[Senate Hearing 118-193]
[From the U.S. Government Publishing Office]
S. Hrg. 118-193
CONNECTIONS TO CARE:
IMPROVING SUBSTANCE USE DISORDER CARE
FOR VETERANS IN RURAL AMERICA AND BEYOND
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
JUNE 14, 2023
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
54-471 PDF WASHINGTON : 2024
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SENATE COMMITTEE ON VETERANS' AFFAIRS
Jon Tester, Montana, Chairman
Patty Murray, Washington Jerry Moran, Kansas, Ranking
Bernard Sanders, Vermont Member
Sherrod Brown, Ohio John Boozman, Arkansas
Richard Blumenthal, Connecticut Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii Mike Rounds, South Dakota
Joe Manchin III, West Virginia Thom Tillis, North Carolina
Kyrsten Sinema, Arizona Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine Kevin Cramer, North Dakota
Tommy Tuberville, Alabama
Tony McClain, Staff Director
David Shearman, Republican Staff Director
C O N T E N T S
----------
June 14, 2023
SENATORS
Page
Hon. Jon Tester, Chairman, U.S. Senator from Montana............. 1
Hon. Tommy Tuberville, U.S. Senator from Alabama................. 2
Hon. Sherrod Brown, U.S. Senator from Ohio....................... 9
Hon. Thom Tillis, U.S. Senator from North Carolina............... 11
Hon. Richard Blumenthal, U.S. Senator from Connecticut........... 12
Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas....... 19
Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire....... 22
Hon. Bill Cassidy, U.S. Senator from Louisiana................... 24
Hon. Joe Manchin III, U.S. Senator from West Virginia............ 26
Hon. Dan Sullivan, U.S. Senator from Alaska...................... 30
WITNESSES
Panel I
Erica Scavella, MD, FACP, FACHE, Assistant Under Secretary for
Health for Clinical Services, Chief Medical Officer, Veterans
Health Administration, Department of Veterans Affairs;
accompanied by Tamara Campbell, MD, PsyD, DFAPA, Executive
Director, Office of Mental Health and Suicide Prevention; and
Bradley V. Watts, MD, Director, Veterans Health Resource
Center, Office of Rural Health................................. 3
Panel II
Julie Kroviak, MD, Principal Deputy Assistant Inspector General,
Office of Healthcare Inspections, Office of Inspector General,
Department of Veterans Affairs................................. 14
Jonathan Cantor, PhD, Policy Researcher, The RAND Corporation.... 16
Naomi Mathis, Associate National Legislative Director, Disabled
American Veterans.............................................. 17
Chelsey Simoni, APRN, MSN, Co-Founder/Executive Director,
HunterSeven Foundation......................................... 19
APPENDIX
Prepared Statements
Erica Scavella, MD, FACP, FACHE, Assistant Under Secretary for
Health for Clinical Services, Chief Medical Officer, Veterans
Health Administration, Department of Veterans Affairs.......... 43
Julie Kroviak, MD, Principal Deputy Assistant Inspector General,
Office of Healthcare Inspections, Office of Inspector General,
Department of Veterans Affairs................................. 53
Jonathan Cantor, PhD, Policy Researcher, The RAND Corporation.... 64
Naomi Mathis, Associate National Legislative Director, Disabled
American Veterans.............................................. 76
Chelsey Simoni, APRN, MSN, Co-Founder/Executive Director,
HunterSeven Foundation......................................... 84
Appendix A--Wait Time Data Chart............................... 90
Questions for the Record
Department of Veterans Affairs response to questions submitted
by:
Hon. Kyrsten Sinema............................................ 99
Statements for the Record
Forge VFR, Eric Golnick, CEO; Dalton McLaughlin, Government
Relations Manager; Casey Lancaster, Policy Analyst............. 105
Personal testimony of T. Paul Provenzano (at the request of
HunterSeven Foundation)........................................ 109
CONNECTIONS TO CARE: IMPROVING
SUBSTANCE USE DISORDER CARE FOR
VETERANS IN RURAL AMERICA AND BEYOND
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WEDNESDAY, JUNE 14, 2023
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3 p.m., in Room
SR-418, Russell Senate Office Building, Hon. Jon Tester,
Chairman of the Committee, presiding.
Present: Senators Tester, Brown, Blumenthal, Manchin,
Sinema, Hassan, Moran, Boozman, Cassidy, Tillis, Sullivan, and
Tuberville.
OPENING STATEMENT OF CHAIRMAN JON TESTER
Chairman Tester. I want to call this hearing to order. Good
afternoon. I want to thank the panelists here. We got another
panel after this one. I want to thank them for being here, too.
And I want to thank my friend, Senator Tuberville, for
filling in for Senator Moran, at least for the first part of
this Committee.
Senator Tuberville. Yes.
Chairman Tester. Many veterans deal with the invisible
wounds of war. For some, that may mean challenges with their
mental health. For others, they may turn to substances in order
to cope with the burdens that they bear. And for many, these
are linked. According to the latest data, about 1.1 million
veterans suffer from both substance abuse/use disorder and
mental health conditions.
Today, we have gathered leaders from the Department of
Veterans Affairs as well as researchers, advocates, and
oversight officials to discuss how we can improve veterans'
access to high quality treatment for SUD.
We know barriers exist, whether it be stigma, wait times,
or finding the right treatment option, and for veterans in
rural communities, like so many veterans in Montana, it can be
even harder to access care. Rural areas often have shortages of
healthcare professionals, and the VA is no stranger to that
challenge. Almost 70 percent of primary care health
professionals shortage areas across this country are in rural
or partially rural areas, and a recent study found that 136
hospitals in rural communities closed between 2010 and 2021.
Improving access to care for rural veterans by purchasing
care from community care may not be the answer because rural
areas are relatively underserved generally. You cannot buy it
if it ain't there.
That is why it is so important to bolster the VA's
workforce. I am proud to say that through resources Congress
has provided VA has added some 1,100 positions nationwide since
FY '22 to improve SUD care veterans. That is good work, and
they need to be thanked for that.
VA provides coordinated care to veterans with an
understanding of the unique life experiences and conditions
that the veterans face. However, there is work to be done to
ensure all veterans have timely access to that care. I have
heard numerous issues with veterans not being able to readily
access VA's residential care for mental health and SUD, the
RRTP program. That is why I included a provision in my STRONG
Veterans Act enacted last December to study RRTP wait times and
availability to better inform the development of additional
RRTP sites and bed spaces.
Building off that effort, I will be introducing legislation
very soon to make community care really work for veterans, and
that includes being able to access residential SUD and mental
health care in the community when that care is needed. For
veterans who need this level of care, there is no time to
waste, and we need to ensure they are given all the options
available.
I want to thank you all for being here today. I look
forward to your testimony. I look forward to the discussion.
With that, I will turn it over to Senator Tuberville for his
opening statement.
OPENING STATEMENT OF SENATOR TOMMY TUBERVILLE
Senator Tuberville. Thank you, Mr. Chairman, and thanks for
the witnesses being here today to discuss this very important
topic and a top priority of mine, which is veterans' access to
substance use treatment.
On behalf of Ranking Member Moran, I would like to give a
special welcome to Chelsey Simoni who is here with us today.
She is Co-Founder and Executive Director of HunterSeven
Foundation. Ms. Simoni is an Army veteran, flight medic,
clinical nurse researcher, and advance practice provider. She
continues to serve her country by advocating for her fellow
veterans to get the care that they deserve.
We are here this afternoon to determine if the VA is
meeting the needs of veterans, specifically veterans who reside
in rural and highly rural areas, when they need treatment for
substance use disorders. The VA continues to claim suicide
prevention is their top clinical priority. Therefore, ensuring
veterans have prompt access to high quality treatment for
mental health conditions and addictions is critical in
achieving our shared goal of combatting veteran suicide.
As overdose deaths are increasing across America and
especially in our rural areas, so is the need for high quality
mental health care and addiction treatment. That is why I
continue to wonder why the VA will not use the tools and
authorities Congress has given them to save the lives of
veterans who are most at risk. When veterans make the decision
to seek treatment for their mental health conditions or
addictions, VA must ensure that they are met with high quality
care that provides veterans with timely access choices and no
red tape.
I look forward to hearing from each of the witnesses today
on this important topic, Mr. Chairman.
Chairman Tester. Thank you, Senator Tuberville.
Now, for our first panel. And I want to thank you all for
having names that I should be able to pronounce. Dr. Erica
Scavella, Assistant Under Secretary for Health for Clinical
Services at the Department of Veterans Affairs, she is
accompanied by Dr. Tamara Camel--Dr. Tamara Campbell, I guess I
was wrong, Executive Director of the VA Office of Mental Health
and Suicide Prevention, and Dr. Bradley V. Watts, Director of
the Veterans Health Resource Center at the VA's Office of Rural
Health. I thank all three of you for being here.
Dr. Scavella, the floor is yours.
PANEL I
----------
STATEMENT OF ERICA SCAVELLA ACCOMPANIED BY
TAMARA CAMPBELL AND BRADLEY V. WATTS
Dr. Scavella. Thank you. Good afternoon, Chairman Tester,
Ranking Member Tuberville, and distinguished Members of the
Committee. Thank you for the opportunity today to discuss VA's
substance use disorder treatment programs in rural America.
Accompanying me today are Dr. Tamara Campbell, the Executive
Director of the Office of Mental Health and Suicide Prevention,
and Dr. Bradley Watts, Director, Veterans Rural Health Resource
Center.
For the past decade, there has been an increase in
morbidity and mortality from substance use disorders as
powerful and illicit drugs have become more widespread. For
fiscal years 2018 through 2022, the number of veterans
diagnosed with a substance use disorder and receiving treatment
in VA increased from 522,000 to over 550,000.
VA is committed to ensuring all veterans have access to
treatment for substance use disorder regardless of where they
live. Core characteristics of substance use disorder services
include timely same-day triage, a no-wrong-door approach,
concurrent treatment for co-occurring needs, and veteran-
centered and individualized treatment based on the needs and
the preferences of veterans.
Over the last decade, VHA has worked to mitigate risk
factors associated with overdose and suicide among veterans
related to opioids and stimulants, including launching a
national Opioid Safety Initiative and Stimulant Safety
Initiative. Beyond treatment for substance use disorder, VA
provides primary and secondary prevention specific to opioid
use disorder in addition to efforts specific to the risks
associated with substance use in general. As an integrated
healthcare system, VA is uniquely positioned to address the
needs of veterans diagnosed with substance use disorder.
Current policy requires facilities to provide access to the
comprehensive continuum of care of substance use disorder
treatment services ranging from early intervention and harm
reduction services through intensive outpatient and, when
needed, residential or inpatient treatment. Current policy also
requires facilities to provide same-day outpatient access to
veterans with emergent substance use treatment needs. This care
can be provided in person or via telehealth in several
settings, to include our general mental health clinics, our
Primary Care-Mental Health Integration clinics, and substance
use disorder specialty clinics.
VHA national policy explicitly states that veterans cannot
be denied care due to their use of a substance. Further, both
national and the VA DoD Clinical Practice Guideline for the
Management of Substance Use Disorders define expectations that
veterans be retained in care and that programs do not use
criteria that would automatically discharge them from
treatment.
VHA offers comprehensive care in Mental Health Residential
Rehabilitation Treatment Programs, or MH RRTPs, to veterans
with co-occurring mental health, substance use, medical, and
psychosocial needs. Today, more than 70 domiciliary substance
use disorder programs are in operation, with over 1,700 beds.
We are focused on specifically providing intensive residential
substance use disorder treatment.
VHA recognizes the importance of timely access to the
Mental Health Residential Rehabilitation Treatment Programs for
veterans and requires this intensive level of care to be
available to them. We will continue to review our policies and
address concerns from many stakeholders related to the concerns
you mentioned.
Veterans living in rural communities often face unique
characteristics that limit their access to health care.
Barriers such as long distances to clinical facilities and a
shortage of qualified providers can put rural veterans and
their families at risk. To overcome these challenges and reach
rural veterans with critical health care needs, VA has expanded
access through telehealth programs and leveraging the skills of
our existing clinicians. This includes the development and
ongoing expansion of Clinical Resource Hubs, which are a
network of VA centers in large urban settings that are skilled
in delivering their services to veterans in rural areas at
medical centers, VA Community Care Clinics, and in the home
through the telehealth services.
In conclusion, we appreciate the Committee's continued
support with this shared mission. Nothing is more important to
VA than supporting the health and well-being of the Nation's
veterans and their families. VA has employed broad evidence-
based strategies to address the opioid epidemic. This critical
work saves lives.
My colleagues and I are prepared to respond to any
questions you may have and look forward to working with you on
some remaining barriers that make it challenging for us to meet
this mission. We are committed to providing world-class care to
our Nation's veterans. Thank you.
[The prepared statement of Dr. Scavella appears on page 43
of the Appendix.]
Senator Tester. Thank you, Dr. Scavella. To the second, I
might add, on that testimony.
So I will start out with a few questions that I have. I
come from a State that is pretty darn rural. In fact, in some
departments, the whole State is considered a rural State. Even
our most populated areas are considered rural.
We have a treatment facility at Fort Harrison. It is a 24-
bed--by the way, Fort Harrison is a long ways from Plentywood,
Montana. Okay? And so it is our State capital. It is where we
have our VA hospital. And they have a 24-bed residential
treatment program for veterans' mental health, eight beds for
SUD, eight beds for co-occurring SUD, and then eight beds for
PTSD.
I have got two questions. The first question is: What makes
VA unique and able to provide residential care for veterans
that have comorbidities like SUD and PTSD?
And then the second question is: How common is it--because
in my world there is not a lot of treatment centers out there.
There is just not a lot of treatment centers. So how common is
it in rural America that the only choice they have is the VA
for a veteran that has these issues?
Dr. Scavella. Thank you, Chairman Tester, for that
question. So to answer your first question related to why VA is
uniquely able to provide the care to the veterans with these
substance use disorder diagnoses and other co-occurring
comorbidities, the first is that we are the largest integrated
healthcare system in the United States. We provide
comprehensive care for our veterans from primary care through
pain management, general mental health, as well as substance
use disorder. And so we treat the whole patient, and we are
able to see that due to the fact that we have an integrated
record. We can communicate with our colleagues to provide that
care. So that is one of the reasons why we are certain that we
can communicate internally, do warm handoffs when required to
pass patients' information along, to make sure we are providing
that care.
The second question that you asked, which is related to the
availability of services in rural locations, you recounted your
statistics in your State very well. We know that we have
challenges, but we do have facilities in Montana specifically
for substance use disorder.
And our commitment is from the time of identified need to
make sure that we are bringing those veterans in if they need
inpatient or residential services, to start that referral and
to get the care provided as soon as possible, preferably on the
same day but within 72 hours if it is for priority needs.
Chairman Tester. Okay.
Dr. Scavella. Yes.
Chairman Tester. So I talked to you about the distances. So
when you are referring to community care, oftentimes you have
no choice. Oftentimes, it is a long ways away. What role does
that figure in your decision-making, distance from home?
Dr. Scavella. So distance from home is important to us to
consider. The average patient may have to drive an average of
185 miles or greater to get the residential inpatient--the
residential services that we would like to provide to them. So
distance is a consideration.
What we want to do is provide the soonest care possible in
the best way possible. If we can keep them within the VA system
to provide that care, we will. If distance is prohibitive, and/
or the time between the appointment referral and the time that
the appointment is going to be given, we can make a referral to
the community, and we do that through some of the authorities
provided in legislation.
Chairman Tester. Okay. So what is the wait time for RRTP,
typically?
Dr. Scavella. Thank you for that question, Chairman Tester.
The first question that you are asking about the wait times, we
have a goal of getting our patients in within 72 hours if it is
for a priority care. If it is for routine residential care, the
goal is 30 days. We are able to meet that need in over 50
percent of our patients, but if there is a concern voiced by
the veteran or the family, we can work with our community
partners.
I am going to turn it to Dr. Watts to see if there is
anything he would like to add to that answer.
Chairman Tester. Sure.
Dr. Watts. I think, as you indicated, the challenge is
often that there are not community resources available for the
most vulnerable rural veterans even if we do want to make those
referrals. So the action could end up causing the veteran to
need to travel many hundreds of miles in order to achieve that
care in a timely way. So it is often a sense of tradeoff
between those two.
Chairman Tester. Okay. So before I turn it over to Senator
Tuberville, you said 50 percent of the time you are hitting the
72. Fifty percent you are hitting the 30 days for routine, too,
or are you making the 30 days more often than that?
Dr. Scavella. Our average time, Senator Tester, for the
referrals is between eight to 20 days when we look at our data,
so we are hitting that. However, we are also being very
aggressive with making sure that we are staying engaged with
those patients, making sure that if something changes that we
are able to adjust our plan. If something changes in the acuity
of that veteran, their situation changes, we can make those
adjustments.
And again, I will turn it over to Dr. Campbell to see if
there is anything she would like to add to that answer.
Dr. Campbell. Thank you again for that question. I just
want to reiterate that many of our veterans choose to stay
within VA, and so if they choose to stay within VA, we will
keep them in VA and engage them in other forms of treatments.
We have stepped care models. So we may be engaging them in
telehealth services or outpatient treatments while they are
waiting for residential care because they have chosen, or they
choose, to stay within VA.
Chairman Tester. Okay. Thank you.
Senator Tuberville.
Senator Tuberville. Thank you, Mr. Chairman.
Dr. Scavella, is that how you pronounce it? Scavella? I
know people mispronounce my name all the time, too.
Chairman Tester. Never.
Senator Tuberville. Never, right? Doctor--and this is for
all three of you. I would like to kind of get to the bottom of
this. I just recently reviewed a memo issued on May 24, 2021,
signed by the Assistant Under Secretary of Clinical Services,
which recommends all VA medical centers establish syringe
service programs, also known as clean needle exchanges, for
veterans enrolled in VA health care experiencing substance use
disorders.
Now Federal law prohibits taxpayer funds to be used to
purchase needles or syringes for the injection of illegal
drugs. Why do we believe that the VA is above this? I do not
understand that. Doctor, could you start out? And if anybody
has got any--just all we are looking for is information.
Dr. Scavella. So thank you for that question, Senator
Tuberville. One of the things that we understand from looking
at the research is that veterans who participate in a syringe
exchange program, or people in general, are more likely to seek
care from the entity providing those services for their
substance use disorder. So in addition to reducing the passing,
the contracting of other infectious diseases through those
syringes, we also know that there is a greater likelihood that
they are going to look toward us, look toward that entity to
get overall help with their substance use disorder.
I will turn it over to Dr. Campbell for some additional.
Senator Tuberville. Okay.
Dr. Campbell. Just to reiterate--and thank you again for
that question--our job is for the protection of veterans and
also for the protection of the public. So the comorbid and co-
medical issues that present with IV drug use, HIV and hepatitis
C, we are able to help reduce that with this program.
Senator Tuberville. Dr. Watts, you got anything to add to
this?
Dr. Watts. Nothing to add.
Senator Tuberville. Okay. I just do not know who authorized
this, number one. I know if Secretary McDonough did it, he is
not a doctor, and so you know, it is very concerning to me that
we are giving out needles, you know, for drugs and when it is
illegal. You know?
So what authority does the Assistant Under Secretary of
Clinical Services have to issue guidance to every VA medical
center given the priority VA has had on care and pain
management? You know, why is the memo not signed by the
Secretary himself? He did not even sign this. I mean, do you
know? Do you have any follow up on that?
Dr. Scavella. So thank you for the question, Senator
Tuberville. That memo was drafted, as you stated, in May 2021
through the authority that the Assistant Under Secretary for
Health for Clinical Services had, which is to oversee the
clinical care provided as a chief medical officer for the
Department of Veterans Affairs.
Senator Tuberville. Ms. Campbell, do you know anything
about that?
Dr. Campbell. Just to add that within the Federal
guidelines within the hospital we provided them within our
hospital setting.
Senator Tuberville. Yes. Dr. Scavella, I wonder why the
Secretary did not sign this himself. Do you know?
Dr. Scavella. Senator Tuberville, I cannot answer that
question.
Senator Tuberville. Okay.
Dr. Scavella. I do not know.
Senator Tuberville. I will ask him myself, but it is pretty
concerning.
Do you know who is administering this program at facility
level? Do you know who has the authority?
Dr. Scavella. Thank you. I will ask my colleague, Dr.
Campbell, to provide an answer to that question. Thank you.
Dr. Campbell. So each facility--thank you. Each facility
certainly has a ``quad member,'' medical director, as you know,
chief of staff, and the SUD coordinator or manager over that
program would assist in overseeing it.
Senator Tuberville. Is this person also in charge of care
management plans; do you know that?
Dr. Campbell. So they would have a team, a
multidisciplinary team, sir, to help them with the planning,
with the entire care team planning for this.
Senator Tuberville. All right. Is the VA managing data
surrounding these programs; Dr. Scavella; do you know? Do we
have data on where this is headed?
Dr. Scavella. So we do have some data on outcomes related
to our veterans and their ability to successfully engage with
us for substance use disorder. We know through all of our
multidisciplinary care plans related to substance use disorder
that we have reduced the number of veterans who are starting
opioids for the first time, that are taking opioids in
combination with other medications such as benzodiazepines. We
also know that we are seeing fewer deaths from accidental and
intentional overdoses. So there are some improvements with the
overall comprehensive substance use disorder program that we
are very proud of as far as ensuring that our veterans are
improving.
Senator Tuberville. Do you know if we are handing--if we
are just handing out syringes to newly--I guess new patients
from the VA that come in first off? And are we just handing out
needles, or are we putting them in some kind of detox plan?
Dr. Scavella. So thank you for that question, Senator
Tuberville. We would be bringing our patients in for
comprehensive care. It would not be provided in a vacuum. But I
will rely on my colleague, Dr. Campbell, to add some details to
that answer.
Dr. Campbell. Thank you again. Dr. Scavella is absolutely
correct. It is an entire team that works with these patients.
They are not in isolation. And that team includes--medical
practitioners are included in that team, and we emphasize
certainly the biopsychosocial approach to treatment.
Senator Tuberville. Well, just a quick statement on it, I
think this is pretty concerning when we are really not
following the law here, and I hate that we fall back on an easy
plan when we should be really, really helping these veterans
because we got a huge problem. You know, the fact that the VA
is the country's largest integrated healthcare system and it is
administering a clean needle exchange program when they should
be creating treatment plans for veterans experiencing substance
use disorders, to me, it is not very common sense and it is
really--you know, I do not think we are doing the veterans--I
do not think we are doing them right.
So I think, to me, it is poor use of taxpayer money and
again it is really a disservice, you know, when we have got all
these veterans out there and a lot of them have huge problems,
that we do not treat the problem immediately and we are just
kicking the can down the road in some of these situations.
So hopefully--and I am going to write a letter to Secretary
McDonough and get some answers from him. It is pretty
concerning that, you know, we just do not make it--we do not
want to make it easy on ourselves. We want to make it tougher,
you know, to make sure that we give good health care.
Dr. Watts, I am sorry I did not have a question for you,
but if you have got anything to add to that.
Dr. Watts. Nothing to add, thank you.
Senator Tuberville. Okay. Thank you, Mr. Chairman.
Chairman Tester. Do you guys want to comment on the
statement as far as treatment plans and furnishing needles? Is
there a treatment plan involved before needles are furnished?
Dr. Scavella. So thank you for that question, Chairman
Tester. As Dr. Campbell stated, veterans would be engaged in a
comprehensive care program to identify all of the underlying
comorbidities including mental health concerns, serious mental
illness, also pain management, to work on a comprehensive plan
to reduce the use of substances and reduce the substance use
disorder in that veteran. So, yes, those veterans would be
engaged in a comprehensive care plan with very specific goals
in place.
We would also be using incentives to encourage them to
change their behavior. And, we are providing comprehensive care
for veterans before they get into a situation where they are
using substances and identifying risky behavior very early on,
if possible, but then when they are in a situation where they
need assistance with substance use disorder, we are providing
comprehensive care.
Chairman Tester. Thank you for the clarification.
Senator Brown.
SENATOR SHERROD BROWN
Senator Brown. Thank you, Mr. Chairman. Thank you. As some
on this Committee know because I have mentioned it fairly ad
nauseam, I have been doing roundtables. And Senator Tester has
written, also by many others on this Committee, the PACT Act. I
have done roundtables in almost half of Ohio's counties now,
and what I hear--I will do it at a VFW or a Legion or a DAV
hall, and I will hear over and over the difficulty of
transition from the military to civilian life and hear
generally the most--many people I talk to, many former
soldiers, marines, or sailors will say that their commanding
officers and the military does not really care that much about
that safe, that easier, handoff to the point that veterans
organizations and the VA do not know where these veterans,
these recently become veterans, live.
So, Dr. Campbell, one question to you and then a comment.
And thank you, Mr. Chairman, for your time. Talk about the VHA
proactive outreach to servicemembers transitioning back to
civilian life, especially on mental health and potential
substance use disorders.
Dr. Campbell. Thank you for that question, Senator Brown.
So we have strong collaborations with the Department of Defense
and interagency collaborations through our Domestic Policy
Council. We are involved with the Transition Assistance
Program, where we are interfacing with the Department of
Defense, with those veterans who are going to be discharged. We
know that that first year is a vulnerable year, and so we
provide them with resources regarding the benefits that they
have as well as all the services that can be provided, not just
mental health services but medical services as well.
Senator Brown. I hope that--thank you, Dr. Campbell. I hope
that suggests that the VA continues to work with us on the Adam
Lambert Improving Servicemember Transition to Reduce Veteran
Suicide Act. It is important that we do more there, and I am
hopeful that you will continue to work with us on that.
Dr. Campbell. Absolutely, sir. We have very strong suicide
prevention outreach workers at every VAMC, and we are
leveraging our Governor's Challenge as well as Mayor's
Challenge to help us.
Senator Brown. I understand you are doing that at the VA
and you work for the VA, but do you believe we are finding
those men and women returning home, or the VA is finding them,
local veterans organizations are finding them? Ohio has one in
each--at least one in each--county, veterans service officers
in all 88 counties, who work for veterans. Are these entities
finding these veterans when they are coming home?
Dr. Campbell. We are certainly collaborating with them. We
know we can do a better job. We have quarterly meetings with
the VSOs, and so we are leveraging every opportunity we have to
find them.
Senator Brown. Is it better than it was 10 years ago?
Dr. Campbell. We are trending better than it was 10 years
ago.
Senator Brown. Okay, one comment. I want to quickly mention
the Chillicothe VA, southern Ohio. The Secretary has come out
at my request, seems perhaps unusually interested in that. It
serves--it is the only rural VAMC in Ohio. It is important in
Appalachia. The past year, my office has worked with community
leaders and local VA staff to ensure that the facility is
resourced in a way that continues to serve Ohio veterans.
During the Trump administration, it looked like it was
slated for closure. Secretary McDonough and all of you and my
office were working with the union, in essence, saved it, but
there still is not the attention paid. I do not think it is as
dedicated to the future of this facility as the veterans in
southeast Ohio. And it is mostly AFSCME members, I am sorry,
AFGE members and AFSCME are believing it should be.
It is essential that access to treatment for substance use
disorders, particularly including inpatient treatment, remain
available for local veterans. So I just want to say VA must
listen better than it has to Chillicothe, to me, to those
advocates, that this VA, which is I think probably the biggest
employer in town, as it often is in smaller communities, but
most importantly, a very, very, very important focal point for
serving veterans. Just wanted to let you know that, how
important that is, and remind you.
Dr. Campbell. Yes, sir. Thank you.
Chairman Tester. Senator Tillis, if you are ready. If not,
I will go to Blumenthal.
Senator Tillis. I am ready.
Chairman Tester. You are up.
SENATOR THOM TILLIS
Senator Tillis. Thank you all for being here. I know that
when we talk about veteran suicide we always, I think
appropriately, point out how many of those who are committing
suicide have no connection to the VA. What do we know about the
population of veterans who have substance abuse problems? I
know it is hard to know what you do not know or take a roll by
asking everybody that is absent to raise their hands, but do we
have any data that would give us an idea of just how many, how
big the problem is, and what the ratios are between people who
have a connection to the VA and do not?
Dr. Scavella. So, Senator Tillis, thank you for that
question. We know that we are actively treating approximately
6.2 million of our veterans of the 9 million that are enrolled,
and we know that there is approximately another 9 million that
are not enrolled. We know that within our system for this most
recent fiscal year that we have approximately 550,000 that are
dealing with substance use disorder. So if we extrapolate those
numbers to the population that is not coming in, it may be
around the same number since we are essentially touching half.
We do--as we previously stated, we have lots of outreach
that we are doing to try to make sure we are meeting veterans
where they are, working with our community partners to bring
them in to service, and also just letting them know that we are
here for them when they are ready to come in.
Specific to data that is outside of our catchment area, I
can check with my colleagues, but I do not believe we have that
readily available, but we would be happy to get that to you.
Senator Tillis. The reason I ask the question is that we
have to find more ways to make more connections and I believe
that we are in a time-sensitive, unique position to do that as
a result of the Camp Lejeune Toxics Act. I do not know if you
all have noticed, but there is a few of those annoying ads that
come on about every 30 seconds on whatever TV outlet you are
watching. And there has been some debate here about capping
legal fees and doing those kind of things for people that are
signing up for law firms.
One of the things that I wanted to do was to simply put
out--and we are going to file a bill. I am going to talk with
members about co-sponsorship. But, something I have told them
to call the Patriot Bill of Rights, and that is simply an
informed disclosure before you sign a retainer with an attorney
who is going to help you with a case for Camp Lejeune, to say:
Did you know that you could call your--did you know you could
call this 1-800 number to the Department of Navy? If you are
not connected to the VA, here is the number for the VA. Here is
the number of your Congressmen and Senators who do casework all
the time and prevent you from having to pay legal fees. And
then here are these Veterans Service Organizations that are
building expertise around this area, who can also provide you
help at a far lower cost than the legal fees. Have them fully
understand all the tools that many of them would not have.
But just imagine, even if they decide to sign the retainer,
if we can just get them to make the call and get connected,
what benefit that has for the population. And we have got a
free sort of opportunity here to increase awareness because the
trial lawyers are trying to go out there and sign everybody.
Why wouldn't we want to formally or fully inform them and
potentially create a relationship that does not exist today?
I mean, we could have hundreds of thousands of veterans
make a contact they have never made before. We can save their
life. We can determine whether or not they have substance abuse
problems and actually get them into care that you all do an
extraordinary job of.
So I am hoping we are going to speak with more Members
about it, but it seems like it ends the debate of capping legal
fees. It gives us an opportunity to touch a number of veterans
who for the first time that they may ever be connected is
through a law firm that is trying to make money, and hopefully,
get a benefit for the veteran.
But it seems to me to be a fairly sensible approach. What
is wrong with my idea?
Dr. Scavella. Senator----
Senator Tillis. I am not trying to poison the well by
positioning it as a sensible approach, but----
Dr. Scavella. Yes, I will say that since this is the first
time that any of the three of us on this panel have heard about
this and since the Secretary has not had an opportunity to
weigh in, we would be happy to review----
Senator Tillis. We are going to send the text over to you.
It is literally as simple as I have described it, so I will be
very interested to see what the Department's position is on the
bill fairly soon here. Thank you all.
Thank you, Mr. Chair.
Dr. Scavella. Thank you.
Chairman Tester. Senator Blumenthal.
SENATOR RICHARD BLUMENTHAL
Senator Blumenthal. Thank you, Mr. Chairman. You know, I
have believed for some time that one of the challenges is
outreach, whether it is through the media or person-to-person
contact.
In Connecticut, we have a partnership between the
Connecticut VA health system and a group that is called
Connecticut Harm Reduction Alliance run by a very able young
man named Mark Jenkins, and they have established what is
called a Rover Program since RVs, literally, recreational
vehicles, provide harm reduction supplies to communities. I
have gone around with some of them, and they are stocked with
all the stuff that is necessary to provide what people
suffering from substance disorder need. And the program in
Connecticut has been tremendously successful, now has over 35
of these rovers serving 26 communities, and it plans to expand
nationally.
As I mentioned, outreach partnership with the VA--the VA
cannot operate in isolation. It has to seek partnerships with
community groups like the Connecticut Harm Reduction Alliance.
What plans do you have to try to seek to provide more access to
substance use disorder treatment programs in the non-VA
community?
Dr. Scavella. So thank you for that question, Senator
Blumenthal. We clearly understand within the Department of
Veterans Affairs that substance use disorder, especially
considering opioid use disorder, is a whole-of-government and
whole-of-nation approach that is required. We do need to
continue to leverage those community partnerships, as Dr.
Campbell stated earlier, to make sure that we are reaching
veterans where they are, especially if they are not engaged in
our care.
We do have several programs in place to address veterans
who may be at risk, to include our Overdose Education and
Naloxone Distribution program, to make sure that we are
providing tools and education, to give both veterans and their
families and caregivers the signs and symptoms to look for if
someone is potentially getting close to overdosing, and then
giving the tool, the naloxone, to actually do the reversal. So
that is one of the things that we are doing.
We are also engaged with many different community
partnerships, to include the Governor's Challenge and others,
to really identify veterans who may be at risk. The Hannon Act
provided for the ability to engage with veterans within the
first year of post-separation from the Department of Defense.
So we are leveraging that as well, making sure that we are
reaching those veterans where they are, participating in their
TAP classes, to make sure that we are giving them the tools
that they need to engage with us, perhaps not immediately but
hopefully when they think of it and realize that they have that
benefit and they are entitled to that care.
Senator Blumenthal. I may have missed it in your testimony,
but do we have--you know, we use these figures, 21 veterans
every day commit suicide. Is there an accurate, up-to-date
number?
Dr. Scavella. Senator Blumenthal, I am going to turn that
over to Dr. Campbell, but we do have some updates on that
number.
Dr. Campbell. So thank you for that very important
question. We all know one suicide is one too many, and so we
really are leveraging everything we can. That number has
trended downward to 16.8 according to the last annual report,
and we continue to review those numbers daily.
Senator Blumenthal. According to which report?
Dr. Campbell. The last annual suicide----
Senator Blumenthal. Oh, the last annual report.
Dr. Campbell. Yes, sir.
Senator Blumenthal. And how do you--what data do you--how
do you access data on veteran suicide? What kind of data is
available?
Dr. Campbell. Sure. Thank you for that question. So we work
with the Centers for Disease Control and World Health
Organization, and we use scientific methodology utilizing their
definitions of what a suicide is to develop that report and to
look at those numbers.
Senator Blumenthal. And did they have--how did they define
suicide? In other words, is there a definition of suicide?
Dr. Campbell. So that----
Senator Blumenthal. Substance use disorder taken to a
certain level can constitute a form of self-destruction?
Dr. Campbell. That definition certainly is determined by
the coroner's office, and they look at each individual case and
determine that.
Senator Blumenthal. Thank you. My time is expired, but I
will want perhaps to follow up on this issue. Thanks.
Chairman Tester. And there will be opportunities for
questions for the record, Senator Blumenthal.
That concludes our first panel. You got off lucky because
there usually is more people than that here, but there is a
vote going on right now. Thank you guys for your testimony. I
appreciate it very much. You are certainly welcome to stay for
the second panel if you choose.
And now I will introduce the second panel. I would like to
welcome Dr. Julie Kroviak, Principal Deputy Assistant Inspector
General in the Office of Healthcare Inspections at the VA's
Office of Inspector General. Then we have Dr. Jonathan Cantor,
who is Policy Researcher at the RAND Corporation. Then we have
Naomi Mathis, who is Associate National Legislative Director of
the Disabled American Veterans, and we have Chelsey Simoni, Co-
Founder and Executive Director of the HunterSeven Foundation.
Dr. Kroviak, you have the floor.
PANEL II
----------
STATEMENT OF JULIE KROVIAK
Dr. Kroviak. Thank you, Chairman Tester and Committee
members. I appreciate this opportunity to discuss the OIG's
oversight of VHA's substance use disorder treatment programs.
The OIG's Office of Healthcare Inspections reviews the
quality and safety of health care provided across VHA and
communicates these findings through public reports. The
majority of our healthcare inspection staff have significant
experience providing direct clinical care to veterans, and such
experience adds unique insight to our oversight work. This is
particularly true of mental health teams staffed with board-
certified psychiatrists, psychologists, licensed clinical
social workers, some of whom are combat veterans. These team
members have cared for veterans facing the very issues we are
discussing today.
VHA faces significant challenges in meeting the needs of
individuals with substance use disorders, and rural settings
can pose additional obstacles in addressing these patients'
needs. In that veterans with substance use disorders often have
additional mental health diagnoses that place them at higher
risk for suicide, seamless and timely care coordination is
critical. The Committee's focus on rural veterans is
appreciated as veterans living in highly rural areas are 65
percent more likely to die from suicide than those residing in
urban settings, an unsettling statistic that VHA faces in
addressing their top clinical priority, to reduce veteran
suicide.
Our oversight is much broader than just major medical
centers. We reach out into rural communities with our VISN and
CHIP reviews that analyze VA rural facilities, including the
most highly rural CBOCs, and our Vet Center reviews will review
the Mobile Vet Centers, important outreach units for many of
our rural communities.
To meet the increasing demand for services, including
mental health and substance use disorder treatment, VHA depends
on community care. The OIG has identified persistent
administrative errors and communication failures among VHA, its
third-party administrators, and community care providers, as
well as between the care providers and their patients. These
failures amplify risks for patients with high-risk mental
health issues and complex disease. My written statement details
two reports that provide insight into the complexity of
coordinating care for patients with substance use disorder at
two distinct stages of treatment needs.
Earlier this year, we substantiated the allegation that in
2020 and 2021 North Texas staff did not follow VHA policy
requiring that patients be offered alternative options for
residential substance use disorder treatment within VA or the
community when the wait time for this service exceeded 30 days.
This practice not only potentially delayed the treatment for
these veterans but also has the potential to fracture trust
between patients and the healthcare system upon which they
rely.
The second report describes the mismanagement of a patient
at the Tomah VA, a rural facility in Wisconsin, who was
suffering from acute alcohol withdrawal and subsequently died
at another VA hospital. We found failures in the clinical
management of this veteran that likely contributed to their
death. Assessments and stabilization efforts for patients at
risk for life-threatening consequences of alcohol withdrawal
leave no room for error, especially in rural settings when
transfers to higher level care must be anticipated early.
To improve the quality of administrative and clinical
practices in rural facilities and across the system, VHA
frontline staff need policies and guidelines that are clear,
standardized, and current. For example, just last month, our
office published an advisory memo alerting the Under Secretary
for Health that VHA's Mental Health Handbook had not been
recertified as required by 2013. Handbooks support frontline
clinical decision-making, and such direction must be clear,
accurate, and current. Standardizing the oversight of frontline
performance can also support consistency and accountability.
Additionally, while it is important for VHA staff to inform
veterans of all care options available for their needs,
ignoring that the current community care framework does not
adequately address critical gaps in coordination may further
increase the risk to patients. Our office has published reports
related to community care, detailing delays in diagnosis and
treatment, lack of or miscommunication between providers, and
significant quality of care concerns.
The OIG will continue to provide meaningful oversight to
support and improve the quality of health care provided to our
Nation's veterans. We also recognize the need to enhance and
adapt our work to best support this dynamic healthcare system.
We remain grateful for the participation and cooperation of VHA
staff across the country and for their commitment to caring for
those who have served.
Chairman Tester, this concludes my statement. I would be
happy to take any questions you may have.
[The prepared statement of Dr. Kroviak appears on page 53
of the Appendix.]
Chairman Tester. Thank you, Dr. Kroviak.
Next up we have the policy researcher from the Rand
Corporation, Dr. Jonathan Cantor.
STATEMENT OF JONATHAN CANTOR
Dr. Cantor. Chairman Tester and Members of the Committee, I
want to thank you for your invitation to testify today on what
is a pressing and urgent public health problem. My name is Dr.
Jonathan Cantor, and I am a policy researcher at the nonprofit
and nonpartisan RAND Corporation. I have conducted extensive
research on the geographic availability and accessibility of
substance use disorder treatment for veterans, military
servicemembers, and the civilian population.
In my testimony, I will discuss three main issues: first,
the complexity of substance use disorder treatment for veterans
given the frequent existence of co-occurring mental health
disorders. Second, a brief overview of the geographic
accessibility of substance use disorder treatment for veterans.
Third, why it is difficult to assess disparities in access.
And then finally, I have a few recommendations to enhance
data collection and reporting to improve our understanding of
the geographic availability and accessibility of substance use
disorder treatment for veterans.
In 2020, around 12 percent of veterans 18 years or older
had a substance use disorder, and approximately 1.1 million
veterans suffered from both a substance use disorder and mental
illness. Less than 10 percent of veterans with a substance use
disorder in 2020 received any treatment.
There are a multitude of reasons for why a veteran would
not receive the necessary care. First, some veterans who use
substances do so to self-medicate their post-traumatic stress
disorder symptoms. Second, many veterans fear seeking mental
health or substance use disorder treatment because it could
negatively affect their career advancement. Third, co-occurring
disorders often go unidentified. A practitioner may identify a
substance use disorder or a mental health disorder but not
necessarily both. Fourth, the appropriate treatment for an
individual with a substance use disorder and co-occurring
mental health disorder is more complex than treating one or the
other alone.
A key determinant for whether an individual receives
substance use disorder treatment is how far they have to travel
for care. To date, there have been very few studies that have
examined distance to substance use disorder treatment as a
barrier to care for a national sample of veterans.
In 2019, the Wounded Warrior Project partnered with RAND
researchers to understand geographic accessibility of co-
occurring substance use disorder and mental health treatment.
Our calculations indicated that, on average, Wounded Warrior
Project alumni were around a 10-minute drive time from the
nearest substance use disorder or mental health treatment
facility with a co-occurring program. In contrast, for these
veterans, the closest VA medical center with a co-occurring
program was around a 60-minute drive time from where the
veteran lived.
Our results were encouraging. Most Wounded Warrior Project
alumni veterans were able to access treatment programs for co-
occurring substance use disorder and mental health disorders
within 60 minutes.
Almost one-quarter of U.S. veterans reside in rural
communities. There is a concern that it is more difficult for
rural veterans to receive care given they must travel farther
than veterans that live in urban settings. The geographic
accessibility of substance use disorder care could also vary
based on the race and gender of the veteran.
Our study did not focus on these potential disparities
because there are extensive data challenges in quantifying
these differences. Such analyses should require at least
detailed data on the addresses or the ZIP codes of the veteran,
as well as data on their race, ethnicity, age, sexual
orientation, and gender. Finally and perhaps most challenging,
the data would need to include whether the veteran suffered
from substance use disorder only or substance use disorders and
mental health disorders.
Drawing on my research and existing work, I provide several
recommendations in my written testimony. I want to highlight
two.
First, the Substance Abuse and Mental Health Service
Administration's Behavioral Health Treatment Locator could
include additional information on specific treatment approaches
available for veterans.
Second, either the Substance Abuse and Mental Health
Service Administration or VA should consider conducting regular
audit studies among non-VA facilities to get a more accurate
understanding of the forms of treatment offered, approximate
wait times to the next appointment, and total capacity of the
facilities for substance use disorder treatment, and they
should vary the calls based on the sociodemographic
characteristics of the veteran.
Far too many Americans, especially veterans, fail to
receive treatment for substance use disorder each year. I am
confident that we can increase the number of veterans who
receive treatment and reduce the number of drug overdoses.
However, that will require an infusion of funding to improve
current data collection systems and ensure that veterans can
access the information necessary to make treatment decisions.
Thank you for your time, and I am happy to answer your
questions.
[The prepared statement of Dr. Cantor appears on page 64 of
the Appendix.]
Chairman Tester. Thank you for your statement, Dr. Cantor.
Next, we have Naomi Mathis, Associate National Legislative
Director of the Disabled American Veterans. Naomi?
STATEMENT OF NAOMI MATHIS
Ms. Mathis. Chairman Tester, Ranking Member Moran, and
Members of the Committee, DAV is grateful for the opportunity
to appear before you today to address concerns with access to
the VA substance use disorder treatment program.
DAV members are injured and ill, service-disabled, wartime
veterans that utilize the VA healthcare system at extremely
high rates, which many depend on as their sole source of health
care. Our one million-plus members live throughout the country
and provide us with an insight into their unique struggles with
access to care.
Our written testimony provides our entire position.
However, I will focus on the challenges, barriers, and our
recommendations.
First, rural veterans face issues accessing health care
similar to those faced by the general population, including a
lack of transportation. In rural communities, distance to a
healthcare facility, time, cost of fuel, and access to
transportation are all exacerbated and known barriers to care.
Veterans who lack access to public transportation or are no
longer able to drive because of age, health, or driving
restrictions rely on family, friends, or community service
organizations.
To help such veterans, DAV operates a fleet of vehicles
around the country to provide free transportation to VA medical
facilities for injured and ill veterans. While this program is
highly successful and beneficial for the veterans we serve, we
continue to face administrative challenges with expediting
volunteer driver examinations. Specifically, there is a
breakdown in the onboarding process for our volunteer drivers.
For example, our transportation coordinator in Montana told
us they had 30 applications for volunteer drivers. However, by
the time VA completed the onboarding process, a year and a half
later, only two applicants remained interested in volunteering.
During my recent trip to New Hampshire, our coordinators there
expressed similar concerns. By contrast, we are hearing of
other facilities that can onboard in as little as 3 days.
We recommend VA standardize and expedite the volunteer
driver onboarding process VHA-wide.
Next, the Philippines is the only foreign country in which
there is a VA outpatient clinic to serve eligible veterans. In
October 2022, we began receiving complaints from our members
who indicated VA Manilla had completely stopped dispensing
controlled medications, including those undergoing mental
health and substance use disorder treatments. Options faced by
this population of veterans are to either stop the medication,
utilize the community, travel to Guam or to the United States
whenever a refill is needed.
Guam, American Samoa, Puerto Rico, U.S. Virgin Islands, and
the Northern Mariana Islands face even greater challenges due
to limited or poor infrastructure. Veterans living in these
areas often have to take commercial aircraft, which are not
disability-friendly, to get to medical appointments or fill
prescriptions. Not one of the VA OCONUS has a specialty SUD
program.
We recommend VA conduct a needs assessment to determine if
adding substance use disorder programming for outside
community--outside CONUS communities is warranted.
Mr. Chairman, an additional barrier facing veterans
residing outside of the United States is the Beneficiary Travel
Self-Service System, which was designed to automate the travel
reimbursement claims process. However, there continue to be
complaints regarding the slow processing of payments and
improper payments made to beneficiaries. VA must fix and
modernize this system in consultation with stakeholders on the
Beneficiary Travel Self-Service System.
Lastly, as we celebrate the 75th anniversary of the
integration of women into the Armed Forces, we must remember
that women veterans are the fastest growing cohort in the VA
system. Therefore, VA must continue to accommodate this growing
population and their gender-specific needs.
As a combat woman veteran, I experience longer wait times
for specialty care at VA than my male counterparts, including
mental health care. VA reports fewer than half of all
residential facilities have separate dorm space for women
veterans and only 13 programs have gender-specific services for
women veterans compared to 27 programs exclusive to men. I will
note that none of them are located in rural areas.
Additionally, women veterans with substance use disorder
who experience longer wait times for treatment could have an
increased risk of suicide. This may be due to VA's lower
capacity to address women's needs.
We recommend VA conduct a nationwide analysis to determine
if expanding gender-specific substance use disorder inpatient
care is warranted.
This concludes my testimony, and I look forward to any
questions you and the Committee may have.
[The prepared statement of Ms. Mathis appears on page 76 of
the Appendix.]
SENATOR JERRY MORAN
Senator Moran [presiding]. Thank you very much.
Now, Ms. Simoni, we look to you for your testimony. Ms.
Simoni is the Co-Founder and Executive Director of the
HunterSeven Foundation.
STATEMENT OF CHELSEY SIMONI
Ms. Simoni. Senator Moran, Senator Hassan, thank you so
much for sitting here and listening today. This story is very
personal to me as it is a lived experience, so I appreciate it.
Today, I speak before the Committee as a licensed
healthcare provider with advanced medical degrees, including
public health and epidemiology as well as specialty
certifications. I have spent over 15,000 hours working in
emergency medicine, long- and short-term substance use
settings, and military veteran-specific mental health clinics.
I have published in numerous academic journals and presented at
conferences nationwide.
However, I speak to the Committee today as a sister of a
combat-wounded marine losing his battle with addiction, as the
child of an alcoholic mother and heroin-addicted father. I
speak today as a disabled Army veteran dealing with constant,
debilitating pain and the uninterrupted emotional burden I face
daily. The testimony I share today is, unfortunately, entirely
true.
By 14, I had a job, I skipped school, and I never got my
homework done. I got into fights and did everything I was not
supposed to do, so I failed my freshman year of high school.
At 15 years old, I lost my oldest brother to an overdose.
My mother told me my 24-year-old brother planned to enter
substance abuse treatment the following Monday. He did not make
it. He had shot up the night before with friends of my
father's, and he had fallen asleep and began to choke on his
throw-up. Instead of calling 911 and keeping him awake, those
he was with had moved his body into the hallway where he choked
on his vomit and died.
Shortly after his death, I was expelled from school. My
behavior was self-destructive, and I lacked structure and
discipline. It was difficult to talk about my situation at home
with those who did not understand, especially those who had
just thought I was a bad kid but never figured out to ask why.
By 16, in 2007, my youngest brother had signed up to serve
as an infantryman in the Marine Corps. We wrote each other
often. And while he was in boot camp at Parris Island, he loved
it. He loved every single minute of it. And I had just
graduated high school when my brother told me he was going to
be deployed as one of the first marines into Marjah,
Afghanistan, under President Obama's surge to disrupt Taliban
forces. He spent 7 months in southern Afghanistan.
While he was deployed, I would sit at night and watch the
evening news and keep to myself in the loop about what was
going on in the war. Every time I heard an unnamed marine
casualty occurred, my heart sank. It was almost daily. In
total, 68 marines were killed in action during that 7-month
deployment, and 694 marines were wounded in action. In turn, I
enlisted in the Army.
In August 2011, he redeployed to Sangin, Afghanistan, for 8
months. Thirty marines had been killed in action while 582
marines were wounded in action. Of those wounded marines was my
brother. While he was on--while he had lost men he considered
brothers and witnessed his closest friend suffer near-death
amputations from hidden explosive devices and others who had
been physically ripped apart by RPK machine gun rounds, my
brother felt lucky. He had sustained outrageous blast injuries
from explosions and rocket-propelled grenades, one blast so
severe that an MRAP vehicle had flipped over on top of him,
throwing him from the turret, causing him to break four ribs,
fracture his skull and sections of his lower back.
He came home, but the physical pain was mute compared to
the emotional guilt and moral injury he tried so hard to hide.
Over the next year, he struggled with pain, physical,
depression, and guilt overwhelmed his life. What began as a
short-term Vicodin prescription for pain management became a
full-blown addiction where he would steal fentanyl patches from
the regiment's Navy corpsmen.
He had kept his habit under the radar until a random drug
test had found opioids in his system. Sixteen days later, he
was discharged under other than honorable conditions for
illicit drug use, and he was homeless, jobless, emotionally and
physically unstable, and addicted. He was too embarrassed to
seek help and suffered in silence.
Around the same time, I suffered a severe spinal cord
injury while serving in the Army. I remember the electrifying
pain. It was like no pain I had ever experienced before, but my
adrenalin was high, and the mission made the pain seem
nonexistent. It was not until later that evening I lost control
of my bladder, and pins and needles drove up my leg, causing
debilitating painful paralysis.
At 21 years old, I was told my injury led to the discs in
my lower back partially paralyzing my spinal cord and I needed
surgery. My military career was placed on hold, but that was
not the case for the rest of my team.
In the months leading up to the major surgery I was
scheduled for, I was given more than 300 pills of the mild
opiate, hydrocodone-acetaminophen, better known as Vicodin. I
was told to take them every six hours for pain. In case the
Vicodin was not working, I was given 100 pills of tramadol, a
synthetic opioid that reduces the pain felt through the central
nervous system. To lessen the right-sided leg numbness and
severe neuropathy and muscle spasms, I was given 100 pills of
Flexeril. My anxiety was front and center, so I was given 30
pills of Lorazepam, the anti-anxiety benzodiazepine to take as
needed for anxiety.
Two weeks later, I received a call that one of my closest
friends that I had known since I was 14 was killed in Dawlat
Shah, Afghanistan. I felt hopeless, motionless, and stuck in
time, and I could not move. The pain had gotten worse. And the
more pills I took, the pain I had was less and less, and as
time went on everything became easier to deal with or at least
what I thought.
I went through a three-hour surgery and was on the road to
recovery. The first few nights were hell. I had severe
nightmares, dreams I would never wish on anyone. I would wake
up covered in sweat and unable to move, and the pain worsened.
I was given 60 pills of oxycodone-acetaminophen, also known as
Percocet, and was told to stop taking the Vicodin as it may
have been an adverse reaction.
I could not swallow the pills without vomiting, worsening
my post-operative pain. I was sent home with an eight-ounce
bottle of Oxydose, liquid oxycodone. It helped with the pain.
Eventually, it subsided as I healed.
I felt great. Looking back, I cannot remember a time in my
life where I felt that relaxed or carefree. I could sleep. My
mind stopped overthinking, and my heart stopped racing. I was
not sad, and I was not worried about the future. I was enjoying
the present. And when I started to feel myself come back to
reality, I grabbed the medicine bottle, and I would take
another sip.
Like most 21-year-olds, I did not have a way to measure the
amount I was taking, instead, relying on my balance to let me
know if I had taken enough. I do not remember much besides
laying in bed, thinking, isn't life great. I loved how I felt
in those moments. It was an unmatched feeling.
I took medication not for the physical pain but to cover my
emotional pain, which worked very well until it almost killed
me. Late one night, I was laying in bed, and I had drank too
much. I laid back and felt a sudden sickness. I went to get up
and felt my legs get weak. Using the side of my bed, I slowly
slid to the ground, and I do not remember much afterward as I
woke up a few minutes later covered in vomit. I cried as I knew
what had happened.
The next day, I knew I had to get rid of it, which was not
easy, but what kept me motivated was returning to uniform and
being with my team again. There is a reasonable probability
that this is what kept me alive today. To this day, I know I
cannot take Percocet as I enjoy it too much.
While dealing with my situation, my brother battled
something similar. He figured out his steps, and he ended up
staying with my aunt on her couch. He was addicted to
prescription opiates. When those ran out and he could not get
more, he turned to heroin.
He was alone one night and had shot up heroin, and it was
discovered later that it had traces of fentanyl. He passed out
on her couch, and when our aunt found him he was covered in
vomit and not breathing. She called 911 and began CPR. His lips
were dusky and cold. He was given Narcan, intubated, and rushed
to the emergency department where the medical team worked to
save his life. The doctor said it was a miracle he was alive.
While my brother faced his battles, I received medical
clearance to remain in the Army despite having a life-changing
surgery. My provider told me that the chances of another injury
occurring were highly likely. As mentioned and as predicted,
years later, I suffered a reinjury, this time equally as
painful, but I could still move and manage. For me, long story
short, my career was over.
It was always--it will always be the most dangerous time in
any servicemember's life when you are leaving a tight-knit
group and leaving a feeling of belonging and reintegrating into
a society that could not care less about you, your service,
your situation, or your struggles. There is no team or tribe
that you can turn to or fall back on. There is no safety net or
mirroring experience in a fellow veteran for you to voice your
feelings on.
I went to bed as a servicemember and woke up the following
day as a civilian. My pain had become increasingly worse. My
temper was short, and my frustration grew.
I woke up one morning my senior year of college, and it was
like a trap door falling underneath me. I had a commemorative
military pistol from my unit, a Sig Sauer P250 .45 ACP under my
bed, and I laid down on my bedroom floor, looking up at the
ceiling, with my pistol in my right hand. I pointed the gun
toward myself and put the barrel in my mouth. I can still
remember the cold feeling and taste of steel.
The only reason I am still here today is twofold. I could
not kill myself in my grandparents' house, and I reached out to
somebody who served in the military, and I said to them, I am
not okay, and got the help I received.
In short, I invite you to read the remaining of my
testimony as this is something very personal to me, and I
appreciate the time. I know I went over, so thank you very
much.
[The prepared statement of Ms. Simoni appears on page 84 of
the Appendix.]
Senator Moran. Ms. Simoni, thank you very much.
SENATOR MARGARET WOOD HASSAN
Senator Hassan. Thank you, Ranking Member Moran.
And, Ms. Simoni, thank you so much for your testimony. Just
a couple of things, I was Governor of New Hampshire as we began
to see what had been an increasingly bad opioid and heroin
epidemic turn to a fentanyl epidemic. The thing that gives me
hope and the thing that has made some progress possible
although we have much more work to do, as your testimony
indicates, is that people like you have spoken up about their
experience, about the fact that opioids, and particularly this
new class of opioids and fentanyl, is extraordinarily addictive
and that we have to treat substance use disorder as the
disorder that it is.
And we have a lot of work to go, both to help people get
into recovery and stay in recovery and recognize that sometimes
relapses happen, right, and treat it like an illness that way.
We also have to go after the unbelievably insidious cartels
that are trying to drive up demand for this drug that is so
cheap for them to make and easy for them to transport.
I also want to thank you for talking about the difficulty
of the transition period for servicemembers because what I hear
from especially servicewomen and women veterans in New
Hampshire is how difficult this period is and how alone people,
veterans feel, especially women veterans, especially women
veterans in rural areas.
So I thank you for giving voice to that. I thank you for
being brave enough to do it. And I know that everybody on this
Committee, both sides of the dais, want to work with you and
veterans throughout the country to make progress on these
issues and to make sure that veterans understand how deeply we
appreciate your service.
With that, I am going to turn to a couple of questions to
Dr. Cantor just because I want to--what I want to do is not
only recognize the problem but talk about what is working and
what is not and what we still need to do.
And with that, Dr. Cantor, as we are talking about veterans
and particularly veterans who fall through the cracks as they
transition out of service, or as they are dealing with
substance use disorder, or whether they are dealing with mental
health challenges, we now have the 988 Suicide and Crisis
Lifeline that veterans in crisis can call, and they can be
connected to the Veterans Crisis Hotline for help just by
pressing option 1. What impact has 988 had on connecting
veterans to the Veterans Crisis Hotline?
Dr. Cantor. Thank you for the question. I do not know of
any specific research at present that has discussed or looked
at the linkage between the 988 lifeline to the veterans crisis
line as of yet.
Senator Hassan. Okay. Is it an area that you think we need
data about and explore, yes?
Dr. Cantor. Yes, I would agree with you.
Senator Hassan. Okay. And I want--part of my reason for
asking the question is just so that any veterans who may follow
this hearing know that now this crisis hotline is there and the
wait times are relative--you know, I think they are averaging
about 40 seconds, if I have got my data correct, and that there
is this option for people. And so I hope veterans will take
advantage of this.
The other thing I would want veterans watching to know is
that there are a couple of programs, the Buddy Check program,
our Solid Start program, that are really intended to lift up
Veterans Service Organizations as they reach out to their peers
to provide support.
I also, Dr. Cantor, wanted to talk about telehealth. My
colleagues and I have worked together on a bipartisan basis to
expand access to opioid treatment. Last year, we passed into
law the Mainstreaming Addiction Treatment Act, which I led with
Senator Murkowski. That removed unnecessary barriers for
doctors to prescribe lifesaving medication-assisted treatment
for people struggling with opioids, including veterans.
However, veterans in rural areas may still have limited
access to in-person healthcare providers to initiate and
monitor substance use disorder treatment. So we are going now
from about 150,000 docs nationally who could prescribe
buprenorphine to opioid addiction to 1.8 million now that we
have removed this barrier, but we still have to be able to get
people in front of a doctor to get that treatment.
So, Dr. Cantor, can you discuss the role of telehealth in
expanding veterans' access to lifesaving medication-assisted
treatment?
Dr. Cantor. Thank you for the question. I think since the
COVID-19 pandemic there has been this drastic increase in
telehealth availability.
Senator Hassan. Yep.
Dr. Cantor. And I think that it is an outstanding question.
There has been some research that has examined the telehealth
utilization rates.
Senator Hassan. Yep.
Dr. Cantor. I think it is still under review as to whether
or not the effect of the quality of care that veterans receive
differs between inpatient and telehealth.
Senator Hassan. Yep.
Dr. Cantor. And I think without that being answered first I
think we just need more information, data.
Senator Hassan. Yes. Well, one of the things that I am
trying to drill down on here is if you have veterans in a rural
area who do not have a primary care doctor in the area or a doc
who is expert in treating substance use disorder. We need to
get people in front of a doctor and begin that relationship.
I am going to continue, Mr. Chair, to push for telehealth
resources when it comes to treating opioid abuse disorder
because if we are expecting people to drive hours for this kind
of treatment I think it is going to be an effective denial of
access to them. Thank you for letting me go over.
Senator Moran. A Kansan can relate to what you say.
Senator Cassidy.
SENATOR BILL CASSIDY
Senator Cassidy. Thank you all. I have been pulled every
which way, so if I sound like I am asking something which
others have already asked, I apologize because I probably am.
Ms. Simoni, your statement that military veteran care
should be less about the VA and more about the veterans
themselves, what a powerful statement. And we know, oftentimes,
it becomes the other way around; it becomes more about the
institution than it is about the veteran. So can you just say
what should we be doing to make sure that the VA provides the
services that veterans need, when they need it, in a location
which is convenient?
Ms. Simoni. Sure. I appreciate that. Yes, I have noticed
from being a veteran myself and utilizing the VA, but also
being a healthcare provider, that we start to come to these
hearings and we hear more about the actual--you know, the VA
more, less about the veteran. And so you know, for a lot of
these veterans, Post-9/11 specifically, less than 40 percent
are enrolled in VA care.
So when you look at the rural health aspect and you look at
somebody who is (a) suicidal or has a dual diagnosis of, you
know, TBI, chronic pain, mental health disorder, you have got
to look at it holistically. You can treat one thing. You can
treat substance use the day of, sure, within 48 hours, but if
you do not have something to back that with--you know, physical
pain, such as myself, or emotional pain. I was discharged
honorably but medically retired. I was without my team.
So mental health is lacking. You know, polytrauma,
substance use, dual diagnosis, we have nothing to do that with.
So when a veteran comes to me and says, I am in crisis, I
know my time is limited. If that veteran is addicted to
substances and they are wanting treatment, you have to meet the
veteran where they are at. You cannot expect them to drive
hours away or wait days, hours. Hours is too much. It takes 10
minutes from the time you have a thought of suicide to the
action itself. Ten minutes. That is a short amount of time.
And if you cannot help a veteran when they say, I am
ready--because you can spin your wheels and you can say, hey,
you know, we have treatment available, but if they are not
ready, if they are not committed, they are not going to do it.
You know, you have to bring health care to them. And with
all due respect, as somebody who has telehealth and virtual
care, I can tell you right now as a provider that is not the
right route to go for substance use because you cannot
physically assess that patient. You cannot physically determine
if they have injection marks on their arms. You cannot see if
they are currently struggling. You cannot see below, my legs,
where I cannot stop moving my legs.
So we need to meet the veteran where they are at, and it
does not matter the extent of how that is. You just make sure
you get it done. You know? And that is--these are people I
served with. If I have to stay awake 24 hours a day and make
sure that they are okay and they do not kill themselves, I will
do that because----
Senator Cassidy. So as a doc who greatly knows the
advantage of being in the room with somebody to give me
information, I can totally relate.
Dr. Cantor, you kind of put the statistics on this, that
your testimony is showing that less than 10 percent of veterans
with a substance use disorder in 2020 received any treatment
and a key determinant is whether an individual receiving SUD,
how far they have to travel.
Now Ms. Simoni, a health provider, finds telehealth as a
poor substitute for in-person health. Any comments on that?
Dr. Cantor. I think that we just basically need more
research in terms of the quality of care for telehealth, and I
have already stated that previously. I think that there is not
enough known currently in terms of actually to determine
whether or not one provides better care versus the other. I
just think we need more information.
But to your point about veterans in general, about not
receiving care, I think it is a persistent issue across the
healthcare system; it is not just veterans. A large,
significant proportion of the country does not receive care for
substance use disorder as well. So I would not just say it is
just a veterans' issue in terms of the lack of care.
Senator Cassidy. So is the issue specific--we know about
the deaths from despair and how that is often centered in men,
and now increasingly in women, who do not attend college or do
not graduate from college, et cetera. So are we talking about a
veteran issue, or are we talking about a demographic issue
because you mentioned how it is true whether you are a vet or
not? So again, is this peculiar to veterans, or they are just
part of that same demographic?
Dr. Cantor. I think it is a systemwide issue. I think
veterans have unique challenges in terms of both receiving
treatment and then comorbidities when frequently having mental
health issues along with substance use disorder. So they are a
very unique population, but in terms of actual capacity and
delivery of care, I think it is a systemwide problem.
Senator Cassidy. It seems like that a veteran would have
more options for care because the veteran still has the VA plus
a more traditional healthcare system. So is that not a correct
analysis?
Dr. Cantor. I think it is just that mostly that most folks
who need care do not actually receive it.
Senator Cassidy. I am a little frustrated on this, sorry.
Are they not receiving it because they do not seek it because
they are too much into their addiction and they do not want to
get out of their addiction or because they do not have access
to the resource even if they want to get out of their
addiction?
Dr. Cantor. For veteran-specific or just people in general?
Senator Cassidy. Well, let us just stay with veterans.
Dr. Cantor. I think it is a combination of both, that there
is a lack of knowledge in terms of where they can receive care
and it is difficult to navigate the actual system and the fact
that whether or not there are numerous barriers about care, but
I do not want to just oversimplify any one individual person's
decision as to whether or not to seek care.
Senator Cassidy. Yes, but unless we have some sort of--I am
not simplifying an individual.
Dr. Cantor. Yes.
Senator Cassidy. But unless we have some sort of--kind of--
you know, we actually feel like, you know, 40 percent of people
just do not want care. They are in their addiction. They would
rather be an addict than actually go seek care. I worked in an
inner city hospital, and frankly, that is kind of what I found
sometimes. But we need to have numbers behind that because we
are being asked to apply resources, but unless you have a sense
of what the need is and the particulars of it--so anyway, that
is--anyway, okay. I yield.
Senator Moran. Thank you, Doctor.
Senator Manchin.
SENATOR JOE MANCHIN III
Senator Manchin. Thank you, Mr. Chairman, and thank all of
you. I appreciate very much you all being here.
Dr. Kroviak, according to the U.S. Census, we are the third
most rural State in America, West Virginia. We do not have one
city or one town over 50,000 population. So we are a State of
towns and about 1,800,000 people.
But with that being said, how do you all determine what a
rural veteran is? What is your determination of rural veterans?
Dr. Kroviak. So in our oversight work, we would look to
VHA's definition of rurality. So they have highly rural and
rural locations that are based on data. I believe it is with
HUD and--I am blanking on the other. But they have a system in
place that we follow when we conduct our oversight work.
Senator Manchin. Yes, if you could get back to me on that--
--
Dr. Kroviak. Absolutely.
------------------------------------------------------------------------
-------------------------------------------------------------------------
VHA Response: The Veterans Health Administration (VHA) relies on
standard definitions of rurality developed by the U.S. Department of
Agriculture Economic Research Service (USDA-ERS). The USDA-ERS uses a
framework for determining rurality called the Rural-Urban Commuting
Area Codes, or RUCA codes. The RUCA codes consider population density,
urbanization, and daily commuting to classify geographic areas. RUCA is
based on U.S. Census data and the 2006-2010 American Community Survey
(ACS) and can be applied to either counties or census tracts. The VHA
uses RUCA codes to group Veterans into Urban, Rural, and Highly Rural
based on their residential address that is mapped to a census tract and
its corresponding RUCA value assigned for rurality.
RUCA includes primary classification codes numbered from one to ten,
with one being an urban area and ten including the most rural.
Generally, a Veteran is considered rural or highly rural if their
residence is in a census tract with a RUCA code between two and ten.
USDA-ERS is due to update the RUCA data using 2016-2020 ACS data in
Fiscal Year 2024.
OIG Response: The VA OIG does not make our own determination of which
VHA facilities are considered rural. Rather, we follow VA's
definitions. We have provided Senator Manchin's staff a link to VA's
website where they explain their methodology. Because the definition of
rurality is managed by VA, we have also connected the Senator's staff
with the appropriate contacts at VA to provide any additional
information that is needed.
------------------------------------------------------------------------
Senator Manchin [continuing]. Because my whole State should
be. I have four different veteran hospitals and some clinics.
Also, I was going to ask you on services. I understand we
are having a hard time. Basically, in a very rural area, we
have the mobile. We have a mobile VA clinic. Are they able to
treat for substance abuse?
Dr. Kroviak. So there are Mobile Vet Centers that do not
provide treatment but can serve to set veterans up with
clinical support for detox, withdrawal, more intense services
as well as long-term substance abuse treatment.
Senator Manchin. I mean, I am saying if they are far away
from a center and they need services and they cannot get to the
centers on a frequent basis because of transportation, is the
mobile service available to them?
Dr. Kroviak. So I would have to get back to you on whether
the mobile services can actually offer intensive--the intensive
treatment you are describing.
------------------------------------------------------------------------
-------------------------------------------------------------------------
VHA Response: Readjustment Counseling Service (RCS) maintains a fleet of
84 Mobile Vet Centers (MVCs) to extend focused outreach, direct
services, and referral services to communities that do not meet the
requirements for a ``brick-and-mortar'' Vet Center. In many cases,
these communities are distant from existing services and are considered
rural or highly rural. Each MVC includes a confidential counseling
space for direct service provision, as well as a state-of-the-art
satellite communications package that includes fully encrypted
teleconferencing equipment; access to all relevant Veterans Affairs
(VA) information technology systems; and connectivity to emergency
response systems.
MVCs are placed at parent Vet Centers with close access to rural
communities, major military installations, and used as demand
developers in areas with unmet needs. MVCs are easily moved to meet the
demands across the country, whether it be to support an event or a long-
term solution to unmet demand. RCS utilizes MVCs in these communities
while often seeking to establish a Vet Center Community Access Points
(CAPs). RCS staff work with local partners to establish CAPs by using
donated office space for face-to-face appointments to occur in the
communities where the need exists. Services are provided anywhere from
once a month to several days per week. These partners are often
Veterans Service Organizations, community providers, and local
governments. Additionally, virtual services are available for all Vet
Center clients, and would be available to support those who are unable
to attend in person.
OIG Response: The programs and services that can assist rural veterans
with accessing intensive substance use disorder treatment are managed
by VA. We have therefore connected Senator Manchin's staff with the
appropriate contacts at VA to assist in providing additional
information on their capabilities.
------------------------------------------------------------------------
Senator Manchin. One final thing from the clinics, I was
at--we have some problems, as you know, in some of the deaths
that we had in one of our hospitals. But I was there talking
about substance abuse, and I had one of the nurses who was very
straightforward, and she says, well, if you all did not call
and raise so much Cain with us about because we will not give
veterans their drugs they want, because if we do not give it to
them they would call and berate that service, that that
hospital is poor and give them poor ratings, which brought more
scrutiny. Are you familiar with all of this?
Dr. Kroviak. So I understand the concern they are finding.
I am not familiar with the specific statistics.
Senator Manchin. Do you know if that has been changed?
Dr. Kroviak. If the----
Senator Manchin. I understand we put a piece of legislation
that changed you could not--you cannot complain about the
disbursement of drugs because I can tell you a lot of the
veterans knew exactly. They knew more than the pharmacists knew
about what drugs they wanted and why they wanted them, and they
were determined to get those drugs. And if they did not, they
would call their representatives, Senators or Congress people,
and complain they were getting poor service, and we found it
mostly over drug dispensation.
Do you have a--I can see you want to say something.
Dr. Kroviak. If I could just add, though, it is a fair
concern. The pendulum has swung dramatically, and veterans who
are on a chronic opioid or any type of chronic pain treatment,
to aggressively taper is not an appropriate form of management.
Senator Manchin. We are not saying, aggressively. Some of
these nurses know better than what anybody else knows.
Dr. Kroviak. No question.
Senator Manchin. They are not able to do their job, but I
am hoping that has reversed. Does anybody up there know about
what I am talking about? Have you heard? Chelsey, do you want
to talk?
Ms. Simoni. Yes, I have heard about it, and I have
experienced it, and it is twofold like you mentioned.
Senator Manchin. Tell me which way it is going.
Ms. Simoni. Well, so it is not always the veteran that is
seeking the drugs. You know, I mean, it is an interesting move,
but I bring this as one month of pills from the VA that I did
not ask for, that the providers thought I needed. And I said to
them, if I take all these, I probably will not wake up.
This is one month, and so with all due respect, trazodone
to help me sleep, ropinirole and----
Senator Manchin. Is that on a daily basis?
Ms. Simoni. This is on a daily basis.
Senator Manchin. Oh, someone take a picture of this.
Ms. Simoni. But this is--so it is not always the veteran
that is asking for these.
Senator Manchin. So it is basically being prescribed to
them.
Ms. Simoni. We are not looking at it from a holistic
perspective.
Senator Manchin. You got to be kidding me. This is----
Ms. Simoni. Oh, there is two more. There is two more.
Senator Manchin. Put them all out there. Yes, please, get
this.
Ms. Simoni. And so if I take these together, there is a
good chance I will not wake up. And thankfully, as a healthcare
provider, I know I cannot take this with this and that with
that. But these are all my pills, and so----
Senator Manchin. Have you talked--I mean, knowing that you
have the medical expertise, have you talked to the providers
why they did this?
Ms. Simoni. When I said to the provider--I went to the VA
two months ago, and I said, my back is getting worse. My spine
is collapsing on itself.
Senator Manchin. Right, right.
Ms. Simoni. I am 32 years old.
Go to physical therapy. Here is some more gabapentin. This
should help with the numbness.
I said, that does not work. I have been doing this for 10
years. What else can I do?
Oh, you can have a spinal fusion.
So I cannot walk. I said, this is not--that does not work
for me. I cannot sleep. I cannot stop tossing and turning, and
it is solely based on an injury.
And so if this is not an addiction in the making--and this
is recent. This is one month. If this is not an addiction in
the making, I do not know what is, and this is why it is
critical to see patients in person.
Senator Manchin. Well, this is what I was saying, too. I
have been told basically--and I have talked to a lot of our
servicemembers who have been deployed, and they are able to get
anything they want, any concoction they want, just to get
through the day.
Ms. Simoni. Except if they want alternative treatment,
respectfully.
Senator Manchin. It is the same, isn't it? Mr. Chairman, we
have got to do something.
Senator Moran. Thank you, Senator Manchin.
Senator Sullivan.
SENATOR DAN SULLIVAN
Senator Sullivan. Thank you, Mr. Chairman.
And, boy, Ms. Simoni, that is some serious----
Senator Manchin. I teed it up for you.
Senator Sullivan [continuing]. Drugs you got there. You
know, we have had hearings on this. I want to commend Senator
Manchin. He has done a lot in this area, on this topic.
Dr. Kroviak, that was not one of the questions I was going
to ask, but is there a concern from the IG's Office about these
kind of prescriptions that could lead to a dangerous situation?
Dr. Kroviak. That is catastrophic care coordination like I
have never seen, and it is a huge concern when multiple
providers are involved. Usually we see the greatest concern
between VHA and the community. When that information is not
being shared real time, dangerous concoctions can happen like
this, and patients might be completely unaware.
Senator Sullivan. So are those all from the VA?
Ms. Simoni. Yes, sir.
Senator Moran. How many providers? Does that come from more
than one, obviously, more than one provider?
Ms. Simoni. Neurology, mental health, and that is it. Two.
Senator Sullivan. From the same VA? Which VA is that?
Ms. Simoni. New England VA Healthcare System. It is in the
New England VA Healthcare System.
Dr. Kroviak. So there is a misstep in medication
reconciliation, and I obviously do not know the specifics of
your care, but that sounds like a big gap in medication
reconciliation.
Senator Sullivan. Yes, you might want to look into that.
Right? We do not want anyone from that system or any system, or
any of our veterans, dying of a drug overdose that is induced
by too many pills. That is outrageous.
Let me turn to the topic at hand, Dr. Kroviak, and--by the
way, I want to thank all the witnesses. A lot of you are
veterans and are caring for veterans. It is not easy. So all
four of you I actually appreciate very much. I read all your
backgrounds. Impressive what you have done and your concern, so
thank you to all the witnesses here.
Do we have a sense--just going back to some basic issues--
on wait times with regard to the VA, and is there a significant
difference between urban and rural areas in terms of wait
times?
Dr. Kroviak. So we do look at those in rural versus urban.
We do see somewhat of an increase in rural if you look at
fiscal year '22. It is not--I think some of the mental health
differences for referrals were seven or eight days' difference,
and I can get those exact numbers that our office drew from VA
data. But it is measurable in terms of when you compare rural
to urban, that rural has a longer wait time, especially for
specialty care.
Senator Sullivan. Okay. You know, I come from a State with
more vets per capita than any State in the country, and our
very rural State, Alaska, we do not even have one full-service
VA hospital in the State.
And one of the issues that my State has experienced,
particularly with regard to rural providers, is the lack of
experience in terms of the providers themselves. And so can you
speak to that? Are there recruitment efforts that are being
made with regard to trying to get more experienced providers in
our rural areas? Maybe this is an issue beyond Alaska.
And what can we do about it? Is there pay scales that we
can provide? Are there incentives that we can provide to make
sure we are getting high quality providers to people in rural
Alaska? It should not matter on your ZIP code how good your VA
or private care provider is.
Dr. Kroviak. So I appreciate the question. Unfortunately,
in oversight, we have no role in determining VA's hiring or
retention and recruiting activities. So that would be better
directed to them.
But if I could just say, we do understand the quality
concerns that you are describing, particularly again when you
go out into the community, that clinical information sharing
opportunities are lost or so delayed that I cannot tell you
what type of quality of care is happening outside of the VA,
and I am very concerned they cannot either. So your concerns
about the caliber or the credentialing, the experience of the
providers they are hiring, in VA as well as in the community,
is definitely warranted.
Senator Sullivan. Let me ask one final question, and I will
throw it out for all the witnesses. Senator Cassidy, Dr.
Cassidy, was talking about this issue of the prevalence of
substance abuse in the veteran population, and then beyond just
the veteran population, Dr. Cantor, he was a having a
discussion with you.
But it also certainly seems like it is a younger generation
issue. Is that a trend that you are seeing, any of you, in your
experience, that these substance abuse issues are hitting a
younger demographic, and if so, why? And if not, then maybe
that is not an area of focus. Anyone on that? No one knows
whether--go ahead.
Ms. Simoni. I can speak on behalf of civilian. Every--I
work 40 hours a week in the ER, doing three on, four off, and I
see roughly, at Mass General Hospital, 10 overdoses a week in
just my practice alone in individuals under the age 35.
Senator Sullivan. So it is a younger demographic.
Ms. Simoni. From my practice and personal experience, yes.
Senator Sullivan. Anyone--Dr. Cantor, have you seen this as
a broad demographic trend, or you do not have the data on it?
Dr. Cantor. I do not have the data on that.
Senator Sullivan. Anyone else? Dr. Kroviak?
Dr. Kroviak. I do not have the data, but if you are
targeting an age group, we are doing work now in that high risk
transition period from active duty to civilian, or to veteran,
when you will find typically a younger age. And we are doing
work now looking specifically at ensuring that those diagnosed
during active duty with opioid use disorder, that that
information is translated into the VA record. We are seeing
there are a lot of gaps in even ensuring that once the
diagnosis is made in active duty that veterans are being
recorded as having that diagnosis and immediately getting
treatment and support for it. So it does softly hit your age
target that you were describing.
Senator Sullivan. Okay, good. Thank you.
Thank you, Mr. Chairman.
Senator Moran. Thank you, Senator.
Maybe for Dr. Kroviak or anyone, so are there statistics
that--let me preface what I am going to say. So 2014, we saw an
inability of the VA within their hospital system to meet the
needs of veterans. That is when we saw and learned about the
fake waiting lists, the fake appointment lists, and we
responded; Congress responded with CHOICE in 2014. So for 10
years, we have been trying to figure out how we can get the
Department of Veterans Affairs to provide health care in more
locations by using community care.
Community care existed before CHOICE. My view is that
CHOICE was implemented by the Department of Veterans Affairs in
which it needed more, greater restrictions in our language to
make sure that community care was actually provided. We had to
encourage the Department to use that option.
So we passed MISSION, giving some pretty specific
directions and outlines in which the circumstances--and again,
only in the circumstance in which a veteran wants to have
community care. And still, we find that the gaps continue.
My interest in this, I mean, is broad across the country--
the deaths in the hospital in Arizona, et cetera--but it is
also very local for me. I represent a State--a congressional
district at the time that is the size of the State of Illinois.
There is no VA hospital, and it is hours to drive for almost
every veteran to a VA hospital.
And so we have tried legislatively to encourage, force,
require when the choice was the veteran's to receive care in
the community.
Any inspector general reports that demonstrate any success
in those efforts? Are things getting better? Do we still have
problems in the utilization of community care?
I have legislation that we are going to, I hope, mark up
soon that will require you to make those analyses so that we
can determine whether or not the efforts that we have
undertaken over a decade are making a difference. Any
commentary?
Dr. Kroviak. Your question is massive; I mean, it really
is. I am a bit biased as a former provider in the VA. What
CHOICE did not solve, what MISSION has not solved is when you
are engaging with the community, reliably getting that clinical
information back, so VA and the community provider are on the
same page at the same time to manage the veteran's care.
It gets so much worse when there is complexity introduced.
So if there is a mental health diagnosis, if there is a cancer
that requires multidisciplinary specialties to get involved,
the coordination is enormously difficult, and it remains so.
And technology is likely the ultimate solution, but we are
not there yet to where the EHRs can interface, to have that
real-time connection going.
Every report the Office of Healthcare Inspection writes
touches on some form of care coordination gaps, failures, and
they are usually highlighted in that community care
collaboration setting. So until there is a way to ensure that a
primary care provide in the VA who sends their patient out to
the community for that dermatology or cardiology referral,
until they can know in real time how that patient is being
managed, you have no assessment of the quality.
Senator Moran. What is the current capability?
Dr. Kroviak. It depends on the part of the country. You
know, there are HIEs, but our understanding is very few
community providers participate in the Health Information
Exchanges. We are still especially in some rural communities
relying on faxes, and those faxes get sent to a space in a
facility where already a stressed staff in terms of number have
to just scan those records in, and we do not even find there is
uniformity in the scanning. So the record might be there for
the provider to look at, but they have no idea how to find it,
what is the naming convention. It is a dangerous relationship
right now.
Senator Moran. And are there other reasons? Perhaps you are
suggesting that a provider within the VA would be reluctant to
make the referral because the lack of communication between----
Dr. Kroviak. I do not want to imply that they would delay
care intentionally for their patient, but when we do hear
stories where the veteran is choosing to stay, I can, you know,
honestly say, I get it, where they are choosing to wait for the
VA provider as opposed to being sent into the community. But I
do not want to suggest that we have anything that VA providers
are scared to send their patients so they do not because that
is something we have not looked at.
Senator Moran. I would tell you that, anecdotally, so many
times I have--mostly what I know about what is going on in
veterans' lives is the conversations I have with veterans. No
offense to RAND or to the Inspector General.
Dr. Kroviak. None taken.
Senator Moran. I should read your reports more frequently,
but veterans are willing, usually, to have a conversation. And
so often it is that, I am seeking community care, but I cannot
get the referral from the Department of Veterans Affairs.
So there seems to me to be some bias if it is based upon a
concern about medical care, but it is certainly a slow
process----
Dr. Kroviak. Yes.
Senator Moran [continuing]. By which the VA will make the
decision when someone asks, when a veteran asks for community
care.
And what I have heard in the time that I have been here in
front of this panel is that there is no time to spare. And so a
system that is designed to save lives and improve one's well-
being, particularly, I suppose, it could be other things than
mental health and drug addiction, but certainly in those
circumstances we need a system in which a referral is made
quickly.
I understand that in many communities across Kansas and the
country there are not enough providers in mental health and
substance abuse services to make those referrals to. It is a
shortage across the board. But I want--it is a goal of mine--to
make sure there are no artificial, unnecessary impediments, or
no bias against a veteran who chooses or needs care quickly or
needs care because of geography, that the VA is not making
those referrals in a timely, medically necessary fashion.
Dr. Kroviak. Again, that is a huge undertaking, and I
really appreciate the concern. Even if you take it out of this
one aspect of community care you are looking at, this is a
massive system, and it has a lot of policies and practices in
place. And getting frontline staff to consistently apply those
rules is difficult, especially when you do not have
standardization across the board that builds in that
accountability.
In my oral testimony, I highlighted incredibly dated
handbooks and guidelines for clinical practice. So we cannot
fix the interface of EHR today, but things that we can do in
the immediate term is update the policies and practices,
clinical and administrative, give the front line a chance to
practice the rules consistently, and then standardize some type
of structure at whatever level, maybe even looking at the VISN,
to make sure those rules are being carried out. That is an
immediate or a near immediate solution that will at least get
you more comfortable that the staff is offering the veteran,
based on the wait times, care that they need and the
opportunity they have to get care outside the VA.
Senator Moran. Well, it is another experience, and as an
Inspector General you would not, I do not think, find this
surprising. So many times, I mean, I bring a case to the
Department of Veterans Affairs, and nationally, here in
Washington, DC, I am told that this is the policy and if it was
not the policy we have now fixed the policy. But that is--well,
let me be more precise. It is often the case that that is not
what the person in the VISN or in the hospital or in the
community outpatient clinic--that is not what they know the
policy to be.
So I am often told, here is the policy. Senator Moran, we
have got the policy that you want. But that is not close to
what----
Dr. Kroviak. The SOP, the local business rule, might be
completely different. So the frontline staff is being honest;
here is what I do because I am told to do this. And they are
being honest when they are delivering the policy. And when they
conflict, who loses? The veteran.
Senator Moran. Yes. I am not off this topic. I mean, I am
off this topic for the moment, but I am not off this topic
generally.
Let me highlight how grateful I am to Ms. Simoni for what
is a very difficult testimony to provide. I appreciate you
sharing your personal and family story.
You indicated in your testimony that the data you shared
with the Committee also notes many examples of where care
offered by the VA has fallen short for many of your fellow
veterans. Would you expand on what you are telling us?
Ms. Simoni. Of course. You know, you are the Senator of
Kansas. So I mean, a perfect example, you know, in terms of
community care----
Senator Moran. You have got something else in your bag?
Ms. Simoni. No, no. I wish. I usually have a lot of--no.
You know, it brings me back to the fact I deal mostly with
oncology and veterans with terminal cancers, and you know, SOP
goes out the window when time is on the clock. And I mean, I
say that in the most humble way possible, but year to date, we
have lost--only the ones that I know of, that I have physically
cared for--119 Post-9/11 veterans from cancer.
And so two years ago, we had a veteran who was in the
Kansas VA healthcare system. He was on this third diagnosis of
terminal cancer, and the VA said to him, there is nothing more
we can do. And being he was only 34 years old, with three kids,
I did not accept that. I said, let me try. Let me call. Let me
do something.
And so we finally got him care down at MD Anderson, and
when he requested through his provider who writes the order or
the allowance for community care, his provider says, that is
not evidence-based. You cannot go there. I am not writing that
order.
And we fought for two weeks, and as two weeks goes by, time
is running out. Finally, I said, I will pay for it myself
because you can always make more money but you cannot save a
life once it is gone. And myself and my co-worker, Matt,
reached out to your office, and you had him squared away, like
squared away instantly. And it saved his life, and he is still
alive today, which is incredible because he was given a
terminal diagnosis two years ago.
So this is something we face every day. And I mean it in
the most humbling way possible; I do not have time. My
patients, my veterans, the people I served with, myself, my
brother, we do not have time to wait for processes to be
implemented or systemic problems to be fixed. These are--time
is running out.
Twenty-four hours in a day. Time is running out. Every
single 24--every hour that goes, that time matters. And if I
have to pay for it myself, I will because you can always make
more money but you cannot save a life once it is gone.
Senator Moran. That was not the answer I was soliciting,
but I appreciate the fact that you took extra--greater
willingness to go another step to make a difference.
It is also a good reminder. And I make the same mistake. I
talk about the MISSION Act in terms of geography, which is a
huge component to people for substance abuse and mental health
issues and suicide and just general care. But the MISSION Act
is also designed to get expertise that may not exist within the
VA, perhaps such as oncology, that can also serve a veteran if
that is, again, his or her choice.
You know, Ms. Simoni, that I recently introduced the
Veterans' HEALTH Act that aims to address some of the issues
that we are talking about today. Would you share with me, so I
can repeat it when we have a debate and conversation about this
legislation, why your organization decided to endorse that
legislation?
Ms. Simoni. Absolutely.
Senator Moran. Please do. Please tell me why your
organization endorsed that legislation.
Ms. Simoni. Oh, sure. So I have bad hearing.
Senator Moran. My wife tells me I am a terrible
communicator.
Ms. Simoni. I just--I cannot hear that well. So our
organization supported that legislation because, you know, at
the end of the day, like I said, it is not about if we vote
Democrat, Republican, you know, whether veterans--whatever it
may be. This is about the veteran.
And so the HEALTH Act I found very interesting because it
allows us to get the veteran care where they are at. And for a
lot of these rare cancer cases--and a lot of these are rare
cancers that we deal with. Substance use. Like I mentioned, it
is dual diagnoses and polytrauma. It has to be looked at
holistically.
And so a lot of my patients end up dying because they do
not receive unique veteran-specific care, and I believe that
your HEALTH Act can make a big difference in that. I believe
that they will be able to receive care at some of the best
hospitals in the country, such as MD Anderson, such as Moffitt,
such as Dana-Farber, more quickly, more adequately, more
holistically, and at the end of the day, that is all that
matters to me and our organization.
Senator Moran. Thank you.
Ms. Mathis, your written testimony included a
recommendation to the VA to increase the number of Clinical
Resource Hubs to better aid veterans who live in areas that
experience bandwidth problems. We have been talking about
technology, and we have been talking about telemedicine,
telehealth.
My staff and I are proponents of this initiative of the
Office of Rural Health and routinely ask the VA if they are
requesting adequate funding for Clinical Resource Hubs or could
benefit from additional hubs. In addition to serving on this
Committee, I am an appropriator as well.
Can you share with us DAV's recommendations on how many
additional Clinical Resource Hubs VA could use to serve VA's
rural and highly rural veteran population?
Ms. Mathis. Thank you for that question, Senator. I do not
have the data as far as how many they need. That would be a VA
data-driven kind of answer.
But I will say that in rural communities, as you know, they
do have bandwidth issues. And if a veteran cannot get to the
technology that is supposed to help them because they do not
have the capacity to do so, then how is technology supposed to
be helping that veteran?
So the Clinical Resource Hubs are really beneficial for the
rural veteran to be able to get the quality care that VA
provides, and so they do have efforts such as the Virtual
Living Room where you can go to, say, your local DAV chapter
and have a private conversation with your provider using these
Clinical Resource Hubs or these Virtual Living Rooms as well.
Senator Moran. I want to hear what you had to say, but I
also thought of another issue.
Ms. Mathis. Sure.
Senator Moran. I could not hear either. So related to these
topics, ATLAS pods was something that was touted--we have one
in Kansas, in Emporia--in which mental health services were to
be provided so that a veteran who did not have access to the
technology or the broadband width to receive and send signals
to a provider could go to a central location within the
community. In this case, a Veterans Service Organization worked
with a private company to put in the pod. The VA has paused the
implementation of that.
Do disabled American veterans know about that program?
Anything that you want to share with me or just I will use this
as an opportunity to remind myself and the VA that pause has
been going now for months.
Ms. Mathis. I do not know about that program, but I am very
interested to hear about it.
Senator Moran. Okay. Do you think it could have merit?
Ms. Mathis. I do not--I do not know.
Senator Moran. Do not know.
Ms. Mathis. I would have to look at it.
Senator Moran. Okay. Anyone else?
[No response.]
Senator Moran. Thank you very much, all, for your
testimony. I want to thank you, I do thank you, for being here.
We will continue to make certain that we do everything we
can to see that veterans receive high quality care,
particularly as it relates in this hearing to mental health and
substance abuse disorders, and I am grateful for the care and
compassion that each of you has shown for those who served our
country.
One reason I was late, incidentally, is today is the 248th
anniversary of the Army, and so we were cutting cake. I chair
the Army Caucus, and I was responsible for helping cut the
cake. But I am glad I made it to hear the testimony that I did
and have the conversations with you.
We will keep the record open for a week in case my
colleagues and I have questions that you can then reply to the
record, and for today, the hearing is adjourned. Thank you.
[Whereupon, at 4:48 p.m., the hearing was adjourned.]
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