with a cool little handbook and that 
was the extent of it.
    Senator Brown. Last question, Mr. Chairman. Thank you.
    If that could have been an important discussion, meeting, 
briefing, how should they have done that TAPS different than 
that way?
    Mr. Karnaze. I feel that this is such an important issue, 
that the servicemember at the time does not realize how 
important it is. If the VA or a representative took the time 
and fully outlined the process, this is what you need to do, 
this is where you need to submit your records, this is who you 
need to engage with aboard this base to get into the system, 
these are numbers that you can reach out to, expect this 
timeframe. What is going to happen now is we are going to 
review your medical records and then we will get back to you 
with your disability rating. At that point, you can contact 
whoever to get assigned your primary care physician.
    The process was never outlined to me or any of the Marines 
that I served with, so we were quite confused about what was 
going to happen next. I think just explaining it, just 
communicating to the veteran the way the process works would be 
of great assistance.
    Senator Brown. To your recollection, Mr. Karnaze, it is 
basically that they gave you a brochure to tell you that?
    Mr. Karnaze. Yes, sir.
    Senator Brown. Yes, Mr. Butler, sure.
    Mr. Butler. Senator Tester----
    Senator Brown. He is Tester, I am Brown, but that is OK.
    Mr. Butler. Oh, I am sorry.
    Senator Brown. Do not ever call me that again. [Laughter.]
    Mr. Butler. OK. Sorry, Mr. Brown. So, prior to----
    Chairman Isakson. They look a lot alike.
    Mr. Butler. Prior to the program changing from TAP to 
Transition GPS, service officers were allowed to participate in 
the program. Now, since the program has changed to Transition 
GPS, service officers are no longer a part of the program. If 
Veterans Service Organizations were allowed to participate in 
the program, we could bring a wealth of experience and 
knowledge and assistance to servicemembers prior to their 
transition from active military service to the VA.
    Senator Brown. Thank you. Perfect. Thanks.
    Chairman Isakson. With the indulgence of the Committee, I 
am going to pass on a second round except for one question that 
Senator Blumenthal has----
    Senator Blumenthal. I have a----
    Chairman Isakson [continuing]. Because of the importance, I 
think, that the VA testimony be heard in the context of this 
testimony. Thank you for being here.
    Senator Blumenthal has a question, then we are going to 
switch panels.
    I want to acknowledge for Senator Tillis that although he 
failed in his 6 minutes and 13 seconds to mention Camp Lejeune, 
Mr. Karnaze did it four times in 1 minute, so it got done. 
[Laughter.]
    Senator Blumenthal.
    Senator Blumenthal. I have a very quick question for you, 
Dr. Draper. I am looking at your chart on page six----
    Ms. Draper. Mm-hmm.
    Senator Blumenthal [continuing]. Which shows that the VA, 
at least in some of its facilities, is still vastly under-
calculating the amount of wait time, in effect, in this 
instance, measuring it from not the date of the request for 
health care, but from the date of the veteran's preferred date, 
which then was unfulfilled. The veteran had to wait another 5 
days, and that is what was measured as the wait time, not the 
full 17 days that the veteran actually had to wait.
    Ms. Draper. Yes. The policy is that it is measured using 
the preferred date as the basis----
    Senator Blumenthal. That is exactly the kind of, in my 
view, wrongdoing that the VA was committing in facilities 
around the country that we sought to correct and the VA said it 
was correcting in the so-called reforms that it instituted 
after the Phoenix debacle and other revelations, which, in my 
view, cast doubt on the reliability and trustworthiness of a 
lot of the data we have been receiving from the VA.
    Ms. Draper. It is how you define wait times. It can be a 
wait time is when somebody initially requests care to when they 
actually receive treatment. Another part of the issue with the 
way that they are calculating it is their IT system does not 
support the calculations on that longer wait time. They could 
do what we did, do some audits. We have one, as I mentioned, 
one VISN that is doing that, and there is a lot to be learned 
by doing those types of audits as to what kind of systemic 
things you see during that period of time before the 
establishment of the preferred date.
    Senator Blumenthal. Well, you know, I think a lot of us are 
expressing frustration with the apparent finding of your report 
that the VA may have learned nothing from what has happened in 
the past. Thank you.
    Chairman Isakson. For the Committee's information as well 
as the audience, we are going to have a hearing in December on 
transition from DOD health care to veterans health care, to 
focus on that problem, because there is a black hole that 
everybody seems to fall into from one to the other, and the 
Warrior Transition Centers at active duty, which are such a 
good service, kind of do not get transferred to the VA when the 
veteran is getting ready to transfer, and we want to see if we 
cannot expedite that process and make it better.
    I want to thank our panelists for testifying and ask our 
second panel to please come forward. [Pause.]
    I am pleased to introduce our second panel for the hearing 
today for testimony, Dr. Harold Kudler, the Chief Consultant 
for Mental Health Services, Department of Veterans Affairs, who 
is accompanied by--I think that means they are going to back up 
his answers if he screws it up, but anyway, Dr. David Carroll, 
Executive Director, Mental Health Operations, Department of 
Veterans Affairs, and Dr. Michael Davies, Executive Director, 
Access and Clinical Administration Program, Department of 
Veterans Affairs.
    Thanks to all of you for being here today. We welcome you 
to begin your testimony, Dr. Kudler. About 5 minutes, if you 
will.

 STATEMENT OF HAROLD KUDLER, M.D., CHIEF CONSULTANT FOR MENTAL 
     HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DAVID CARROLL, 
   PH.D., EXECUTIVE DIRECTOR, MENTAL HEALTH OPERATIONS; AND 
 MICHAEL DAVIES, M.D., EXECUTIVE DIRECTOR, ACCESS AND CLINICAL 
                     ADMINISTRATION PROGRAM

    Dr. Kudler. Thank you, sir. Good afternoon, Chairman 
Isakson, Ranking Member Blumenthal, and Members of the 
Committee. Thank you for the opportunity to discuss access and 
timeliness of veterans' mental health care. I am accompanied, 
as we say, by Drs. Carroll and Davies.
    Just today, GAO reported a need for clearer guidance on 
access and wait times, and VA is committed to providing timely 
access which supports veterans' reintegration into their 
families and communities. We appreciate GAO's review, concur 
with its recommendations, and have taken action to address 
them, and will continue to take action.
    GAO found that VA met mental health hiring initiative goals 
at the national level, but individual VAs continued to face 
challenges in hiring and in meeting the increasing demands for 
care. In 2012, VHA began its hiring initiative under Executive 
Order, and as of June 2013, approximately 5,300 new clinical 
and non-clinical mental health staff were hired. Almost half of 
these filled existing vacancies. Nationally, outpatient mental 
health staffing increased by 25 percent between 2010 and 2014. 
By December 2013, we had also hired 932 peer specialists. Peer 
specialists, as Mr. Maiers said, can say, ``I have been where 
you have been and VA can help.'' GAO documented local 
improvements in the wake of these hires.
    VA has revised and tested its metrics and management 
process and is now ready to update to a 30-day timeliness 
standard based on the requirements of the Veterans Choice Act. 
The target completion date for this is March 2016.
    Open access ensures that any veteran can receive urgent 
mental health care at any entry point in our system within 24 
hours. Each facility must have a defined process for warm 
handoffs to a professional who can conduct same day mental 
health evaluations and arrange appropriate follow-up. VHA has 
trained more than 23,000 schedulers this year in support of 
open access. VHA has simplified access measure methods and 
definitions and publicly releases wait times for every facility 
and service every 2 weeks.
    In June 2015, we issued clarification to all network 
directors, saying VHA measures patient wait time using 
preferred date or clinically indicated date as the first 
reference point and the pending or completed appointment date 
as the second reference point. An updated data definition will 
be posted on our Quality of Care public site this month.
    Although excessive appointment delays do exist at specific 
locations, the recent MITRE-RAND assessment required by the 
Choice Act found that there were no systemwide crises in access 
to VHA care. The Altarum-RAND report of 2011 concluded 
timeliness for mental health or behavioral health care in VHA 
is as good or better than in commercial and public plans.
    VA integrates mental health services into primary care and 
other settings to minimize barriers to care. By combining 
effective engagement with systemwide screening, VA produced a 
71 percent increase in the number of veterans receiving mental 
health care between 2005 and 2014, outpacing overall growth 
among veterans receiving any VA health care. Still more 
dramatic was an 87 percent increase in the number of mental 
health encounters during that same period.
    Last year, more than 1.5 million veterans--that is 27 
percent of all veterans served by VA--receive mental health 
care in VA, and 200,000 combat veterans, servicemembers, and 
family members were engaged and served by our 300 Vet Centers 
and 80 mobile Vet Centers.
    Access means nothing, however, without quality. The 
Altarum-RAND study found that the quality of VA mental health 
care is as good or better than that reported for patients with 
comparable diagnoses who receive care through private 
insurance, Medicare, or Medicaid.
    VA is an innovator in telemental health care and has 
provided 335,000 telemental health encounters in 2014. Ten 
thousand of these were by video in the veteran's own home, and 
new technology and new policy will allow us to expand that 
tremendously. This is particularly important to the one in four 
veterans who live in rural areas. Telemental health also allows 
VA to adjust the supply of providers across the country, even 
where those providers do not live. VA mobile apps and award 
winning online services further enhance access and engagement.
    The Veterans Crisis Line reaches an ever-growing number of 
veterans on an urgent basis through voice, chat, and text 
options. As the number of calls increases, so do referrals to 
VA.
    VA leads the world in the treatment of deployment mental 
health problems and develops gold standard tools used around 
the globe. We are developing integrated treatments for 
depression in veterans with spinal cord injury and for chemical 
dependents and those with chronic pain.
    Our Mental Health Centers of Excellence, including the 
National Center for PTSD and our MIRECC produced over 1,300 
peer reviewed scientific papers per year in the last 3 years.
    Mr. Chairman, VA is committed to the care of our veterans, 
the care they have earned. We appreciate Congress's support, 
and we are prepared to respond to any questions you may have.
    [The prepared statement of Dr. Kudler follows:]
Prepared Statement of Harold Kudler, M.D., Chief Consultant for Mental 
  Health Services, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
    Good morning, Chairman Isakson, Ranking Member Blumenthal, and 
Members of the Committee. Thank you for the opportunity to discuss the 
important topic of access to and timeliness of Veterans' mental health 
care. I am accompanied by Dr. David Carroll, Executive Director, Mental 
Health Operations and Dr. Michael Davies, Executive Director, Access 
and Clinical Administration Program.
                         vha mental health care
    The Veterans Health Administration's (VHA) mission is to honor 
America's Veterans by providing exceptional healthcare that improves 
their health and well-being. Providing timely access to that care is a 
critical aspect of our mission. Access enables VHA to provide 
personalized, proactive, patient-driven health care; achieve measurable 
improvements in health outcomes; and align resources to deliver 
sustained value to Veterans. VHA is continually monitoring wait times 
and making adjustments as needed to ensure that Veterans have access to 
the best care they rightfully deserve.
    Between 2005 and 2014, the number of Veterans who received mental 
health care from VA grew by 71 percent. This rate of increase is more 
than 3 times that seen in the overall number of VA users. The increase 
in the number of mental health encounters or treatment visits, from 
10.5 million in 2005 to 19.6 million in 2014, has been even more 
dramatic--an 87-percent increase. This reflects VA's concerted efforts 
to engage Veterans that are new to our system and stimulate better 
access to MH services for Veterans within our system. These include 
outreach and engagement through 300 Vet Centers, 70 Mobile Vet Centers, 
Primary Care/MH Integration at VA medical centers, and large community-
based clinics. VA Telemental Health innovations provided more than 
335,000 encounters to over 108,000 Veterans in 2014. Telemental Health 
reaches Veterans where and when they are best served. VA is a leader 
across the US and internationally in these efforts. VA's 
MaketheConnection.net, Suicide Prevention campaigns, and the PTSD 
mobile app (which has been downloaded over 208,000 times) add to the 
increase in MH access and utilization. These efforts align with VA's 
interagency activities including the Cross Agency Priority (CAP) Goals 
and expanding VA MH policy and practice. As a result of these trends, 
the proportion of Veterans served by VA who receive mental health care 
increased to more than 1.5 million Veterans. In 2005, 19 percent of VA 
users received mental health services, and in 2014, the figure was 27 
percent.
                               gao report
    This month the Government Accountability Office (GAO) released a 
report regarding the need for clearer guidance on access policies and 
wait time data relating to VA mental health care. VA is committed to 
providing timely access to high quality, recovery-oriented mental 
health care that anticipates and responds to Veterans' needs and 
supports their reintegration into their communities. VA appreciates the 
GAO review of timely access to mental health care issues at VA medical 
centers (VAMC) and concurs with GAO's recommendations. We take the 
findings very seriously and have implemented action plans to address 
the recommendations.
    The GAO report found that the way in which VHA calculates mental 
health wait times may not always reflect the overall amount of time 
Veterans wait for care. Specifically, GAO notes that a patient who 
presents with Mental Health concerns receives an initial evaluation 
within 24 hours and may not receive a full evaluation until a later 
date. However, this initial evaluation is the start of treatment. It 
includes initial diagnostic evaluation and treatment of the most acute 
problems as appropriate. It may result in a patient being admitted to 
the hospital, for example, or medication adjustments. At the same time, 
these patients are often scheduled for a full and comprehensive 
evaluation at a later time. Of the 100 Veterans whose records GAO 
reviewed, 86 received full mental health evaluations within 30 days of 
their preferred date.
    The GAO report noted four findings. First, the Veterans' preferred 
dates were, on average, 26 days after their initial requests or 
referrals for mental health care, and ranged from 0--279 days. Second, 
the conflicting access policies for a full mental health evaluation--
one which mandates a 14-day deadline versus another which allows for 30 
days from the Veteran's preferred date--created confusion among VAMC 
officials about which policy they are expected to follow. Third, GAO 
found that data may not be comparable over time as the definitions or 
updated definitions of new patients have not been communicated with 
VISN and Medical Center leadership and managers. Fourth, GAO found 
inconsistencies in the implementation of these appointments; including 
one VAMC that manually maintained a list of Veterans seeking mental 
health outside of VHA's scheduling system.
    GAO recommended three items for action in response to its findings. 
First, VA should issue clarifying guidance on which of VHA's policies 
(14 or 30 days) should be used for scheduling new Veterans' full mental 
health evaluations. Second, VA should issue guidance on how appointment 
scheduling for open-access appointments is required to be managed. 
Third, VA should issue guidance about the definitions used to calculate 
wait times, such as how a new patient is defined, and communicate this 
to VISN and Medical Center leadership and managers any changes in wait 
time data definitions.
                 increasing access and hiring practices
    The GAO report found that VHA met Mental Health hiring initiative 
goals, but that VAMCs reported continued challenges in ongoing hiring 
of mental health staff and in meeting the increasing demands for such 
care.
    In 2012, VHA began a two-part hiring initiative under Executive 
Order 13625 issued in August 2012. The first part focused on recruiting 
1,600 new mental health professionals, 300 new non-clinical support 
staff (such as scheduling clerks), and filling existing vacancies as of 
June 2012. The second part was the hiring of 800 peer specialist 
positions by December 31, 2013. As a result of this initiative, VHA 
hired approximately 5,300 new clinical and non-clinical mental health 
staff. As of the third quarter of fiscal year (FY) 2013, this included 
1,667 new mental health staff, 304 non-clinical support staff, and 
2,357 staff to fill existing mental health vacancies and those that 
opened during the initiative. As of December 31, 2013, VHA had hired 
932 peer specialists. GAO found that VAMC officials reported local 
improvements due to the additional hiring, such as more evidence-based 
therapies offered, mental health care provided at new locations, and a 
variety of benefits provided by the new peer specialists such as 
modeling effective coping, engaging Veterans who are resistant to 
discussing mental health issues, and providing peer-to-peer counseling. 
VAMC officials also cited several challenges to hiring mental health 
care providers such as pay disparity with the private sector, 
competition among VAMCs, the lengthy hiring process, lack of space and 
support staff, and an underlying nationwide shortage of mental health 
professionals.
    At a national level, VHA outpatient mental health staff totals 
increased from 11,138 full-time equivalents in 2010 to 13,975 in FY 
2014. Over the same time period, the number of Veterans receiving 
outpatient mental health care increased from 1,259,300 to 1,533,600. 
The increase in Veterans receiving mental health care outpaced both the 
related hiring and the overall growth in the number of Veterans using 
VHA services.
    The recent rapid growth in the number of Veterans seeking mental 
health treatment in VA has posed challenges in the area of staffing. In 
Figure 1 below, the solid line shows the growth in numbers of Veterans 
using mental health services, from 897,600 in 2005 to 1,533,600 in 
2014. The number of patients is expressed in terms of hundreds to show 
staff and patient numbers on the same graph. For example, 10,000 on the 
vertical axis represents 1,000,000 patients and 10,000 full time 
equivalents employees (FTEs).

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

  Figure 1. Growth in annual numbers of patients using mental health 
   services and in outpatient and inpatient FTE levels, 2005 to 2014.

    This graph also shows the growth in numbers of mental health 
clinical staff, measured in terms of the FTE providing outpatient and 
inpatient treatment. Consistent with a shift to outpatient care, the 
inpatient mental health FTEs began to level off after 2009. Outpatient 
mental health FTEs began to lag behind the growth in patient numbers in 
2012, but as part of the President's 2012 Executive Order 13625, 
``Improving Access to Mental Health Servicemembers, and Military 
Families,'' VA hired more than 1,600 new clinical providers by the 
June 30, 2013, target date.
    In the absence of any national benchmark related to mental health 
staffing, VA continues to refine a model that is intended to inform 
local facility decisionmaking about the number of staff necessary to 
meet local demand for mental health services. In addition, VA is 
addressing access through the following efforts:

     Veteran-centered operating hours: Extended hours help 
increase capacity when space is limited and improve the match between 
available staff hours and the needs of Veterans who are employed or 
have other competing responsibilities during day-time hours.
     Leveraging trainees and fellows: These professionals 
provide substantial amounts of clinical care under the direct 
supervision of appropriately licensed and privileged mental health 
staff. Training programs also provide ready access to well-qualified 
candidates for recruitment into vacant positions.
     Support staff, adjunct professions, and peer support 
staff: VA has hired over 900 peer specialists and is developing a pilot 
program in response to the President's August 2014 Executive Actions to 
expand the role of peer specialists into primary care settings.
                    community provider pilot program
    In 2013, 12 VA medical centers (VAMCs) partnered with 24 Community 
Mental Health Clinics (CMHCs) across the country to establish Community 
Mental Health (CMH) pilots. These pilots were created in response to 
Section 3(a) of Executive Order 13625 which focused on the creation of 
``Enhanced Partnerships between the Department of Veterans Affairs (VA) 
and Community Providers'' designed specifically to decrease wait times 
and increase the geographic reach of VA mental health services.
    Pilot sites were able to select a model of care to best meet the 
needs of local Veterans. All sites used one of two broad approaches: 
Non-VA care or VA telemental health (TMH), with most sites choosing to 
provide Non-VA care to Veterans. Non-VA care uses community providers 
that are paid by VA. TMH care utilizes technology to deliver mental 
health services via modalities such as video conferencing and allows 
for real-time (or ``synchronous'') encounters between health care 
providers and patients who are not in the same location. During the VA/
CMHC Pilot partnerships, TMH services enabled Veterans to receive care 
at designated community clinics that were closer to their homes than 
the nearest VA medical facilities or clinics.
    VA and CMHC staff worked together in determining roles and 
responsibilities within each pilot partnership. Partnerships using 
telemental health required space, equipment, a technician, and a 
protocol for handling emergencies (e.g., a Veteran becoming distressed 
during a TMH session). For Non-VA care partnerships, there were other 
responsibilities that needed to be addressed: coordination of care 
(between VA and CMHCs), billing, and payment. While some pilot site 
VAMCs developed strong systems for coordinating care, monitoring 
patients, and billing, other sites, especially smaller ones, 
experienced challenges in these areas.
    Evaluation of the pilots included both gathering data from not only 
Veterans about their experiences, but also from key staff at each of 
the participating Veterans Integrated Service Networks (VISN) and VA 
Central Office (VACO) and a review of key documents associated with the 
pilots. Results from follow up surveys indicate that Veterans were very 
satisfied with the services they received via these pilots. When the 
pilots concluded, each participating VAMC was allowed to determine 
whether to continue the partnership. Since that time, VA has also moved 
to Patient Centered Community Care, a centralized contracting 
mechanism, and has implemented the Veteran's Choice Program. Regardless 
of how such care is provided, the growing Veteran's need for mental 
health services will increase the need for efficient leveraging of Non-
VA community providers when access to care is not available within the 
VA system of care. VA is rising to the challenge through its Community 
Mental Health Summit program which engaged over 11,000 individuals at 
144 sites in FY 2014 and continues annually to bring together DOD, VA, 
State, and Community providers and stakeholders for vital conversations 
at the local level. VA and DOD developed a joint Military Cultural 
Competence Training Program as part of the Integrated Mental Health 
Strategy which is now housed on the public facing TRAIN Web site and 
which, to date, has provided free training to over 2,000 providers. 
Whether mental health care is delivered directly by Non-VA mental 
health care providers, through TMH care at Non-VA sites, or any other 
means, it is critical for VA to continue to provide Veterans with 
access to high quality mental health care in coordination with other VA 
services.
                    va response letter to gao report
    VA concurred with all of GAO's recommendations in its October 7, 
2015, response and added some additional explanation for some of VA's 
policies.
    Regarding the recommendation to clarify guidance on which deadline 
to use, VA cited VHA Handbook 1160.01, which established that all new 
patients requesting or referred to mental health services must receive 
an initial evaluation within 24 hours and a more comprehensive 
diagnostic and treatment planning evaluation within 14 days. The 
primary goal of the initial evaluation is to identify patients who 
require urgent care, such as hospitalization or immediate outpatient 
care. VHA's policy directs that patients needing mental health care 
receive clinically indicated care as quickly as possible.
    VA explained that the 30-day policy was a result of a goal 
published in the Federal Register as required by the August 2014 
Veterans Access, Choice and Accountability Act. VHA has since revised 
and tested its metrics and management process and is ready to update 
its policy to the 30-day standard consistent with the published goal, 
rather than a 14-day standard developed internal to VA for new mental 
health patients. Once the policy is updated, VHA will announce it on 
the appropriate national calls with key stakeholders. The target 
completion date for this recommendation is March 2016.
    For patients who already have a mental health provider who need 
follow up care, VHA's policy of less than 30 days wait time from a 
Veteran's preferred dated is consistent with The Veterans Access, 
Choice and Accountability Act. Therefore, this policy does not require 
revision.
                 management of open-access appointments
    Open access, also known as same-day scheduling, is a method of 
scheduling in which all patients can receive an appointment on the day 
they call in or walk in. VHA's open access is an essential component of 
VHA's standard of care for conducting an initial mental health 
evaluation within 24 hours of a Veteran's request for care. As the 
identification of a Veteran who may need or request mental health 
services can occur at several entry points to care, each facility must 
have a defined process that identifies a ``warm hand-off'' to a 
professional who can conduct the same-day initial mental health 
evaluation and arrange any appropriate follow-up.
    Open access scheduling for an initial mental health evaluation 
ensures that if during a visit to a treatment facility, a Veteran 
requests or is identified as needing a mental health assessment, it 
will be provided or at least offered to the Veteran who has the option 
to accept care prior to the Veteran's departure from the facility.
    VHA Directive 2010-027, paragraph 4c(1) established the 
requirements for documenting same day unscheduled appointments. VHA 
conducted extensive scheduler training this year. To date, more than 
23,000 schedulers have undergone training. VHA finds that the 
combination of current policy and training constitutes clear guidance 
on how to manage and schedule open access appointments. Many schedulers 
are still developing proficiency with the training, and therefore there 
are still occasional errors. VHA continues to aggressively monitor 
appointment management and identify areas of local inconsistency in 
scheduling procedures.
    VA agrees with GAO's finding that one medical center was using 
inappropriate processes for scheduling open access appointments. VA 
continues to work with this facility to ensure their processes are 
aligned with VHA.

    Mr. Chairman, VA is committed to providing the highest quality care 
our Veterans have earned and deserve. Our work to effectively and 
timely treat Veterans who desire or need mental health care and ensure 
Veterans have access to the counseling and care they need continues to 
be a top priority. We appreciate Congress' support and look forward to 
responding to any questions you may have.

    Chairman Isakson. Thank you, Dr. Kudler.
    You are the Chief Consultant at VA, is that correct?
    Dr. Kudler. Yes. That is the policy side of mental health 
in VA.
    Chairman Isakson. OK. Are you a contractor or are you an 
employee?
    Dr. Kudler. I am an employee and I have been for over 30 
years.
    Chairman Isakson. The term ``consultant'' does not really 
mean what it does in the private sector, then.
    Dr. Kudler. It is an ancient title. I do not know where it 
comes from, sir.
    Chairman Isakson. Very good. You painted a glowing picture, 
quoting a lot of statistics which I did not have time to write 
down because they were coming out pretty quick, and I want to 
acknowledge from the outset that since 2013, when I became 
interested in this subject, the VA has made some major strides 
to try to address the problems that were there for mental 
health. But, I do not think you can totally agree, as you said, 
with the report done by GAO and then make the defense that you 
made without recognizing there still are some shortcomings in 
the delivery of services at the VA, and that is what we are 
here to talk about today.
    You said that the Veterans Administration this year, which 
is 10 months into the year, has trained 23,000 schedulers, is 
that correct?
    Dr. Kudler. Yes, sir.
    Chairman Isakson. In the open access process?
    Dr. Kudler. Yes, sir. It is part of our response to the 
Choice Act.
    Chairman Isakson. Right. Do you concur with the findings of 
Dr. Draper in the report or her comments that were made about 
the open access process?
    Dr. Kudler. Not entirely, sir. Not entirely. I believe open 
access is a way of matching supply and demand and drilling down 
to answer the questions that this Committee would like 
answered. Do you have enough supply of providers in those 
places to meet that demand? Open access allows us to do that. I 
may defer to Dr. Davies, who has some great expertise in that.
    Dr. Davies. The word ``open access'' can mean different 
things to different people.
    Chairman Isakson. I have learned that.
    Dr. Davies. I think in the specific facility that the GAO 
visited, maybe two of them, they were using that term to run a 
clinic that sort of saved appointment slots and then said to 
veterans, go over there and try and get one of those. That is a 
prohibited practice, putting, you know, time slots on a list 
and saying, go over there. That is a prohibited practice. We 
appreciate GAO finding that. We contacted the facility as soon 
as we became aware of that. They have corrected the issue. We 
hope, and I know Dr. Carroll has done many site visits, that 
that is a rare or at least an unusual thing.
    The word ``open access,'' as a concept, is intended to mean 
you can get care without delay. It is the entry point. This is 
what we do in mental health in VA all the time. Whether you are 
in the emergency room, primary care, or in mental health, if 
you have a mental health emergency, you are evaluated within 24 
hours initially. That is the intent.
    We recognize it is a big system. It does not happen every 
single time reliably. At the same time, we think that most of 
the time it does.
    Chairman Isakson. Well, it is a big system, and there are 
States like Montana and others that are big and where the 
population is separated by great distances where meeting those 
standards are very hard.
    Dr. Davies. Right.
    Chairman Isakson. We acknowledge that. I think the 
importance, at least I feel, is having dealt with mental health 
for a number of years and not being unfamiliar with the problem 
and the tragedy of suicide, timing of communication upon the 
first admission by the patient that they have got a problem is 
probably the most critical time of all.
    Dr. Davies. Absolutely.
    Chairman Isakson. The goal of the VA must be to see to it 
that somebody at risk for their own life, or indicates any 
tendency for that, gets immediate and fast help as reliably as 
possible wherever they may come from. And you think open access 
will accomplish that if it is used in the right way?
    Dr. Davies. The term ``open access'' means walk-in first 
contact, and the system is designed so that when there is first 
contact, that veteran is evaluated and then referred for a full 
evaluation later. I must say that there are many veterans 
inside the system and people who feel passionately about this 
who really are working to make the system work.
    Chairman Isakson. I have no question whatsoever, and I want 
to thank Dr. Draper for making the statement she said about the 
many qualified, dedicated employees within VA are working hard. 
We are not here to castigate VA employees generically, but we 
are here to see to it that we can help the process improve 
dramatically to see to it that veterans in need get the 
services they need.
    In terms of open access, if I understand it correctly, most 
of the open access is with contract providers in the community 
where the VA is located, is that right?
    Dr. Davies. ``Open access'' means you can get care without 
delay. If we use that definition, then it exists anywhere there 
is an appointment available----
    Chairman Isakson. Whether it is in the VA hospital itself, 
or in the CBOC, or probably not a CBOC----
    Dr. Davies. Right.
    Chairman Isakson [continuing]. But in a hospital or a local 
provider who is under contract with the VA, is that right?
    Dr. Davies. Or not under contract and just access through 
Choice. Yes, that is correct.
    Chairman Isakson. But you do have a relationship with those 
local vendors so they are willing to provide that service and 
you know the quality of service they are giving.
    Dr. Davies. In many cases, we do, yes.
    Chairman Isakson. In many cases.
    Dr. Davies. Yeah.
    Chairman Isakson. OK. Senator Blumenthal.
    Senator Blumenthal. Thank you.
    Dr. Kudler, why does the VA continue to measure wait times 
from the preferred date that they express rather than from the 
date of the request for health care?
    Dr. Kudler. Almost all my years in VA have been years in 
the clinic, and in that clinic, I see a patient. We agree on a 
timeframe that is appropriate clinically and that they would 
like to come back. They go out and meet with a scheduler who 
sees my electronic order for when that is going to be. The 
patient and the scheduler take out their independent schedules 
and figure out, is that going to work for them or not. If it is 
not going to work, the scheduler calls me up and says, ``Doc, 
that is not going to work. What is going to work best for him 
and from your medical point of view?'' And we come up with a 
date.
    That date is when the patient wants. The patient may want 
to be seen next week, or the patient may say, I am going to 
Montana to visit my uncle and I cannot be seen for 3 weeks and 
that is when it is going to be, and we will work out a plan.
    In the meantime, we believe that it is appropriate to 
measure the date that the patient would like to be seen, not 
later, but also not sooner than the patient wants to be seen.
    Senator Blumenthal. But the patient's preferred date may 
depend on when she or he is told that there is an opportunity 
to see someone. In other words, the patient does not say, I am 
going to see somebody tomorrow. He is told, well, here are the 
suggested dates, 2 weeks, 3 weeks from now. What is your 
preferred date, correct?
    Dr. Kudler. Yeah. That is like a card trick. We do not want 
to force the card. Here is your card. Is this not what you 
wanted? We want an honest, open conversation with the veteran. 
What makes sense for you, and does that make sense clinically, 
as well----
    Senator Blumenthal. I am talking about data, the 
reliability and trustworthiness of data. When the VA tells us 
and the world that the wait time is 3 days, how can we trust 
that when that wait time is the number of days from some date 
the veteran is given as a possible date and then expresses as a 
preference. That seems to me inherently unreliable.
    Dr. Davies. Could I take a shot at that? My answer would 
be, because VA has a 30-year-old scheduling system, to your 
initial question, I do not know if you guys realize this, but 
the current VISTA scheduling system poster child for not 
working very well is in mental health, because an average 
psychiatrist in mental health does not have one schedule. They 
have seven schedules in mental health. That means you have to 
go to this schedule for PTSD, this schedule for military sexual 
trauma, this schedule for psychiatry, this schedule for alcohol 
treatment, and on.
    Dr. Kudler. All with the same provider. That is----
    Dr. Davies. All with the same provider. Senator Blumenthal, 
we cannot measure waiting times the same way the rest of the 
world does, which, by the way, is a very hard thing to do 
anyway, right? We have invented this time-stamped method of 
measuring waiting times, which no other health care system that 
I am aware of uses.
    Senator Blumenthal. I apologize for interrupting you, but I 
have a limited amount of time. I think I get the thrust of your 
response, which is, to use Dr. Draper's word, this problem is 
systemic. It is one of leadership and management.
    Dr. Davies. And IT.
    Senator Blumenthal. I will just finish my thought, and then 
invite yours. We should make sure when we talk about 
accountability in this body that we are demanding 
accountability from the right people. Senator Moran and I have 
talked about this, and other of my colleagues. When we talk 
about blaming a VA employee, the temptation is to look at that 
person who is doing the data entry using a messed up system. I 
could think of another word for ``messed up.'' But, the 
systemic issues here really have to be overcome. I think we 
need to focus on an accountability measure that puts the blame 
and the responses to that fact finding and blame exactly where 
they should be, not simply having the you-know-what roll 
downhill, as we used to say.
    Now, I want to ask one last question because it relates to 
the peer bill that I offered yesterday to expand the program 
that you have commented on, Dr. Kudler. I assume you would 
agree with me that the peer specialists, the veteran-to-veteran 
helping each other that Dean Maiers testified about and 
implemented so effectively at the Errera Center, should be 
expanded and should be integrated more effectively into the VA 
Health Care System. My understanding is that that has occurred 
only at about six to eight locations, and that is the reason 
why I have offered the legislation that I have done. I invite 
you to comment briefly, and unfortunately, it has to be very 
briefly, on this issue.
    Dr. Kudler. Very briefly, there are 932 peer counselors 
across the country because we believe in them and we agree with 
you. It is an incredibly valuable program. It is a next step 
forward in evolving the VA.
    Senator Blumenthal. Thank you.
    Thanks, Mr. Chairman.
    Chairman Isakson. Senator Moran.
    Senator Moran. Mr. Chairman, thank you very much.
    Doctors, thank you very much for your presence and 
testimony.
    Let me briefly describe what I think the reason that the 
Choice Act was passed and ask you how it now works in the 
delivery of mental health services. I think the belief and the 
evidence was that the VA was incapable of providing the 
services that were needed by veterans in a timely fashion, in 
part because there were a lack of necessary professionals. In 
addition to that, it was designed to help meet the needs of 
veterans who live distances from a VA facility. So, two 
purposes.
    If you look at the money, $15 billion got appropriated for 
the Department of Veterans Affairs, $5 billion of it to go to 
hire more professionals and $10 billion of it to pay for the 
services outside the VA in communities. I think the goal here 
was to alleviate the challenges that the VA has in being able 
to care for our veterans. It was fully designed to help 
veterans get the care they need.
    My question is, what has transpired on the mental health 
side of things as a result of the Choice Act that has improved 
the access for veterans who live distances from a facility and 
the ability within the VA to have the necessary professionals 
to meet the needs of those who are within the VA being treated.
    Dr. Kudler. Well, Senator, the Choice Act has provided 
greater flexibility. It has allowed us to reach out, and with 
Congress's support, now to combine a number of different 
programs for reaching out into one and create a new business 
structure that supports that, which was an essential element 
and, I think, was the hardest part about implementing Choice, 
is creating that business piece that allowed us to work with 
folks.
    We have a long way to go, and I want to go back to what was 
said by the IAVA representative, Dr. Maffucci, that the problem 
that we face still and that we have a lot of evolution to do, 
not just in VA but across the country, is it is not just any 
willing provider can provide this because most providers do not 
have the military cultural competence or the experience in 
treating deployment mental health issues that exists in VA.
    We connect now with people. We can provide more care closer 
to the veteran's home. That is wonderful and Choice allows 
that. But now we have to raise the level of quality and the 
interoperability of our systems. If we cannot coordinate care 
with those folks, then we fragment that care instead. There are 
still challenges, but Choice has started us on a great path.
    Senator Moran. I certainly would not disagree with the need 
for quality care, but I also know that no care, or care that is 
delayed, the quality of that care is zero. In my view, the VA 
ought to be utilizing Choice to meet the needs as best we can 
of veterans who are, either because of time or distance, 
incapable of being currently served within the VA.
    You talked about quality care and the business model, so 
for years, before the passage of the Choice Act, I have been 
trying to convince the VA that they have an opportunity in my 
State of Kansas to contract with community mental health 
centers. These are, I think, 40 across the State. County 
commissioners levy property taxes to pay for these services. 
The State legislature and Governor contribute dollars. Across 
our very rural State, it is the only case in many instances 
that there is any access to health care. Our efforts pre-Choice 
and post-Choice have been pretty fruitless in accomplishing 
that.
    I would ask, Dr. Kudler, is there someone that you could 
direct to meet with me and with representatives of Kansas 
mental health centers to have a direct conversation about how 
to accomplish--assuming that you agree with my goal--to put 
these providers and the VA together in a way that after all 
these years and in light of the passage of the Choice Act, 
which gives, I think as you say, more flexibility to you to do 
that and to pay at Medicare rates, it seems to me that we are 
missing an opportunity. I thought it was an opportunity years 
ago. I think it is an even greater opportunity now. I just need 
you to help me put the puzzle together so that it happens for 
real.
    Dr. Kudler. Sir, that is an opportunity it sounds like 
would be very important to develop, and I would gladly do 
anything I can to help investigate that and make that happen.
    Senator Moran. Please have somebody, you or someone, 
contact me and let us put the people who know the details of 
that in front of you.
    Dr. Kudler. There is a special team that has been 
developing the business rules, and I have a feeling that may be 
where this belongs, and I will make that happen.
    Senator Moran. I appreciate you saying that. I have 15 
seconds only to remind you, Dr. Kudler, we had a conversation 
about a year ago about the hiring of particular mental health 
professionals, those being licensed professional mental health 
counselors and marriage-family therapists, and you indicated in 
your testimony that you had met with those folks, you had an 
interest with that. To paraphrase you, it is not happening as 
fast as any of us hope. But to be absolutely clear, I am 
dedicated to doing that. Has your dedication resulted in the 
additional hiring and, therefore, access to these professionals 
by veterans?
    Dr. Kudler. Not just in additional hiring, but we have 
actually, with the help of our Office of Academic Affiliations, 
created training programs internal to VA to actually produce 
these professionals in our own area so we can actually grow 
them ourselves and keep them when they have been trained.
    Senator Moran. The statistics would show that those 
professionals are now available and are being utilized by 
veterans?
    Dr. Kudler. They will show that, sir, and I still think it 
could be faster, and it will be faster. But, it is accelerating 
rapidly.
    Senator Moran. Thank you.
    Chairman Isakson. Senator Tester.
    Senator Tester. Did I just hear you say that you have 
incorporated the marriage counselors? The veterans can already 
see them, not in the VA that you have trained yourself, but in 
the private sector?
    Dr. Kudler. I am sorry, sir. We have them in the VA and 
they do exist in the private sector----
    Senator Tester. And have they contracted--have you 
contracted with the folks outside the VA, the marriage 
counselors?
    Dr. Kudler. There has been a problem, and I may defer to 
Dr. Carroll on this. There has been a difficulty because the 
law stated, and this is not VA regulation, but the law stated 
that you have to have someone who meets Medicare standards, and 
my understanding is there is still some bump legislatively 
about licensed professional mental health counselors meeting 
Medicare standards.
    Senator Tester. OK.
    Dr. Kudler. This is not our wish.
    Senator Tester. We need to follow up on this, because, 
quite frankly, if we have to change the rules, we will change 
the rules. What you have in rural America is you have no 
service. You have no standard. You have got people who need 
help and there is nobody there except a marriage counselor, and 
that is why we put that bill through. We need to follow up on 
that.
    Let me ask you, one of you said, and it might have been 
you, Dr. Kudler, or it could have been you, Dr. Davies, that 
mental health emergencies are seen within 24 hours. That is 
correct?
    Dr. Kudler. Yes, sir.
    Senator Tester. Is that off of the preferred date, or is 
that when they walk through the door, they are seen that 
quickly?
    Dr. Kudler. Yes----
    Senator Tester. Or when they call with an emergency, that 
they are seen----
    Dr. Kudler. If they call in an emergency, they will be seen 
within 24 hours. If they are actually there physically with us, 
they will be seen immediately.
    Senator Tester. OK. I would just say that, you know, I 
mean, I do not like to spend a lot of time, because as the 
Chairman said, you guys do a lot of things good and we need to 
reinforce the good, too, but that is not what we are talking 
about. We have put a lot of money into the VA, I have got to 
tell you. I mean, we have put a lot, and I have fought for 
every damn penny of it, and because the fact is, is that our 
veterans deserve it.
    Dr. Kudler. Yes.
    Senator Tester. To have a model, an IT model, when, by the 
way, you go down to Silicon Valley, you can go right outside of 
Bozeman, Montana, and find somebody that is still in college 
that can make you a scheduling program that will work. It is 
not that complicated, because they are doing stuff that is 
complicated.
    We ought to be taking care of that, because the wait time, 
honest to God, the wait time is not the preferred date, and 
then if that gets moved. The wait time is when I call into my 
doctor and say I need an appointment, if it takes 2 weeks, I 
waited 2 weeks. If they do it then, it is immediate.
    Dr. Davies. Right. What is published in the Federal 
Register is the method VA uses to measure wait times.
    Senator Tester. I know, and it is not accurate. I do not 
want to beat you up for it, but the fact, we can debate it, but 
it is not accurate, because when I call for a doctor's 
appointment, when I call and they schedule me on the 20th, that 
is a 20-day wait if I call the first of the money. OK? See what 
I am saying?
    Dr. Davies. I do.
    Senator Tester. I got what you have got, and I know you are 
meeting your metrics, but that is not really giving us an 
idea----
    Dr. Davies. I--I----
    Senator Tester [continuing]. Because when I talk to the 
veteran and they said, you know what, I had to wait too long; 
then I talk to you guys and you say, well, no, it was only 
five, 5 days is it. We are not talking about the same standard 
here.
    Dr. Davies. You are correct, and I agree with you.
    Senator Tester. Yes.
    Dr. Davies. I want to point out that we--about 5 percent of 
all of our 55 million appointments that are completed a year 
are new patients----
    Senator Tester. Yes. Yes.
    Dr. Davies [continuing]. And that is a very different 
experience than an established patient.
    Senator Tester. You are not just kidding.
    Dr. Davies. We need to measure that----
    Senator Tester [continuing]. We hear about those new 
patients all the time, because getting through the door is the 
big problem.
    Dr. Davies. Right.
    Senator Tester. Let me ask you about something that is what 
I want to talk about, and that is we heard in the previous 
panel about Vet Centers and how important those Vet Centers 
are. Do you guys have any input on when it comes to what the 
plans are for Vet Centers and increasing the number of Vet 
Centers?
    Dr. Kudler. Sir, I am not aware of that. Uh----
    Senator Tester. OK. OK. OK. We should. I mean, the truth 
is, if you are talking to your vets--I talk to vets all the 
time--they are saying Vet Centers work, and those Vet Centers 
are not talking to professionals, they are talking to 
professional soldiers that have been in the field and they can 
share, you ought to be pushing that kind of stuff. That is all 
I am telling you. It is important, because in a place like 
rural Montana, if you can get vets together and they can hammer 
it out, you might not need some expensive psychiatrist, OK?
    Dr. Kudler. Agreed.
    Senator Tester. All right. I would just encourage you to 
push.
    And, telemental health; what is going on there? What are 
your plans to expand that, or are there no plans to expand it?
    Mr. Carroll. Sure. We are trying to expand it. It is very 
important in terms of access----
    Senator Tester. What are you doing to try to expand it?
    Mr. Carroll. We are working on a regulation so that there 
will be a standard credential, when a provider is in Wisconsin 
and providing services to a facility in Texas that there can be 
a national system for credentialing. They do not--and we are 
also looking at expanding telemental health into veterans' 
homes----
    Senator Tester. When do you anticipate the credentialing 
portion of this will be done?
    Mr. Carroll. I do not know, sir.
    Senator Tester. OK.
    Mr. Carroll. It is being handled by our Telehealth Office.
    Senator Tester. OK. One last thing, and then I will go, and 
that is that I live in Montana. I am in one of the rural 
States. I farm. I do not compare myself to my neighbors. If I 
am as good as my neighbor, that is not success. I have got to 
be better than my neighbor, OK.
    When you compare yourself to the private sector, I will 
just tell you, they have got their problems, too. We have got 
to be better than the private sector, OK. To say that, you 
know, our access times are as good and our treatments are as 
good, that is not good enough. We have got to be better, OK.
    The RAND Corporation did this survey for you. I got it. 
But, the truth is, we are losing a bunch of folks in the 
private sector, too, that are committing suicide every day. We 
have a little different standard for the folks who served this 
country, because if we screwed them up, we ought to fix them, 
OK?
    Dr. Kudler. Sir, rural Americans commit suicide at the same 
rate as veterans do----
    Senator Tester. You are exactly right.
    Dr. Kudler [continuing]. And I chose a career in the VA 
because I believe it is a better system.
    Senator Tester. Got you. We need to make sure it is a 
better system.
    Dr. Kudler. Yes, sir.
    Senator Tester. When you say we are just as good as the 
private sector, that is not good enough, OK.
    Thanks, guys. Thanks for your work. For the record, I did 
not get into all the stuff you guys are doing well. You are 
doing some really good stuff, and we still need to do better.
    Dr. Kudler. Agreed, sir.
    Chairman Isakson. Senator Tillis, followed by Senator 
Boozman.
    Senator Tillis. That is where I was going to start, where I 
think Senator Tester left off. I always try to start by saying 
you all do a lot of great things. I have gone to all my 
hospitals in North Carolina and some of the health centers. 
There are a lot of motivated, dedicated people down there. It 
is as if we have got these incredibly dedicated workers in a 
factory that is about 30 years old and that we do not have the 
right assembly line, we do not have the right systems 
infrastructures, we do not have modern, in some cases, modern 
management structures that are needed. Have no doubt about it, 
I think that there are a lot of good people that are working 
hard.
    Dr. Davies, I wanted to just reinforce your comment about 
old systems and some of the problems that that creates. Senator 
Brown and I are working on a bill that over 10 years will 
provide about $6.2 million in benefits to the families of 
veterans who died in combat. We found out that in over a year, 
it is going to cost $5.1 million to modify the system to allow 
those veterans to receive the benefit. Those ratios are 
unacceptable. We have to figure out what we are doing from a 
people process technology perspective to give you all better 
tools to do the job I firmly believe you all want to do.
    I wanted to go back to Dr. Kudler. On page nine of the 
written testimony that has to do with the VA letter, or, 
actually, I guess, the response to the GAO report, I may just 
be misunderstanding what you are doing to clarify it. It sounds 
like as a result of the Choice bill, that we are moving from a 
14-day standard to a 30-day standard. That seems like it is 
getting longer. Tell me why that is a good thing.
    Dr. Kudler. Yes. Well, I am glad you asked that question 
because it is a key question. The 14-day standard was totally 
arbitrary. It was pulled out of the air some years ago. There 
was no community standard to go against to say this is a good 
thing or a bad thing. It was just, what should it be? How about 
14 days.
    We have been diverting resources from more comprehensive 
care to trying to meet a standard that has no clinical basis. 
Instead, when the Choice Act came out, we looked at what the 
Choice Act said in the Federal Register. Thirty days is the 
standard for all appointments in VA. And, we said, this is our 
opportunity to take something that was arbitrary and actually 
diverting resources.
    Yes, emergencies must be seen emergency, and yes, we 
realize that that does not always happen, and with the help of 
the two gentlemen on either side of me, we are trying to fix 
that by drilling down with the data.
    But the 30 days is the standard that the Choice Act said. 
That is what we are going to get to. We are still going to be 
doing care as it is clinically appropriate. Thirty days does 
not mean you will now wait 30 days. It means, if you are not 
seen within 30 days, something is wrong and we will be there 
asking the questions.
    Senator Tillis. Thank you. Another question really relates 
to long-term. What we are talking about today are the 
challenges we have with just the current inflow of potential 
patients. What sort of modeling have we done? I mean, are we 
going to have more stress on the system going forward? In other 
words, do we see a kind of leveling, or how much more stress is 
going to be placed on the problems you are already trying to 
address just by an increased patient population?
    Dr. Kudler. Yeah. Great question, and I may ask my friends 
to help me on this. But, let me start by saying, 22.5 million 
American veterans, only about nine million of them enrolled in 
VA. About six million users per year, and that includes 
veterans of all eras. But, if you look just at the newest 
generation, roughly three million people have served in Iraq 
and Afghanistan during these conflicts. Half of them who are 
already eligible for VA have been to us, and more than half of 
them have at least one mental health diagnosis, and that is 
because we are asking about things we never asked previous 
generations about. This generation is also more vocal, has less 
stigma, wants help.
    Senator Tillis. A mental health diagnosis related to their 
service?
    Dr. Kudler. A mental health diagnosis, period, sir. But in 
most cases, the most common one is post-traumatic stress 
disorder.
    Senator Tillis. OK.
    Dr. Kudler [continuing]. Followed with depression, 
substance abuse, problems like this. People are asking us for 
more. It is more intense. It is a younger generation. It is 
fresh trauma. It is not looking back 30 years, although that is 
quite complicated in itself.
    There are new demands. They are increasing. They are 
changing. Our workforce and our training has to shift to meet 
that balance. But, we are trying to model it. Women veterans 
are being another issue. Let me pause for my colleagues. Go 
ahead.
    Dr. Davies. No, I think that is right.
    Mr. Carroll. That is a good answer.
    Senator Tillis. OK. Thank you.
    I will yield back my 5 seconds, Chairman Isakson.
    Chairman Isakson. Senator Boozman.

         HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Mr. Chairman.
    Dr. Kudler, as you know, on the Committee, there is just a 
number of us from rural States and the huge challenge is mental 
health care in these areas, in our rural communities. In 2013, 
the VA established a pilot program at various VAMCs to partner 
with local community health care clinics. The pilot is now 
over. Some of the VAMCs have maintained their partnerships with 
the community health clinics while others have ended it. Can 
you talk a little bit about that? I guess, you know, in 
Arkansas, we have got significant problems. We have got 
community health care in all of our counties. Can you talk 
about why if we are using that, if not, why we are not using 
these resources through the Choice Act or whatever.
    Dr. Kudler. Sir, to keep it short, I think we are using it, 
but we are not using it as well as we can. I think that these 
projects were wonderful, including the public-private 
partnerships. The Choice Act innovations in that, Project ARCH, 
very big in rural areas, but still a fairly small program 
overall.
    Now, with the chance to roll these together into one 
program, I think we can get this right, both the clinical and 
the business end, using geospatial modeling for figuring out 
where the demand is and how to best match it with the needs of 
the veterans and what capacity already exists in VA.
    Senator Boozman. One of the problems that we have with the 
outside providers is that the VA does not pay in a timely way. 
Can you address that? I mean, I guess the question is, why can 
we not pay our bills on time?
    Dr. Davies. Well, sir----
    Senator Boozman. The problem is, is that many of these 
individuals do this because of the bureaucracy, because of all 
the other stuff, they do it because they want to serve 
veterans. We are a nation at war, and we can get them to do 
that. But when you have the bureaucracy and you simply do not 
get paid in a very timely way, it just exacerbates it. My 
concern is that we are losing providers simply because they get 
to the point they just do not want to fool with it any more.
    Dr. Davies. I would just offer that I agree with you. You 
are right. We have heard that, also. We are in a very dynamic 
environment with these different changing rules and processes, 
and I know the business office is working hard to improve it. 
That is the extent of it that I could say at this point. It has 
changed so much that they have not been able to standardize it.
    Dr. Kudler. Well, we will gladly join you in putting our 
shoulder to that. You are absolutely right. We reduced capacity 
through a business problem.
    Senator Boozman. Right. It is a huge problem.
    Dr. Carroll, earlier, Mr. Karnaze testified about his 
experience at the VA and essentially being prescribed medicine. 
The medication did not help him. In fact, in his case, as with 
others, the medication actually made him worse. He quit using 
it and then again was not offered other forms of therapy that 
could have helped him. Can you tell us again what we are doing 
to address that problem, and are we just throwing pills at 
people in an effort to say that we are doing something?
    Mr. Carroll. That certainly is not our goal or our mission 
at this point. I think we are priding ourselves in that our 
standard is to offer a comprehensive continuum of care, and in 
the outpatient spectrum, that may include medications. But it 
would include psycho-social treatments, evidence-based 
psychotherapies. It would involve group. It may involve case 
management. We are also looking at complementary and 
alternative medicine options. Our goal is to offer an entire 
continuum of care.
    One of the ways that we are trying to put that in place at 
medical centers is through creating teams within outpatient 
mental health clinics, behavioral health, interdisciplinary 
teams, so that the veteran is not just interacting with one 
provider who may be a prescriber, or it may be a 
psychotherapist. The veteran is working with a team and the 
team can work with that veteran to find the care that is most 
appropriate.
    Senator Boozman. Well, as described by this patient, I 
mean, that was simply irresponsible. I think we are getting a 
little bit better at that than we used to be, but it is 
something that we simply cannot tolerate. Again, it is kind of 
like why can we not pay our bills on time. I understand that 
better than I understand this in the sense that it just does 
not seem like that is standard of care.
    Mr. Carroll. Sir, if I may add one thing, and it goes to 
something that Senator Blumenthal said earlier in terms of the 
importance of peer support services in VA, Dr. Kudler has 
testified that we have increased the number of peer support 
providers. But the statistic that I think is very promising is 
that in 2013, we had just under 900,000 visits or encounters 
with the peer specialists. Last year, we had over 2.7 million. 
This is an additional resource, and to your question about how 
can we help providers look at things, if there is a peer 
support provider on that mental health team in a clinic, it 
also adds a whole another dynamic.
    Senator Boozman. Good. Thank you, Mr. Chairman. Thank you 
all for being here.
    Chairman Isakson. Dr. Carroll, just one question. When we 
had the testimony from Dean Maiers about his experience, I 
believe you said it was the Arena Clinic, is that right?
    Mr. Maiers. Errera, sir.
    Chairman Isakson. Errera.
    Mr. Maiers. E-r-r-e-r-a.
    Chairman Isakson. Are you familiar with that clinic?
    Mr. Carroll. Yes, I am, sir.
    Chairman Isakson. Is that a quasi-VA facility, or is it a 
total----
    Mr. Carroll. No, it is a VA facility. It is a center. They 
have put together their homeless program, their community 
outreach programs for mental health, their peer support 
programs, supportive employment programs, all in the same 
center. It is a remarkable place.
    Dr. Kudler. I just have to mention, Paul Errera was my 
first teacher when I started training at the West Haven VA, and 
one reason I took this job is he had this job. He went to take 
it when I was his student and I thought maybe I could try to 
follow in his footsteps. I am so glad to hear his name conjured 
with here.
    Chairman Isakson. I ran a company and we used a lot of peer 
challenges and peer support to motivate people to meet higher 
standards, and it would seem to me if you had something that 
was that good, based on the testimony of veterans and what you 
obviously both know yourselves, that ought to be the gold 
standard in the VA as to how each VA mental health center ought 
to operate. There ought to be some way we promoted that to give 
them a role model and an example within the agency of what 
really can be done.
    Mr. Carroll. Yes, sir.
    Chairman Isakson. I guess you are ultimately responsible 
for mental health operations?
    Mr. Carroll. Yes, sir.
    Chairman Isakson. One day, we will have a chat. I am going 
to be over there Friday morning of next week. Maybe we can get 
a chance to talk for a few minutes. I would like to see exactly 
how you all are organized and how you follow through on that.
    Mr. Carroll. Yes, sir.
    Chairman Isakson. Thank you very much, Dr. Carroll. Thanks 
to all of you for your testimony.
    Unless there is any other--I guess am next to last. We 
are--the two most important ones are left, Boozman and me. 
[Laughter.]
    This hearing is adjourned.
    [Whereupon, at 4:33 p.m., the Committee was adjourned.]
                                ------                                

Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
                 to U.S. Department of Veterans Affairs
    Question 1.  VA officials testified that the Department's use of 
Peer Specialists has increased over the past several years. Please 
provide the Committee with data on the following aspects of VA's use of 
Peer Specialists:

    Question 1a.  The numbers of Peer Specialists staff and encounters 
with Peer Specialists within VA by location and by assigned unit (e.g 
primary care, behavioral health, etc.).
    Response. Please see attached.

 [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    


    Question 1b.  The number of female Peer Specialists employed by VA 
for each of the past three years.
    Response. Information attached is provided for fiscal year (FY) 
2013-2016.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

  Data Source: VHA PAID data via VSSC ProClarity Data Cube excluding 
    Veterans Canteen Service (VCS), intermittent, non-pay, medical 
            residents, and trainees current as of 10/31/15.

    Question 1c.  The number of female Veterans' encounters with Peer 
Specialists by era of service.
    Response. Information attached is provided for FY 2015.

        Peer Specialist Encounters for Females by Era of Service
------------------------------------------------------------------------
                      Period of Service                       Encounters
------------------------------------------------------------------------
Persian Gulf War............................................     13,3776
Post-Vietnam................................................      76,752
Vietnam Era.................................................      28,514
  Other or None.............................................       1,799
  Other Non-Veterans........................................       1,325
  Champva--Spouse, Child....................................         829
Post-Korean.................................................         423
Korean......................................................         356
TRICARE.....................................................          86
Humanitarian (Non-Vet)......................................          65
World War II................................................          62
Air Force--Active Duty......................................          24
Army--Active Duty...........................................          14
*Missing*...................................................           8
Navy, Marine--Active Duty...................................           6
Special Studies (Non-Vet)...................................           4
World War I.................................................           4
Coast Guard--Active Duty....................................           1
------------------------------------------------------------------------


    Question 2.  VA has undertaken a campaign for gun safety among 
veterans including mass media, other messaging, and dissemination of 
gun locks. Please provide the following specific information regarding 
VA's gun safety campaign:

    Question 2a.  General overview and any relevant web links to VA's 
gun safety campaign.
    Response. In FY 2014, VA developed an outreach video to emphasize 
the importance of recommended practices for safe storage of firearms. 
In addition to the outreach video, VA designed a poster to increase 
awareness of the importance of gun safety that includes information on 
acquiring freely-available gun safety locks.
    The outreach video is primarily used by VA staff in support of 
community outreach and education efforts. Simple actions can help 
individuals and families stay safe, especially during emotional or 
stressful times, or when someone in the home is in crisis. This video 
encourages Veterans, Servicemembers, and their families to make sure 
guns and ammunition are safely secured in their home, particularly when 
someone is experiencing a period of depression or crisis. Content and 
messaging for the video was developed with assistance from subject 
matter experts at the Harvard Injury Control Research Center and the 
National Shooting Sports Foundation. The video is available on the 
Veterans Health Administration YouTube page, at http://www.youtube.com/
watch?v=-fGHTvTsApg&feature=youtu.be
    The poster was created using images and messaging from the gun 
safety video. The poster provides information on where to watch the 
video and where to obtain free gun safety locks, which are available at 
VA medical facilities or from local law enforcement.
                               gun locks
    The promotion of widely supported practices for storage and use of 
firearms is a critical public health and safety intervention that has 
been shown to reduce deaths from intentional and unintentional firearm 
injury. Research suggests that firearms are present in more than one 
third of all homes with children. In addition Veterans of military 
service are more likely than civilian populations to own firearms. 
Distribution of gun safety locks is an important component of a firearm 
safety program that seeks to reduce injury and mortality among Veterans 
and their families.
    Gun locks are provided to all VA facilities and VA Suicide 
Prevention Coordinators as tools to use in patient safety programs and 
in support of safe gun storage practices, especially for Veterans who 
may be at high risk for suicide. In FY 2010-2012, VA conducted a gun 
safety pilot program in partnership with the National Shooting Sports 
Foundation (NSSF). Through this program, more than 1.5 million gun 
safety locks and several thousand Project ChildSafe educational 
brochures were distributed to Veterans and their families. Response to 
that program was overwhelmingly positive and has led to continued 
collaboration with NSSF and continued distribution of gun safety locks 
to VA medical centers and program offices. Gun safety education and 
awareness materials are also provided in addition to gun locks which 
are available to Veterans who ask for one.
ongoing and future efforts (firearm safety outreach toolkit & training)
    VA has developed a firearm safety outreach toolkit which was 
disseminated to VA, government and community partners, and the public 
in June, 2015. The online toolkit helps support teaching of firearm 
safety by community members, VA clinicians and staff, and the public, 
and will contain the videos already described as well as printable 
brochures and materials. VA has initiated discussions with national 
leaders in the development and dissemination of educational materials 
promoting safe firearm storage and use. VA has proposed support for the 
development of a community toolkit that would include educational 
materials, blueprints for community organization, messages for use with 
local media, promotional items, implementation support from a 
recognized leader in firearm safety, and support for implementation in 
select sites through coordination with Veteran Service Organizations. 
The proposed toolkit would buildupon existing educational material for 
programs such as Project ChildSafe, a national education and gun safety 
lock distribution program designed to increase safe gun storage 
practices in homes with children.

    Question 2b.  The number of gun locks that VA has disseminated in 
its gun safety efforts.
    Response. In 2014, VA disseminated 250,000 gun locks to Veterans 
who requested them. In 2015, 1,038,388 gun locks were disseminated from 
VA's Suicide Prevention Program to Veterans who requested them with no 
questions asked.

    Question 3.  VA officials have noted that they are awaiting 
analysis of suicide data by the Centers for Disease Control and 
Prevention before publishing updated veteran suicide data. Please 
provide a specific timeline for when the new data on veteran suicide 
rates will be available.
    Response. Data for the years 2012-2013 have been transferred to the 
Centers for Disease Control and Prevention (CDC) for linkage with cause 
of death information available from the National Death Index. CDC is 
processing this information and expected to return results from this 
search within the next 60-90 days. Once received from CDC, VA will 
process results from the search and calculate rates for these years. 
The process of data validation and analysis is expected to take an 
additional 60-90 days. Barring any unforeseen delays, VA expects 
updated information on rates of suicide to be available within the next 
120-180 days (approximately February-May 2016).
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Bill Cassidy to 
                  U.S. Department of Veterans Affairs
                data on mental health services at the va

    Question 4.  Please provide the following information on the mental 
health services delivered at VHA facilities from 2013-2015 and include:


    Question 4a.  The number of visits and if this number of visits 
includes ``no shows.''
    Response. Mental health outpatient encounters (does not include 
``no shows''):

                Fiscal year (FY) 2013:  18,048,772
                FY 2014:  19,637,837
                FY 2015:  20,797,166

    Question 4b.  If the number of visits includes the number of no-
shows, what is the percent of visits that are ``no shows.''
    Response. Does not include ``no shows''

    Question 4c.  The mean and median wait times for a vet to obtain a 
mental health appointment at VHA facilities, not including ER visits
    Response. The mean (average) waiting times for Primary Care, 
Specialty Care, and Mental Health (MH) are reported in this data (link) 
by facility. Veterans Health Administration Support Service Center 
(VSSC) does not calculate median waiting times. http://www.va.gov/
HEALTH/docs/DR34_112015_Retrospective_Wait_Times_ 
Desired_Date_by_Division.pdf

    Question 4d.  Does the above data vary by VHA facility? What is the 
range of number of visits per provider, number of visits minus no 
shows, mean and median wait times to obtain an initial MH visit?
    Response. VA cannot provide a meaningful range of the number of 
visits per mental health provider because the data vary so greatly 
based on factors such as type of provider, type of service being 
provided, and amount of time assigned to an outpatient clinic.
    The following information is given regarding mean wait times for an 
initial MH visit in FY 2014 and FY 2015. These data are not available 
for FY 2013. VSSC does not calculate median waiting times.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Question 4e.  If there is significant variance, what steps are 
being taken to correct both wait times and variance among facilities?
    Response. MH wait times are regularly reviewed as part of the 
Mental Health Management System (MHMS) quarterly calls with Veterans 
Integgrated Service Network leadership and representatives from the 
Office of Mental Health Operations (OMHO). This call includes review of 
factors related to access, including staffing ratios, vacancy rates, 
and productivity. Additionally, MH waiting times are reviewed as part 
of routine OMHO site visits. Recommendations related to wait time 
improvement are included as part of strategic action plans reviewed 
quarterly for progress.
                           treatment programs
    According to VA MH Services Public Report (November 2014),

        ``The goal of VA mental health treatment is to provide 
        effective care that meets the Veteran's needs and expectations 
        in a timely fashion. No single measure can capture this complex 
        process, so VA monitors programs in terms of timely access to 
        services, the types and quantity of services provided, and 
        patients' satisfaction with care. VA monitors these aspects of 
        the experience of care using various sources of information, 
        such as patient and staff reports and electronic records.''

    Question 5.  Since treatment depends on a good diagnosis, what 
screening does the VA provide in order to properly diagnose a mental 
health disorder? Who receives these screenings?
    Response. All Veterans engaged in VHA health care are screened for 
a range of concerns, including: depression, Post Traumatic Stress 
Disorder (PTSD), alcohol misuse, tobacco use, experience of military 
sexual trauma (MST), and homelessness or being at risk for 
homelessness. Depression, problem drinking, and risk of homelessness 
screenings are completed annually. PTSD screening is completed annually 
for the first five years following separation from active duty, and 
every five years thereafter (to restart if reactivated). MST screening 
occurs once for every activation.
    Positive screening results trigger specific follow-up requirements, 
depending on the condition being assessed, for example:

     Positive screens for depression or PTSD must be followed 
up with assessment for suicide risk and to determine the most 
appropriate disposition, which may include referral to specialty mental 
health services.
     Individuals who screen positive for alcohol misuse or 
problem drinking must be provided education and counseling about safe 
drinking limits and health risks associated with drinking above those 
limits. Individuals with a diagnosis of alcohol use disorder must be 
offered additional treatment to address alcohol related problems.
     Individuals who screen positive for tobacco use must be 
provided education and counseling about tobacco cessation, and be 
offered evidence-based pharmacotherapy to aid in tobacco cessation.
     Veterans who screen positive for homelessness or at risk 
for homelessness must be offered assistance locating safe and decent 
housing through collaborative relationships with providers in the 
community. VA medical staff must ensure that homeless Veterans have a 
referral for emergency services and safe, adequate temporary housing.
     Individuals who screen positive for MST must be offered 
MST counseling services.

    Question 6.  Once a diagnosis is made, does each vet with that 
diagnosis receive the same treatment protocol including medication? Is 
there variation? If so, please explain the variation.
    Response. VA/Department of Defense (VA/DOD) Clinical Practice 
Guidelines (CPG) provide clear and comprehensive evidence based 
recommendations for the treatments that would be effective for a 
Veteran with a given diagnosis. These guidelines complement and inform 
the implementation of the array of services to be offered for a given 
diagnosis as defined by the VA Uniform Mental Health Services Handbook 
(UMHSH). Further, the UMHSH dictates services that are required to be 
available based on facility size and complexity.
    The initial 24 hour assessment provides an evaluation of need for 
emergent care for Veterans with a need for immediate inpatient MH 
hospitalization. For those not requiring inpatient mental health care 
immediately, a full evaluation occurs to determine the best clinical 
treatment options to meet the specific needs of the Veteran. If there 
is a need for a residential level of care, VA Residential 
Rehabilitation Treatment Program services would be sought. Other 
options for care are also available including specialized services for 
Veterans with Serious Mental Illness (SMI) such as the Mental Health 
Intensive Case Management Program (MHICM) or Psychosocial 
Rehabilitation Recovery Center (PRRC), specialty intensive services for 
PTSD or Substance Use Disorders (SUD), and general MH outpatient 
services. Some Veterans may benefit from and prefer treatment within 
primary care and receive services from the Primary Care-Mental Health 
Integration team and their primary care providers within the Patient 
Aligned Care Team (PACT).
    Within each of these levels of care, there are a number of 
different treatment modalities available. Veterans have the opportunity 
to engage in individual therapies, group therapies, and couple or 
family therapy. Additionally, treatment planning is often informed by 
engaging the Veteran's family when family involvement is approved of by 
the Veteran. Last, within each level and modality of care, UMHSH and 
the CPG identify a range of efficacious services to be offered for a 
given clinical diagnosis, these may include evidence-based 
psychotherapies (EBPs) and pharmacological treatment.
    Each Veteran's specific diagnoses and needs, along with his or her 
preferences, are considered during the treatment planning process to 
tailor treatment to address the unique needs of each Veteran. As a 
result of this Veteran-centered approach to treatment planning and 
implementation, there is inherent variation due to a Veteran being 
offered the choice of efficacious treatments that would effectively 
meet his/her needs.

    Question 7.  How many vets complete the treatment program 
recommended by the provider? Please include the number of visits and 
medication compliance.
    Response. VA monitors the types of mental health services received 
by Veterans according to specific types of services, such as PTSD or 
addiction treatment, inpatient admissions, or residential 
rehabilitation treatment. These monitors allow VA to understand how 
many Veterans are being served in these clinics or settings, and how 
much care they are getting measured in numbers of visits or days in a 
treatment program. However, because MH care is tailored to the clinical 
needs and preferences of individual Veterans, there is no ``one size 
fits all'' regimen that can be applied to all those in mental health 
care. In addition, even where there are treatment guidelines for 
particular disorders, those guidelines are not expected to be imposed 
without regard to individual circumstances. It is therefore not 
possible to quantify the number of Veterans ``who complete a treatment 
program recommended by the provider.'' This would require much more 
nuanced and detailed data about what the provider was recommending than 
is available in the administrative data.

                            A P P E N D I X

                              ----------                              


               Prepared Statement of Hon. Patty Murray, 
                      U.S. Senator from Washington
    Thank you, Mr. Chairman, for holding this critically important 
hearing, and thank you to the witnesses for appearing here today.
    I think everyone in this room agrees that our Nation has a duty to 
care for its veterans. With so many veterans diagnosed with mental 
health needs, a significant part of that care is access to mental 
health treatment.
    Veterans face stress and adversity from multiple deployments, and 
the unique challenges they face during tours of duty that can make it 
difficult to readjust to life back home. Difficulties with this 
transition are even worse for those experiencing depression, Post 
Traumatic Stress Disorder, substance use disorder, or those suffering 
from military sexual trauma. These invisible wounds of war can be with 
veterans for many years--but we also have treatments that help, and can 
get veterans back into their lives.
    The VA has a duty to provide the services and foster a culture that 
actually serves our veterans.
    However, I am deeply concerned that despite all of our efforts over 
several years to address gaps in access to mental health care services, 
the VA is not making the changes that are needed--and that they have 
been required to make. As far as I'm concerned, that equates to failing 
our veterans.
    When I was Chairman of this Committee, we held several hearings on 
mental health care. I asked for several IG and GAO investigations. We 
demanded VA hire more providers, and listen to providers in the field 
about the barriers they face in trying to help veterans. We even passed 
into law reforms designed to improve VA's ability to provide for the 
mental health needs of our veterans.
    But as we sit here today, I'm having a hard time understanding what 
has really changed since we covered this exact same ground in 2012, and 
even in 2008.
    I'm frustrated that VA:

     still has does not have an accurate picture of wait times.
     still does not have a staffing model for mental health 
care
     still has an alarmingly high number of vacancies in mental 
health positions

    Now, as the Ranking Member on the HELP Committee, I understand very 
well the Nation-wide shortage of mental health providers.
    But, things need to change. So, I'll be looking for answers on 
exactly how the VA is addressing two things that we identified as 
problems years ago:

    One, how the VA is making sure there are enough mental health 
professionals who can quickly and accurately diagnose and treat our 
veterans; and
    Two, how the VA intends to recruit and maintain this crucial 
workforce. Without proper staffing levels, the VA will never be able to 
satisfy the demand.

    That is a failure we cannot allow.
    Allowing veterans to seek care outside the VA is certainly part of 
meeting this need, but the sobering reality is that half of all U.S. 
counties do not have a single psychiatrist, psychologist, or social 
worker. Even if there were enough private-sector providers, it wouldn't 
solve the problem.
    Because of the unique nature of the veteran experience, we need 
providers specifically attuned to their needs, which include evidence-
based treatment and cultural competency. This ultimately means that for 
far too many veterans and their families, it is unclear where to turn 
for help.
    The VA Inspector General released a report this past August 
addressing the issue of VA efforts to improve veterans' access to 
outpatient psychiatrists. This report concluded that the VHA has not 
been fully effective in its use of hiring opportunities or use of its 
existing personnel to improve veterans access to psychiatrists.
    This is very alarming given that the report also found that 94 out 
of 140 health care facilities needed at least one additional 
psychiatrist.
    But, most concerning--these problems aren't new. IG and GAO have 
reported on these same types of failings for years. We need to fix 
this. And really, it shouldn't take multiple Senate hearings over the 
course of many years to get this done.
    Mental health is just as much of a priority as physical health.
    Veterans must have access to see these professionals, without the 
fear of confusion over where they can go, or lengthy wait times for 
initial appointments.
    The GAO report that was released today discusses some of these 
above concerns. I look forward to continuing the discussion on what we 
can do to address scheduling issues, and how to ensure we have accurate 
information to see where we've fallen short.
    The demand for these services is only going to increase as it has 
been for the last several years. We need to be able to devote the 
resources to these efforts NOW, so that VA has the ability to respond 
quickly and appropriately when someone is clearly in, or approaching a 
crisis.
    We also know that the fastest growing group of new veterans are 
women. Which is why it is extremely important for us to be focusing on 
the unique mental health needs of female veterans, and I'll continue 
working to make sure VA is addressing the needs of this growing 
population.
    So, I am deeply appreciative of our witnesses today for their 
insights, and I hope that this hearing is a step forward in increasing 
accountability, improving access, quality, effectiveness, and 
efficiency of mental health services for our veterans and their 
families.
      

                                  [all]