    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                        BREAKING DOWN BARRIERS: GETTING

                       VETERANS ACCESS TO LIFESAVING CARE

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

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                            TUESDAY, MARCH 25, 2025

                                   __________

                               Serial No. 119-13

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                 GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

                        Available via http://govinfo.gov

                               ______

                 U.S. GOVERNMENT PUBLISHING OFFICE
     60-685          WASHINGTON : 2025

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                             SUBCOMMITTEE ON HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

    JACK BERGMAN, Michigan               JULIA BROWNLEY, California,
    GREGORY F. MURPHY, North Carolina        Ranking Member
    DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,
    JEN KIGGANS, Virginia                    Florida
    ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon
    KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey
        Mariana Islands                  KELLY MORRISON, Minnesota

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.
                             C  O  N  T  E  N  T  S

                                  ----------

                            TUESDAY, MARCH 25, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     2

                                   WITNESSES
                                    Panel I

    Ms. Missy Jarrott, Mother of Navy Veteran Landon Holcomb.........     4

    Mr. Michael Urban, LCSW, Army Veteran and Mental Health Advocate.     6

    Dr. Shankar Yalamanchili, Chief Executive Officer, River Region
      Psychiatry Associates..........................................     8

                                    Panel II

    Dr. Maria D. Llorente, Acting Undersecretary for Health, Office
      of Integrated Veterans Care, Veterans Health Administration,
      U.S. Department of Veterans Affairs............................    17

            Accompanied by:

        Dr. Ilse Wiechers, Deputy Director, Office of Mental Health,
            Veterans Health Administration, U.S. Department of
            Veterans Affairs

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Ms. Missy Jarrott Prepared Statement.............................    29
    Mr. Michael Urban Prepared Statement.............................    32
    Dr. Shankar Yalamanchili Prepared Statement......................    63
    Dr. Maria D. Llorente Prepared Statement.........................    65

                           Statements For The Record

    American Academy of Physician Associates Prepared Statement......    67
    National Association for Behavioral Healthcare Prepared Statement    69

       BREAKING DOWN BARRIERS: GETTING VETERANS ACCESS TO LIFESAVING CARE

                                  ----------

                            TUESDAY, MARCH 25, 2025

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 3:20 p.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meeks [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meeks, Brownley, Dexter,
    and Morrison.
        Also present: Representative Carter.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. Subcommittee on Health will now come to
    order. Before I begin my remarks, I would like to highlight
    some numbers. First, $20.9 billion. That is the amount the
    Veterans Health Administration (VHA) received in 2001 at the
    onset of the global war on terror. In that same year, an
    estimated 16 to 17 veterans took their own lives every single
    day.
        Second, $121 billion. That is the amount the VHA received
    in 2024 after nearly two decades of war and an entire
    generation of veterans now relying on the system billed to care
    for them. 17, that is the number of veterans our Nation loses
    to suicide every single day in 2024. That number could be
    higher as the U.S. Department of Veterans Affairs (VA) does not
    include veterans who lose their lives to overdoses in its
    official suicide statistics.
        The numbers tell a clear story. VA's problem is not a lack
    of resources. VA's problem is not a lack of funding. VA's
    problem is not a lack of staffing. VA's problem is not that
    Congress has failed to provide what it needs to care for those
    who have served.
        Since the beginning of the global war on terror, VA's
    budget has increased an incredible 479 percent. Yet, the number
    of veterans we lose every day has remained approximately the
    same, and these are just to suicides that we know about or that
    the VA counts. Some seem to believe that the solution is
    straightforward. Continue to invest in VA staffing, expand
    services, grow the system, but the number do not lie. If the
    money alone could solve this problem, it would have been solved
    long ago.
        No, the VA does not have a resource problem. It has an
    access and a process problem. It is a blatant failure of the VA
    to adapt to the needs of the very people it was created to
    serve. VA's current processes are not designed to provide
    veterans care when and where they need it. Instead, veterans
    are left waiting, navigating delays, bureaucratic red tape, and
    systemic inefficiencies that create barriers rather than
    breaking them down. Well, I believe that Congress and the VA
    has taken some necessary steps to increase access, it is not
    enough.
        We continue to hear from veterans who are turned away from
    the lifesaving care that they need. Some are denied residential
    treatment because they had not previously sought VA care as if
    a veteran in crisis should have predicted their need for help
    years in advance. Others are told they cannot access community
    care unless a VA facility fails to meet a 20-day threshold,
    forcing them to wait even when immediate alternative options
    exist. Some are simply lost in the system, bounced from program
    to program expected to navigate a maze of bureaucracy while
    struggling with the very mental health conditions that make the
    process overwhelming.
        In one particular case, a veteran suffered from severe
    alcohol withdrawal who was seeking admission into a residential
    rehabilitation treatment program (RRTP) in the community was
    outright denied because the VA stated they had a bed available
    100 miles away. Had the leadership at that community facility
    not stepped up, the VA would have effectively forced that
    veteran into homelessness.
        That is why I support Chairman Bost's Veterans Assuring
    Critical Care Expansions to Support Servicemembers (ACCESS)
    Act, which takes long overdue steps toward fixing these issues.
    The Veterans ACCESS Act recognizes that the goal should be to
    protect veterans, not VA bureaucracy. It cuts through VA's
    arbitrary restrictions by allowing more veterans to seek the
    care they desperately need in the community when the VA cannot
    provide it.
        VA claims that there is no wrong door for veterans seeking
    care. Yet, we continue to hear about doors locked, doors
    hidden, and doors that simply do not exist. It is time we stop
    making excuses and start making changes, real changes and
    putting veterans first.
        Today, we will hear firsthand from those who can speak to
    these process failures, and those that can help us fix them.
    The cost of inaction is too high. Thank you all for being here.
    I look forward to today's discussion. With that, I yield to
    Ranking Member Brownley for any opening remarks she may have.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank you, Madam Chair. I would like to first
    say that we cannot have a hearing discussing veterans' access
    to mental healthcare without also acknowledging the very real
    impacts that the Trump Administration's chaotic and haphazard
    actions are causing both to VA's mental health workforce and to
    the mental health many veterans who rely on VA for their
    healthcare, their support system, and their livelihoods.
        Veterans are scared. Scared that their VA mental health
    providers who are being forced to report to work in person at
    facilities that do not have room for them will decide that
    providing care in an environment that does not ensure veteran
    privacy is not worth it and will resign from the VA.
        They are scared that the very support staff who make it
    possible for VA providers to focus on care and putting veterans
    first will be fired, leaving clinicians less able to focus on
    their care. They are scared that the outside research and
    agencies that help improve VA care will be shut down weakening
    VA's ability to provide world class care.
        Unexpected VA staffing shortages are already affecting
    veterans in my district. Just last Thursday, I held a
    roundtable for veterans to share the impacts they are
    experiencing related to workforce cuts at VA. In a very
    concerning way I heard that at a local vet center that serves
    many of the veterans in my district, there is only one provider
    left to offer care.
        Typically, vet centers employ at least four or five
    providers. Because of this severe staffing shortage and VA's
    failure to fill these critical vacancies, the vet center now
    can only offer group therapy, which is not clinically
    appropriate for every veteran.
        Workforce shortages and cuts at VA should not be what
    determines how and where veterans receive care. If the Trump
    Administration moves forward with its plan to further cut its
    workforce by up to 83,000 employees, I fear this problem will
    only get worse and veterans have less choice than ever before.
    This context leads me to today's hearing topic.
        The Department of Government Efficiency (DOGE) cuts in the
    Trump Administration's workforce actions are already directly
    impacting the programs we are discussing today. My staff has
    heard of at least one researcher who was fired from VA's Center
    for Substance and Addiction Treatment and Education, the center
    responsible for developing best clinical practices for
    substance use disorders.
        The Trump Administration has also taken an aim at the
    Department of Health and Human Services' Substance Abuse and
    Mental Health Services Administration, or SAMHSA, where cuts of
    up to 50 percent of the workforce is expected.
        SAMHSA oversees 988, the national suicide and crisis line
    which routs calls directly to the veterans crisis line through
    988, press 1. Although SAMHSA's programs do not directly serve
    veterans, cutting its workforce will undoubtedly have ripple
    effects across any provider of substance use disorder
    treatment.
        I agree with my colleagues across the aisle that we must
    ensure that any veteran who is ready to seek assistance can get
    that treatment. I do not agree that the answer is to cut
    existing workforce at VA, but other essential services and
    research, and just throw the doors open to community providers
    because VA has not developed a fee schedule for residential
    rehabilitation treatment programs.
        Community providers who treat veterans can effectively set
    their own rates, and VA will reimburse them at rates far higher
    than the industry norms. These providers has a vested financial
    interest in treating veterans, a population that they admit in
    their own statements that they have not been able to access
    because so many already receive care at VA.
        Worse still there is a serious lack of oversight over
    community providers. There is no guarantee that veterans
    receiving care in the community will get better, more timely
    access to care, and we do not know if they do because VA does
    not track that. When veterans do access care at residential
    treatment facilities in the community, we have no way of
    knowing the level of treatment or support that they are
    getting.
        We do not know if veterans are receiving care from
    providers who understand what it means to be a veteran and can
    establish a rapport with their patients. We do not know if they
    are being referred back to VA care in a timely manner as VA is
    in the best position to coordinate their overall care beyond
    treatment for their substance use disorder, which is often just
    one aspect of their overall healthcare needs.
        Unfortunately because VA has not developed a fee schedule
    for resident rehabilitation treatment, there is also no way to
    ensure that VA is overpaying for these services. In fact, we
    have heard of some community residential treatment centers
    charging VA up to $6,000 a day for one veteran's care. It
    simply will not be sustainable for VA to continue paying for
    these services at these rates.
        I have said before, we must find a balance between
    community care and VA direct care. In my opinion, we have not
    found that balance when it comes to residential rehabilitation
    treatment facilities, and I look forward to hearing from our VA
    witnesses on how we can work together to get closer to that
    balance. I thank our witnesses for being here today. With that,
    I will yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I
    would now like to introduce the panel 1 witnesses. Testifying
    before us today we have Ms. Missy Jarrott, mother of Navy
    Veteran Landon Holcomb, excuse me. Mr. Michael Urban, Army
    veteran and licensed clinical social worker, and Dr. Shankar
    Yalamanchili, Chief Executive Officer (CEO) of River Region
    Psychiatry Association (RRPA). Ms. Jarrott, you are now
    recognized for 5 minutes to deliver your testimony.

                       STATEMENT OF MISSY JARROTT

        Ms. Jarrott. Honorable Chairwoman and Ranking Member
    Brownley, and all of the members attending today. I have Landon
    sitting right beside me, right here. If you will notice that
    infectious smile that I am about to mention.
        If soldiers are going to die it needs to be at the attempt
    of an enemy, not a lack of effort and unorganized antics by the
    VA. The VA is killing our soldiers. My son Landon, who served
    as a air traffic controller Navy veteran, Naval Air Station
    (NAS) Jacksonville, 7 years ago was struggling to find mental
    health in a system that completely failed him.
        Like many veterans, he reached out to the VA for help and
    support. His first consultation with a provider was on December
    4, 2023. However, the VA did not provide a follow-up visit
    until April 10, 2024. Landon had scheduled events between this
    timeframe. However, unfortunately the VA canceled multiple
    visits denying him the chance to see a provider who specialized
    in medicine management.
        Landon tried and tried to keep his head up, that the VA
    would follow through. He was experiencing anxiety, insomnia,
    restlessness, and mood swings. Landon knew that he needed a
    mood stabilizer. ``Mom, I am struggling.'' After four
    unsuccessful months, he began to unravel with all of the
    canceled appointments. He became hopeless in the system. He was
    very emotional.
        On April 10, he visited the Savannah VA mental health team
    who determined that he was not under distress. How do you
    determine mental health when symptoms are invisible? Landon
    said the visit was a checklist, and he explained that he had
    been asking for a psychiatrist, medicine management. He was
    hoping for a better outcome and knew that this meant another
    delay in getting the help he critically needed.
        Those that smile the brightest might be fighting a war
    within. Landon was fighting. He came by to see me after this
    visit. At this point, family and friends became involved in
    searching for a psychiatrist and to no avail. We took it upon
    ourselves to call a psychiatrist in the Savannah, Bluffton, and
    Hilton Head, South Carolina areas. They did not accept military
    insurance, take new patients, or charged $300 an hour. More
    stress.
        Landon made numerous call himself. ``Hey Mom. I was calling
    you back. I was on my scooter. I was at the gym. I tried to
    call. I have also been out for some therapy groups, in
    Savannah, and the people over here at Social Empire. I have
    made a lot of phone calls this morning. I am going to get a
    workout in. Call me back when you want to. All right, love you.
    Bye.''
        That call, that voicemail, was the Monday before he died.
    On April 19, he received a call from the Charleston VA for a
    Zoom appointment scheduled for May 3. He did not make that
    appointment and passed away on May 2. The unthinkable happened.
    Landon was found in the restroom of a restaurant on Hilton Head
    Island. He had fentanyl in his system. To numb his pain, he
    thought he was taking oxys. Landon did not plan to leave us. He
    was not suicidal. The hopelessness of canceled appointments,
    feeling abandoned, and not taken seriously and the emotional
    spiraling ended his life.
        Landon was buried at the Beaufort National Cemetery in
    South Carolina with US Naval honors on May 13. He leaves behind
    two beautiful teenagers, a loving family, and many loving
    friends. He was a true patriot who loved his country. Help just
    did not come soon enough.
        Mental health is real. It cannot wait. All Landon asked for
    was a mental health appointment for medicine management. He
    raised his hand over and over again. In memory of my 39-year-
    old son could light up the room with his infectious smile let
    his voice, I am sorry, be heard from heaven above.
        On behalf of the veterans who struggle every day, let us be
    reminded to never leave a soldier behind. These are our
    children. This is why I am here today. How many more
    testimoneys is it going to take for change? How many? May God
    bless our military serving all over the world, and may God
    bless our veterans and all our military families.

        [The Prepared Statement Of Missy Jarrott Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you very much, Ms. Jarrott. Mr.
    Urban, you are now recognized for 5 minutes to present your
    testimony.

                       STATEMENT OF MICHAEL URBAN

        Mr. Urban. Good afternoon, members of the committee. I am
    honored to share my personal story and experiences with the
    Department of Veterans Affairs medical system.
        In 2003, after serving 4 years as a paratrooper in the 82d
    Airborne, I was medically discharged following an accident
    during a jump. The subsequent 13 surgeries led to a regimen of
    heavy opioid use, a path all too familiar to many veterans.
        In 2004, I began receiving care at the Philadelphia VA
    Medical Center. In my journey, I have experienced firsthand the
    challenges of accessing care within the VA system. When I
    sought help in 2004, I faced a wait time of two to 3 months for
    a bed. I have had multiple stays in VA RRTPs where I have
    witnessed practices that now as a clinician I know not to be
    best practices.
        In 2014, I had the opportunity to receive treatment outside
    the VA system, which provided a transformative experience.
    Since December 2, 2014, I have maintained sobriety and achieved
    numerous personal and professional milestones all attributed to
    the quality care I received.
        Community providers are required to operate following
    American Society of Addiction Medicine (ASAM), a standard of
    care which is much higher than that of VA. A standard in which
    I encourage VA to adopt. Office of Inspector General (OIG) has
    applied and referenced this standard during investigation into
    the deaths of veterans related to the lack of alcohol
    detoxification standards.
        In 2021, 2022, 2023, and 2024, how many years, or yet
    better, how many more veterans must die before VA follows a
    standard? In 2020, during the pandemic I developed a program
    for veterans affected by lockdown treating approximately 200
    veterans from Veterans Integrated Service Network (VISN) 4 and
    under 6 months. This experience highlighted the potential for
    collaboration between VA and community providers, but also
    revealed inconsistent practices across different VA facilities.
    In 2021, I joined a national provider to develop a veteran
    program at 18 facilities expanding my presence from local to
    national. This afforded me a unique glimpse of the entire VA
    system.
        Over the past 4 years, I have visited over 75 Veterans
    Affairs Medical Centers (VAMCs), numerous Community-Based
    Outpatient Clinics (CBOCs) and vet centers. I had the privilege
    to address VA service gaps not only at our 18 facilities, but
    by opening facilities in Alaska, Denver, virtual services for
    rural veterans in developing an eating disorder program
    specifically for veterans.
        Through my extensive interactions with veterans, veteran
    advocates and VA employees across the country I have
    consistently encountered growing challenges in accessing
    community care for mental health. We have observed a decline in
    a veteran's ability to receive this essential care, and this
    problem is not confined to a specific region.
        I have witnessed it in VA medical centers from Florida to
    Alaska. Unfortunately, the situation has deteriorated since
    last March. At Brockton VA, I worked with a veteran who was
    denied entry into RRTP due to past behavior. He then requested
    community care, but was denied without reason.
        At Hines, a veteran was told drive time standards do not
    apply to his RRTP needs. In Houston, veterans are restricted to
    facilities only approved by the chief limiting their choices.
    In Denver, veterans are all forced to travel out of State for
    VA care when it is available locally in the community.
        In Portland VA, social workers confirmed, ``We do not use
    community care,'' referring veterans to Medicare-accepted
    providers instead. In Philadelphia, veterans were denied
    community care due to the chief who told me, ``I cannot send
    veterans to the community as it will not allow me to justify my
    budget next year.''
        The issues faced by veterans in accessing community care
    are systemic and widespread. These challenges include VA has
    often failed to provide written explanations for denying
    community care, the interpretation of access standards,
    obtaining a consult and referral for substance abuse and mental
    health have become complex and time consuming, requests for
    services for veterans hospitalized in the community are not
    processed promptly leading to prolonged delays and discharge
    without necessary care. 5, ignoring the best medical interest
    standard.
        Administrators often prioritize VA interest over decisions
    made by the veteran and provider. I have personally witnessed
    the struggles of homelessness and addictive veterans in almost
    every State. Many of them prefer not to seek care at the VA due
    to the barriers that they face, instead opting for Medicaid or
    community resources.
        This raises a question. Why should veterans who are
    entitled to VA services rely on Medicaid when VA is
    specifically funded to support them? VA has a tagline: ``Choose
    VA.'' Well, I must tell you. It is not much of a choice when VA
    employees are the ones making the choice.
        During the pandemic, we demonstrated that community and VA
    can effectively collaborate to address challenges faced by
    veterans. By working together, we can better tackle these
    issues and provide more comprehensive support. It has become an
    ``us versus them'' mentality, and the ones who suffer are my
    fellow veterans.
        Instead of creating barriers, VA should focus on removing
    them particularly for those seeking mental health treatment.
    Each year, VA releases statistics on veteran suicide which
    remains almost unchanged despite VA's significant investments
    and initiatives like increased outreach. While outreach is
    crucial, it is insufficient when a veteran in crisis in met
    with very limited options such as being placed on an acute
    psych ward or the police. Being confined in such a setting can
    feel punitive rather than supportive for those seeking help.
        It is time for us to prioritize improving access to care
    and the appropriate levels of care from the moment a veteran
    requests it rather than subjecting them to a bureaucratic
    nightmare, or worse a literal one. By doing so, we can ensure
    that veterans receive timely and effective support when they
    need it most. Whether it be at VA or in the community, we need
    timely access to care and we only get there by working
    together.

        [The Prepared Statement Of Michael Urban Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Urban. Dr. Yalamanchili,
    you are now recognized for 5 minutes to present your testimony.

                   STATEMENT OF SHANKAR YALAMANCHILI

        Mr. Yalamanchili. Thank you. Good afternoon, Chairman
    Miller-Meeks, Ranking Member Brownley, and members of the
    subcommittee. Thank you for the opportunity to testify today. I
    am honored and privileged to be here and serve our country.
        I am here to be a resource to our country, and our veterans
    and the VA. My name is Dr. Yalamanchili, though many know me as
    Dr. Chili, and I am a board certified psychiatrist with over 20
    years of experience. I currently serve as the founder and
    medical director of River Region Psychiatry Association, soon
    to be Ally Psychiatry, a multi-state behavioral health
    enterprise.
        Our mission is simple. To improve access to high quality
    mental healthcare for those who need it most, close to where
    they live, while reducing cost and increasing efficiency. Our
    practice roots started in, and we continue providing care in
    rural communities. As our future name suggests, we want to be
    an ally to everyone that seeks help.
        After beginning my psychiatric career in the VA hospitals
    of Montgomery and Tuskegee in 2005, I became increasingly
    frustrated with the inefficiencies that prevented veterans from
    getting timely care. I later moved to community health centers
    where I worked to improve operations.
        However, I quickly saw how widespread financial
    mismanagement, systemic inefficiencies, and fragmented care
    there really were, contributing to rising costs and poor
    outcomes not only for patients, but for the healthcare system
    as a whole.
        Today, I stand before you to offer a proven scalable
    solution that has already improved mental health access for
    thousands of patients, and one that has the potential to save
    our Nation, I believe, at least $1 billion annually in
    healthcare costs.
        At RRPA and Ally Psychiatry, we have built a care model
    that delivers patient-centered technology driven here across
    both inpatient and outpatient settings. In 2024 alone, our 68
    physicians and 157 advanced practice providers served over
    115,000 outpatients and completed over 400,000 patient visits.
        Our inpatient services are located in hospitals, jails,
    residential treatment centers ensuring care is accessible
    across a variety of environments. With this expansive
    footprint, our model delivers care at approximately 25 percent
    lower per patient cost than the traditional VA or hospital
    systems.
        Moreover, we consistently outperform national benchmarks
    achieving a 20 percent increase in emergency department
    throughput, 25 percent reduction in inpatient long-term stay,
    and 15 percent reduction in avoidable readmissions for
    behavioral health patients.
        Our providers average 1,000 more patient encounters a year
    more than full time employees at the VA who often see eight to
    ten patients a day on a 4-day work week. With our care model,
    100 RRPA providers working in the VA system could enable
    100,000 more patient visits annually while reducing costs up to
    20 to 30 percent, which is what we have seen in our current
    partnerships.
        There are real challenges in accessing care at the VA.
    Despite the best intentions of both providers and
    administrators, in 2023 a Government Accountability Office
    (GAO) report found that veterans often wait 30 days or more for
    routine mental health appointments, even longer in rural areas
    where sometimes wait times exceed 60 days.
        Community Care Network meant to expand access, but it often
    fails to meet the needs of veterans with chronic mental health
    conditions, providing only episodic care with limited
    continuity. Many of these issues are due in part to staffing
    shortages.
        For example, the VA OIG report reported that over 61
    facilities had severe psychology shortages, and 47 facilities
    have severe psychiatry shortages in 2023. This means that the
    providers that are there often cannot handle the current
    caseloads.
        Patients are not seen in a timely manner, and providers
    suffer burnout. Delayed care, as we hear, can lead to worsening
    mental health conditions, higher rates of hospitalizations, and
    increased emergency room use all of which endanger patients
    while seeing raised costs.
        The VA has a challenge to hire full time psychiatrists,
    nurse practitioners, and physician assistants. They are
    competing with the private market and hospital systems. When
    needed, contracting with practices like mine would allow the VA
    to save on hiring, training, long term benefit costs and
    infrastructure costs. It will enable the VA to scale staff
    based on need and have access to specialized expertise very
    quickly. They can do all of this while enhancing patient access
    and care.
        There are numerous ways that the VA can do this. There are
    models that I have outlined in written testimony. I believe
    that allowing increased public/private partnerships to address
    chronic care needs in a common sense a first step, particularly
    as this is an area where the current Community Care Network
    falls short.
        Under this model, for example, private partners would
    contract the VA for services as needed when there are staffing
    issues, lag in patient wait time, or lack of VA resources.
    Private partners would be required to integrate with the VA
    self-electronic medical records to ensure seamless information
    in sharing and collaboration with the VA teams. This allows for
    continuity of care, greater providers availability, and reduced
    wait times, especially for veterans in rural or underserved
    areas.
        A private practice such as mine, I have more flexibility to
    work with local clinics and provide greater telemedicine
    options. Therefore, we can eliminate typical access barriers
    and to lower the cost, deliver the most appropriate cost-
    effective care. In emergencies, we can quickly get the veteran
    to the best level of care in a very short time.
        In closing, the VA needs support in closing access gaps and
    reducing wait times for mental health care. Our model at RRPA
    and Ally Psychiatry demonstrates that a partnership with
    private providers can expand capacity, improve patient
    outcomes, and reduce costs. This permanent public/private
    partnership model is a win-win for veterans, taxpayers, and our
    Nation. Our success so far is based on a collaborative model to
    improve outcomes, and we ask for the same. Thank you.

        [The Prepared Statement Of Shankar Yalamanchili Appears In
    The Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Yalamanchili. In
    accordance with Committee Rule 5E, I ask unanimous consent that
    Representative Carter from Georgia be permitted to participate
    in today's subcommittee hearing. Without objection, so ordered.
        As is my typical practice, I will reserve my time until all
    other members have had a chance to ask their questions. I now
    recognize Ranking Member Brownley for 5 minutes for any
    questions she might have.
        Ms. Brownley. Thank you, Madam Chair. Mr. Urban, since you
    mentioned having been employed by a national provider of
    substance, excuse me, substance use disorder treatment starting
    in February 2021, the majority of my questions I think are
    going to be toward you.
        First I believe the company you work for starting in
    February 2021 was Banyon Treatment Recovery, LLC. Is that
    correct?
        Mr. Urban. Yes, ma'am.
        Ms. Brownley. Pardon me.
        Mr. Urban. Yes, ma'am.
        Ms. Brownley. Thank you. In your written testimony, you
    mention VA having cut reimbursement rates to this provider by
    90 percent for virtual care, and by 60 percent of her
    residential treatment and detox. What rates was Banyon charging
    VA daily?
        Mr. Urban. Ma'am, I could not answer that because I was not
    in billing.
        Ms. Brownley. You were not in the building?
        Mr. Urban. Billing.
        Ms. Brownley. In the billing.
        Mr. Urban. I do not take part in billing. I just build the
    programs and operate.
        Ms. Brownley. You have no idea how the VA's rates compare
    to other payer's rates?
        Mr. Urban. I do. Their initial rates were, I do not know
    who set them, but they were not educated.
        Ms. Brownley. They were not what?
        Mr. Urban. They were not educated. The rate fee that I did
    see was far beyond what anybody should have been reimbursed,
    but that was the VA schedule. We had nothing to do with that.
        Ms. Brownley. Well, VA does not have a schedule.
        Mr. Urban. They do, ma'am. I can forward it to you.
        Ms. Brownley. There is no established fee schedule for
    community providers in this kind of treatment.
        Mr. Urban. Ma'am, there is one in Alaska because that is
    why we ask for a fee waiver that you--that the VA just put out
    in 2025.
        Ms. Brownley. That might be the VA hospital in Alaska that
    does that, but not VA Central. Anyway, so I guess you do not
    know if your rates were higher or lower, about the same?
        Mr. Urban. No, ma'am. I said originally when I first saw
    the rates they were beyond what anybody should have been
    paying.
        Ms. Brownley. You are saying you are paying a lot less--
    excuse me, charging a lot less?
        Mr. Urban. No. What VA was reimbursing based on their fee
    schedule was beyond what any commercial insurance pays. The
    rates are now in line due to most of the rate cuts. Now they
    have went so far that rural veterans and veterans in Alaska,
    you cannot sustain operations because they just cut them.
        Ms. Brownley. You seem to know a lot about their rates, but
    you do not know what Banyon was charging?
        Mr. Urban. I am not in the department.
        Ms. Brownley. I know, but you do not seem to know a lot
    about, you know, where the rates were, where they are now but
    yet do not have any idea what the number is.
        Mr. Urban. I do not, ma'am, because what I am told is these
    rates are getting cut. If we do not figure this out, you will
    not sustain treating veterans. My job is to build programs and
    operate them. I get told the budget and whatever it is they set
    for that facility. I am not in the internal billing.
        Ms. Brownley. Okay. Just for the record, I disagree the VA
    does not have a fee schedule for community providers, period.
    Full stop. In your bio it says in your current role as a
    consultant that you develop business strategies and train teams
    on outreach to the veteran and military populations. Can you
    elaborate on exactly what that means?
        Mr. Urban. Yes, ma'am. I train organizations who would like
    to work with veterans on veteran language, how the VA operates,
    how it functions, and how to collaborate. We have created
    systems to collaborate effectively with the VA.
        Ms. Brownley. Develop business strategies. What does that
    look like?
        Mr. Urban. That means teaching them how they can reach
    veterans in the community who need resources. In Alaska right,
    the villages where none of the VA employees will go, I train
    the company to go to the villages and find veterans and bring
    them back.
        Ms. Brownley. Okay. It just, honestly it sounds like to me
    that it says you are helping treatment facilities like the one
    you used to work for more effectively targeting veterans to
    receive care at the facilities who you have worked with, which
    also brings along a dedicated revenue stream in the form of VA
    reimbursements. Does a financial incentive to treat veterans
    exist in the facilities like Banyon?
        Mr. Urban. I mean, it is a job. It would be the same as if
    you worked at the VA. You have an interest in keeping veterans
    in the VA. Would you in the private sector?
        Ms. Brownley. I am talking about incentives, about how many
    people you can bring into the facility, et cetera.
        Mr. Urban. Not where I have worked. No, ma'am.
        Ms. Brownley. Okay. I will just say I think, you know, the
    providers in this industry seem to have, to me, a profit motive
    to serve veterans. VA's mission is to honor the promises we
    have made to our veterans and ethically care for their whole
    health after they serve our country. Their motivation is to
    provide world class care to veterans. It is clear to me that
    through the actions of your past employers and your own actions
    as a consultant that your motives are very different. With
    that, I will yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley. The
    Chair now recognizes Dr. Dexter for 5 minutes for any questions
    she may have.
        Ms. Dexter. Thank you, Madam Chair. First, thank to our
    panel for coming in. Ms. Jarrott, I am so sorry for the loss of
    your son, and thank you for your courage coming to share his
    story with us. It means a great deal. Having taken care of many
    patients unfortunately like your son as a critical care doctor,
    what I can say for certain is that he is not unfortunately
    alone, and we are failing not just our veterans, but everyone
    in our community across this country. This is a tragic reality
    that we are all facing.
        I also know having been both a VA and community provider
    that community standard as Mr. Urban talked about is actually
    not superior in many areas to the Veterans Administration care.
    I know we are failing everyone broadly. To be clear, what we do
    not know with these policies, and this is just for the record,
    we do not have any ability to compare when we refer someone
    whether or not they will get community care faster than they
    will get in the VA, or if it is better quality.
        On that quality note, Mr. Urban, I wanted to first thank
    you for your service to our country and for sharing your story
    as well with substance use disorder, and your desire which is
    clear to help our veterans deal with that. I just your
    intentions are good and that you share in this committee's
    commitment to ensuring our veterans receive the highest quality
    of care.
        What I read in preparing for today's hearing, similar to
    what I think on my Ranking Member, we are trying to get to is
    that we are concerned about the reimbursement that does not
    have a fee schedule. I know that different areas may have
    different policies. That we are paying as much as $6,000 a day
    for inpatient care for some of this treatment. Mr. Urban, does
    that seem consistent with community levels of reimbursement in
    your experience?
        Mr. Urban. Currently, or when they started?
        Ms. Dexter. $6,000 a day reimbursement.
        Mr. Urban. It is absolutely insane. I said that in my last
    statement.
        Ms. Dexter. Yes.
        Mr. Urban. No one should be paying that amount of money.
        Ms. Dexter. I agree. I think what foundationally I would
    usurp is that before we pass any such policy as this, we should
    have a fee schedule. We need to have control over what we are
    paying to the community because there is waste, fraud, and
    abuse that is potentially going to be a risk with this without
    better control. We also should know how long it should take for
    someone to be expecting treatment if they are sent to the
    community, and whether it is sooner than the VA. Those things I
    wanted to establish.
        I also understand that you were the manager. You were not
    in charge of running these facilities necessarily. Is that
    correct, Mr. Urban?
        Mr. Urban. Correct, ma'am.
        Ms. Dexter. Okay. There clearly were many issues at both
    Banyon Treatment and Recovery, as well as is it correct that
    you worked at the Livengrin Foundation in 2019 through 2021?
        Mr. Urban. Yes, ma'am.
        Ms. Dexter. Okay. Also at Sobriety Solutions from June 2018
    to May 2020?
        Mr. Urban. Yes, they were not community providers though.
        Ms. Dexter. None of those are providing----
        Mr. Urban. Just Livengrin.
        Ms. Dexter. Okay, thank you for that clarification. The
    thing I wanted to offer is there could be community care in
    different areas of the community. That may be a reflective
    experience that these facilities each had improper safety--
    well, I will say to Banyon there were improper safety measures
    at one of their facilities that led to a permanent paralysis of
    a patient who fell from the fourth floor roof. That there were
    nurses who had wages that were revoked. That the New Jersey
    Commission of Investigation found that Banyon was engaged in
    patient brokering and the practice of paying for referrals.
        I am not asserting that this is your practice by any means.
    What I do want to suggest is that there is incentive for waste,
    fraud, and abuse when we do not have clear expectations for
    community care and the quality of that care. Even when
    providers have the best interest, that you may not have control
    of that. Is that a fair assertion, Mr. Urban?
        Mr. Urban. Yes, ma'am.
        Ms. Dexter. Thank you. For the committee what I wanted to
    establish is that even for someone who clearly cares for the
    wellness of our veterans and is a veteran who has suffered with
    substance use disorder and wants to serve, it is challenging to
    maintain high levels of care. Our veterans deserve to have that
    highest quality, most effective care. We know that that is
    provided within the Veterans Administration.
        Until we have a fee schedule that is established and
    disincentives waste, fraud, and abuse, I would assert that we
    should not be considering further exploration of expansion of
    this. Thank you.
        Ms. Miller-Meeks. The gentlewoman yields. The Chair now
    recognizes Representative Carter for 5 minutes.
        Mr. Carter. Thank you, Madam Chair. Thank you for holding
    this hearing. I appreciate this very much, and thank you for
    allowing me to waive on. I also want to thank the witnesses,
    particularly my constituent, Ms. Jarrott.
        Thank you for being here. Your courage is an inspiration to
    all of us, and I want you to know how much we appreciate this.
    I know this is not easy for you, and you have been up here--it
    is the second time you have been up here, I think, in less than
    a month, and we appreciate that very much.
        I know that I say I know. I can only imagine what it is
    like to lose a son. I cannot even go there. I want you to know
    that you have made a purpose of making sure that you are
    advocating for necessary changes that, and reforms to the VA,
    that would raise awareness about the dangers of illicit
    fentanyl poisoning. As you know, I am a pharmacist, and I am
    very familiar with fentanyl, and I am very familiar with the
    illicit use of it.
        I want to tell you, Madam Chair, members of the committee,
    first class, as you have heard, first class Landon Holcomb
    exemplified what it meant to be and to serve his country. He
    was born in Savannah, Georgia on April 22, 1985, and he was a
    proud veteran, and he was a patriot of this great nation.
        He served as an air traffic controller in Jacksonville,
    Florida. He was a father to two children. They are now
    teenagers. He passed away on May 2, 2024, due to fentanyl
    poisoning. Poisoning, not addiction. No. Poisoning.
        He was a veteran who was experiencing mental health issues
    like many of our veterans do once they get out of the service.
    Like many of our veterans he reached out to the VA, but
    unfortunately the VA's response was not adequate, and it was
    unsuccessful from preventing the tragedy from occurring. Under
    the previous administration, the VA canceled multiple visits
    and denied Mr. Holcomb a chance to see a healthcare provider
    during a time of need.
        Ms. Jarrott, do you believe that had your son been able to
    receive care from qualified providers in the community without
    delay, do you believe it would have changed the outcome?
        Ms. Jarrott. Yes, he would be with us today. What we
    experienced with him and the emotions to the point here I let
    the committee hear his voicemail, which was Monday prior to
    passing away on Thursday, went to work Tuesday, went to work
    Wednesday, called Thursday morning to talk to his brother and
    myself, and who was vacationing from Colorado in Savannah. We
    all had plans.
        After it was around 5:22 p.m. he walked into a restaurant
    as I said on the Island. They found him 45 minutes later. They
    worked on him 20 minutes. Of course, the telephone call,
    receiving the call, and you know I will never forget it. You
    know, grieving, it is always going to be there. I question as
    to whether I was going to come back up here. Thanks for
    Congresswoman Miller-Meeks, I received an invitation to come
    back.
        Giving back I guess I could call this a way for me to give
    back, maybe in Landon's memory, a veteran's memory, veterans
    out there like I said are waiting. I sit here, and I listen. I
    sat through your, you know, your previous meeting. I sit here
    listening, going back and forth about what should be covered in
    benefits under the VA. I am thinking, why is this even an
    issue?
        In the private health sector under private plans, we cover
    bariatrics. We cover the therapy you are talking about, and you
    are still talking about it. Preventative care has been there
    100 percent down the line. We even cover vitamins in our plan.
    Preventative care is all about providing those tools and
    resources to keep people healthy, and that includes veterans
    and their dependence as well.
        I am like therapy. In 2019 under the Trump Administration,
    he passed the right to try. Yet, you are sitting here talking
    about are we going to cover this or that? Well, a veteran has
    the same right as we do to try psychedelics, to try cancer
    treatments, and to try therapy programs. If I am wrong, let me
    know. In my mind, I was thinking right to try is out there. Why
    is it a question? Why cannot they do it if they want to do it,
    and they make that decision as to whether they want to have it
    or not based on whatever they know.
        Under the VA I cannot imagine. I just realized you talking
    about there is not a fee schedule. How do you operate without a
    fee schedule? I mean, networks operate, doctors operate with
    fee schedules. When you are in a network, the whole reason you
    have a network is because doctors are looking for you to steer
    patients to them, which reduces fees.
        A network, okay so there is networks. You have the
    community care group. By the way, when I went to our zip code
    in Savannah here is your VA website, va.gov, and you can go
    across and you can review benefits, resources, tools, mental
    health. I went to the mental health site, and I typed in--you
    can search a provider by the zip code or city.
        I typed in our zip code in Savannah, Georgia, the facility
    type which is required. It comes up, community providers in
    VA's network, service type required. You can type in
    chiropractic or optometrist. I typed psychiatrist. It pulled
    up, we could not find that. Please try another service.
        Mr. Carter. Ms. Jarrott, wait. I am sorry, we have already
    gone over.
        Ms. Jarrott. Yes.
        Mr. Carter. The Chair has been very indulgent.
        Ms. Jarrott. Yes.
        Mr. Carter. Again, I want to thank you for being here.
        Ms. Jarrott. Yes.
        Mr. Carter. I want to thank you for your courage and your
    advocacy. You have made it your purpose to bring this to the
    attention to all of us, and we appreciate that very much and
    God bless you.
        Ms. Jarrott. Well, thank you, Congressman. I appreciate it.
        Mr. Carter. Absolutely.
        Ms. Jarrott. Thank you for the invitation.
        Mr. Carter. I thank you for your indulgence, all the
    committee.
        Ms. Miller-Meeks. The gentleman yields. Thank you very
    much, Representative Carter. Ms. Jarrott, thank you for your
    bravery and being here. I guess I just have a simple question.
    Your son was denied and delayed numerous appointments.
        Ms. Jarrott. Right.
        Ms. Miller-Meeks. The initial appointments were months
    apart when he received one visit. Did anyone at the VA ever
    explain your family's right to access community care or offer
    you alternative treatment options when VA programs were not
    available?
        Ms. Jarrott. To my knowledge, no.
        Ms. Miller-Meeks. Yes. You know, today we have heard that,
    you know, veterans should have the highest quality, most
    effective care. Do you think that your son, through the VA, had
    the highest quality most effective care?
        Ms. Jarrott. Congresswoman, Landon lived in Colorado, so he
    accessed the VA in Colorado. There was not a problem there. He
    said, ``Mom, it is state-of-the-art.'' He lived in Asheville,
    North Carolina. He was pleased with the facility there, okay,
    the VA there. As a matter of fact, he made a comment. He said,
    ``Mom, if I were back in Asheville, you know, I would have
    gotten in sooner.'' Okay. He moved south to be near family, his
    daughter, et cetera.
        What I am saying is what he saw, there are inconsistencies
    between the centers, and they are not--there is not
    coordination of care.
        Ms. Miller-Meeks. Precisely, which is why we have community
    care.
        Ms. Jarrott. Right.
        Ms. Miller-Meeks. Because of the inconsistencies and lack
    of care, do you believe that no care is better than care in the
    community? Mr. Urban, is no care better than care in the
    community?
        Mr. Urban. Absolutely not.
        Ms. Miller-Meeks. Dr. Chili, is no care better than care in
    the community?
        Mr. Yalamanchili. No, ma'am.
        Ms. Miller-Meeks. How cost effective is it if people die
    waiting for care at the VA? Dr. Chili, you noted the practices
    like yours achieve significant cost savings up to 30 percent
    while expanding patient capacity. That does not sound like you
    are driven by a profit motive to me. Can you provide more
    detail on how these savings are realized without compromising
    care quality, particularly within the VA system's regulatory
    framework?
        Mr. Yalamanchili. One of our philosophies is that, you
    know, we went to school with the community at large, actually
    families and universities that have given us a unique skill to
    treat patients. With that we kind of, in the group anyway, we
    think that how many people can we reach? How many people can we
    touch? How many people can we help?
        In that model we set up our schedules in such a way that
    there is gradience in schedule where new patients require more
    time, patients in crisis require more time, patients that are
    midway through the treatment require a little bit less,
    patients that are stable require less. We collaborate between
    the providers and the therapist to see if how things are
    flowing and getting either better or worse. If patients need to
    come back sooner, we bring them back in sooner. If we need to
    see them more frequently, we see them more frequently.
        With this is kind of a matrix of how we see patients I
    think we are able to see more patients in a given day. At the
    end of the day it is the same cost, right? Then when you look
    at how much is--you know, let us say if we are spending
    whatever amount of money, but then we are seeing more patients
    then your per patient cost comes down.
        Ms. Miller-Meeks. Thank you. Mr. Urban, given your story
    and both your written and verbal testimony, it seems to me like
    your experience at the VA or lack of care, inconsistent care,
    difficulty accessing care is really propelled you into the
    profession you now hold. Based upon your experience, what is
    the single most consequential policy failure that prevents
    veterans from receiving timely residential substance use
    disorder treatment through the VA.
        Mr. Urban. I think the time it gets access to care. If you
    read VHA Directive 1016.01, it says you know you have 7 days to
    complete a screening from when someone asks for help. 7 days?
    Good luck. Do you know how long it took me to get to those 7
    days before I was finally offered a bed 2 months away?
        I mean, I think the access to care and how long it takes to
    get care and the different--I do not want to say schemes.
    Different ways VAs have set up the process delays care, like,
    and every VA is different in the way you want to get a mental
    health referral to treatment and people just give up. They just
    say, I do not care. I will go to Medicaid, or I will use a
    community resource as opposed to get timely access.
        I am not opposed to getting care at the VA. Like, it should
    not take a month, 2 months. As far as standards, we cannot
    compare apples to apples when VA makes its own standard, and
    ASAM is what the industry follows.
        Ms. Miller-Meeks. Let me address that. What clinical
    standards, such as ASAM criteria, do you believe the VA should
    be required to adopt nationally to ensure consistent levels of
    care for substance use disorder treatment? If, Dr. Chili, you
    have input please provide that as well.
        Mr. Urban. I think it should be utilizing ASAM because it
    dictates the level of care someone should get at. It dictates
    the intensity of care. It dictates the services, the staffing
    ratios. It lays everything out in places somewhat appropriately
    as opposed to this, ``Well, we have a bed in the acute psych
    ward. We will put you there until an RRT''--like that is the
    difference.
        Ms. Miller-Meeks. If I can allow you to redeem yourself,
    and I know I am going overtime. Mr. Urban, is what drives you
    to do what you do a profit?
        Mr. Urban. No, ma'am. I do not want someone waiting two to
    3 months for a bed.
        Ms. Miller-Meeks. Dr. Chili, given what you do and the
    model that you have created, is profit the reason why you do
    what you do?
        Mr. Yalamanchili. No, ma'am.
        Ms. Miller-Meeks. Thank you very much. On behalf of the
    subcommittee, I want to thank you all for your testimony and
    for joining us today. You are now excused. We will wait for a
    moment while the second panel comes to the table.
        [Recess.]
        Ms. Miller-Meeks. I would now like to introduce the panel 2
    witnesses testifying before us today. Dr. Maria D. Llorente,
    Acting Assistant Under Secretary for Health for Integrated
    Veteran Care at the Veterans Health Administration who is
    accompanied by Dr. Ilse Wiechers, Deputy Director, Office of
    Mental Health at the Veterans Health Administration. If I
    mispronounced your name, please feel free to correct me. Dr.
    Llorente, you are now recognized for 5 minutes to deliver your
    opening statement.

                      STATEMENT OF MARIA LLORENTE

        Ms. Llorente. Before I start my oral testimony, I just want
    to acknowledge and thank the first panel for sharing their very
    personal stories, particularly of one such devastating loss. It
    really does take a lot of courage, and I want to thank them for
    advocating for other veterans.
        Chairwoman Miller-Meeks, Ranking Member Brownley, and other
    members of this subcommittee, my name is Maria Llorente, and I
    was recently appointed as the Acting Assistant Under Secretary
    for Health for Integrated Veteran Care. It is been my privilege
    to work as a VA psychiatrist, being board certified in adult
    and geriatric psychiatry and addiction medicine for the past 30
    years.
        I take care of veterans with mental health and substance
    use disorders, and it is an honor to serve veterans who have
    made such significant sacrifices for our country. Thank you for
    the opportunity today to discuss the provision of residential
    substance use disorder, or SUD treatment through VA's mental
    health residential rehabilitation treatment programs, or MH
    RRTP and community care residential treatment programs.
        Joining me here today is Dr. Ilse Wiechers, Deputy
    Director, Office of Mental Health, Veterans Health
    Administration, also a geriatric psychiatrist and provider.
        Prior to the John S. McCain III, Daniel K. Akaka, and
    Samuel R. Johnson VA Maintaining Internal Systems and
    Strengthening Integrated Outside Networks (MISSION) Act, one of
    my prior roles as the associate chief of staff for mental
    health at a VA medical center experienced firsthand the
    challenges our veterans faced related to access for residential
    treatment programs. The facility where I worked did not have
    its own residential treatment program, so we had to refer
    veterans to other facilities that did. The demand for this
    lifesaving care often exceeded the supply of available beds,
    and this delay in care increased the risk of relapse and worse
    health outcomes.
        Offering our veterans access to residential treatment
    through community care address this concern. This allowed us to
    seamlessly transition the veteran into residential care when
    indicated. Timely access to residential treatment programs
    enhances overall outcomes, so that the veteran was more likely
    to engage in mental health services and treatment, and maintain
    sobriety.
        MH RRTPs provide care within specialized SUD programs,
    referred to as Domiciliary SUD programs, as well as across the
    full MH RRTP continuum, which includes programs for the
    treatment of post traumatic stress disorder, general mental
    health concerns, and services for homeless veterans.
        These programs have evolved over time to better meet the
    needs of veterans. For example, in 2012 as part of the first
    culture of safety standdown, VA introduced Naloxone as a
    critical tool to prevent overdose deaths. The passage of the VA
    Mission Act of 2018 expanded access to community care,
    furthering transforming veteran care. This law expanded access
    to eligible veterans who can elect to receive care in the
    community in certain situations.
        In October 2020, VA developed the MH RRTP's standardized
    episode of care which made it easier for VA to order
    residential treatment in the community. This has led to
    significant growth in the number of community programs
    providing residential treatment and the number of veterans
    receiving this care.
        To help maintain high quality care for veterans, VA
    requires that residential community care providers maintain
    appropriate credentials, such as by the Commission on
    Accreditation of Rehabilitation Facilities or by the Joint
    Commission.
        As of March 2025, there are over 260 MH RRTP's across 125
    locations providing more than 6,600 operational beds. In fiscal
    year 1924, approximately 32,000 veterans used MH RRTP care with
    97 percent diagnosed with SUD, and over 92 percent with co-
    occurring SUD and mental health diagnoses. During the first
    quarter of the current fiscal year, 70 percent of veterans were
    admitted to VA domiciliary care within 20 days.
        Increasing access to community care is a significant
    component of VA's strategy to ensure that veterans have access
    to the care they need. On average, veterans must travel 150
    minutes or more to receive this specialized care, whether
    through VA or through community care.
        For VA to continue to meet the growing need for MH RRTP
    care, we acknowledge that changes are needed to VA's current
    access standards. As a result, VA was proud to support the
    Veterans Access Act of 2025 before the full House Committee on
    Veterans Affairs on February 25, 2025, while ensuring the
    offsets or additional appropriations were provided.
        We are committed to working with Congress and other
    stakeholders to reduce barriers, improve access to the care
    veterans have earned. We want to thank the committee for its
    continued oversight, and we would be happy to answer any
    questions you or other members of the subcommittee may have.
    Thank you.

        [The Prepared Statement Of Maria Llorente Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Llorente. As my typical
    practice, I will reserve my time until all the other members
    had a chance to ask their questions. I now recognize Ranking
    Member Brownley for 5 minutes for any questions she may have.
        Ms. Brownley. Thank you, Madam Chair. Dr. Wiechers, can you
    tell me how many mental health providers have resigned or
    retired earlier than expected since January 20, 2025?
        Ms. Wiechers. I do not have those numbers in front of me
    for the national set of numbers. No, I do not.
        Ms. Brownley. You know how many.
        Ms. Wiechers. No.
        Ms. Brownley. You just do not have those--that information
    with you.
        Ms. Wiechers. I do not. I do not have that number. It is
    not under the purview of my office.
        Ms. Brownley. Who is purview is it?
        Ms. Wiechers. It would be some information that we would
    have at a facility in a VISN level. I would have to dig in to
    get those numbers for you. I do not have those numbers
    available to me right now.
        Ms. Brownley. Okay. I presume by your answer that mental
    health providers who accepted the so-called fork in the road
    offer, you have the same answer for that as well? You do not
    know the numbers and it is not under your purview.
        Ms. Wiechers. Correct.
        Ms. Brownley. Okay. Dr. Llorente, as you probably gather
    from my questioning in the first panel, you know, I am very
    concerned that VA has not developed a fee schedule for
    residential treatment facilities. You are currently reimbursing
    these providers at much higher rates than industry norms. On
    average, VA has been paying $3,000 per day for this type of
    care. Some providers are getting paid as much as $6,000 a day,
    far more than the average cost of care per day in an Intensive
    Care Unit (ICU).
        I understand that the VA has been looking for sometime to
    establish this fee scheduled and bring its payment rates more
    inline with industry norms. I also understand that VA will have
    to modify its contracts with TriWest and Optum in order to
    implement a new fee schedule. Can you tell me what the status
    of this effort is? When will you have this fee schedule in
    place?
        Ms. Llorente. Yes, ma'am. I am very appreciative actually
    that you asked those questions. It is my understanding that in
    December, this past December, TriWest did establish a policy
    with respect to reimbursements for RRTPs that are within their
    network. I believe that that was in part with what the first
    panelist was referencing. Because those payments are now per
    diem rather than multiple line items, it did make differences
    with respect to the providers in that network.
        In addition to that with respect to Intensive Outpatient
    Programs (IOPs) and Partial Hospitalization Programs (PHPs),
    those fees are now in keeping with Centers for Medicare and
    Medicaid Services (CMS) standards. With respect to Optum, I
    would have to take that question back in order to provide you
    with a more accurate status update.
        Ms. Brownley. Okay. If I understand you correctly you are
    saying that the schedule that the previous witness was
    referring to was possibly a schedule that was--my understanding
    is that it might be a percentage of a cost that is charged or,
    you know, a percentage of what the rate would be rather than,
    here is the rate for this specific, you know, for an hour of
    care, this specific care. It is not explicit and sort of
    complete for everything that possibly these residential
    providers would provide.
        Ms. Llorente. My understanding is it is per diem.
        Ms. Brownley. Okay.
        Ms. Llorente. As opposed to multiple billings.
        Ms. Brownley. Okay.
        Ms. Llorente. I can get you the details, ma'am.
        Ms. Brownley. Okay. Are residential treatment providers
    qualified to provide emergency stabilization care for veterans
    experiencing acute suicidal crisis under the authority provided
    by the Veterans Comprehensive Prevention, Access to Care, and
    Treatment (COMPACT) Act?
        Ms. Llorente. It would have to depend upon the residential
    facility itself. Standalone residential treatment programs, no.
    If the residential treatment program is part of a healthcare
    system that includes an emergency room department with 24/7
    coverage then it could.
        Ms. Brownley. Okay. For standalone providers that do not
    have hospitals or emergency care, the answer is no, correct?
        Ms. Llorente. That is my understanding, yes.
        Ms. Brownley. Is it true that VA has detected a pattern of
    certain community providers admitting veterans for residential
    rehabilitation treatment without VA authorization, and then
    attempting to bill VA for this care under the COMPACT Act?
        Ms. Llorente. I personally do not have detailed information
    of what you are referencing.
        Ms. Brownley. Okay.
        Ms. Llorente. I am more than happy to inquire and get
    information back to you.
        Ms. Brownley. Okay. I will just say that your predecessor
    told both the House and Senate committee staff that that was
    occurring.
        Ms. Llorente. That is entirely possible, ma'am.
        Ms. Brownley. Okay.
        Ms. Llorente. I just do not have firsthand knowledge.
        Ms. Brownley. The Office of Inspector General also issued
    this fraud alert in December 2024 requesting the public's help
    in stopping scams involving substance use disorder treatments.
    Specifically the OIG warned quote, ``Certain drug and alcohol
    rehabilitation facilities or treatment centers are attempting
    to exploit veterans with substance use disorders for profit
    through various unethical and illegal practices.''
        Do you know what the VA is doing to remove bad actors like
    these from the community care program?
        Ms. Llorente. Yes, ma'am, several different things. The
    first is when we do identify concerns with respect to those
    types of practices, we often will reach out to the OIG, request
    an investigation to describe the nature of the concerns that we
    have identified. At the same time, we will also notify the
    Third Party Administrator (TPA) if that particular provider is
    within one of our networks.
        Based on my understanding of how the contracts work, the
    TPA will then conduct an investigation based on the results of
    those investigations. Then, there is typically a back and forth
    with the VA. When findings are substantiated, then those types
    of providers could be removed from our network.
        Ms. Brownley. Okay. It is my understanding that the OIG is
    still investigating some of these issues. You might get some
    results in the near future. I yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley. The
    Chair now recognizes Dr. Dexter for 5 minutes.
        Ms. Dexter. Thank you so much, Madam Chair. Thank you again
    to our panel for being here. I share my Republican colleagues'
    concerns about the veterans access to wait--access to care and
    the wait times they are facing for mental healthcare, substance
    use disorder treatment, and residential rehabilitation
    treatment programs.
        As I shared previously, this is not a specific problem to
    our Veterans Administration facilities. This is a community
    wide problem. In fact, in my district we continue to have far
    too few care providers and far too long of delays, and that is
    not improving. It is getting worse.
        I think it feels like magical thinking when we offer
    proposals to codify additional community care access standards
    when it is abundantly clear that there is not the capacity in
    the community to accept our veterans and get them the urgent
    care that they need.
        I will just state that I believe in controlling the
    controllables. We cannot control outside of the VA, but we can
    control what we are doing within the VA. As Ranking Member
    Brownley pointed out earlier, the VA does not have a set fee
    schedule. That needs to be changed. Clearly paying $6,000 a day
    is egregious and a waste of taxpayer dollars.
        I also think it is not exactly shocking that while
    referrals to inpatient care, including residential treatment,
    made up about 13 percent of the VA's total behavioral health
    referrals to community care providers in Fiscal Year 2021
    through 2023. Those referrals at 13 percent made up nearly 3/4
    of the total expenditures for behavioral community care
    referrals.
        We have a problem. I think we can agree on that. I will
    just state for the record that Dr. Llorente is nodding her
    head.
        Ms. Llorente. Yes, ma'am, agreed.
        Ms. Dexter. I will just ask you. Do you also agree that we
    should be seeking to ensure that veterans are getting proven
    high quality care in all instances as much as possible?
        Ms. Llorente. Yes, ma'am. There is no question about that.
    Veterans deserve the very best care, and we are very proud that
    we are able to demonstrate with studies and research that VA
    delivers that care. Unfortunately, not every VA has that care
    available, and that is where community care can fill a gap.
        Ms. Dexter. Exactly. I absolutely agree that we need to
    make sure that they have that care. I think accreditation
    requirements into community care contracts is important. For
    instance, there is this mind blowing case in South Florida of a
    community care provider that employed patient recruiters to
    give illegal drugs prior to admission to ensure that patients
    were admitted for detox services, which were the most
    expensive. Obviously, none of us want our taxpayer dollars used
    at the harm--doing harm to our veterans.
        Community care standards, fee schedule. I also just wanted
    to ask Dr. Llorente, can you confirm that in late January
    President Trump fired the VA's Inspector General Mike Missal?
        Ms. Llorente. That is what I read in the news, yes, ma'am.
        Ms. Dexter. Yes. We have been talking about the Inspector
    General's office and the importance that they play in
    investigating some of these things. Would you agree that not
    having an inspector general impedes our ability to do that?
        Ms. Llorente. I do not know if I can fully agree with that
    because we continue to engage with the Inspector General's
    office. We continue to participate in investigation inquiries,
    in audits. We receive reports and findings, and really engage
    very collaboratively with the Inspector General's office. That
    work has continued.
        Ms. Dexter. I am so happy to hear that it is continuing,
    and I think it is probably a short term reality that until
    there is some upper level director--in my experience, when
    there is no captain things kind of derail over time. That is
    not a question. You do not have to make a position on that.
        I just want to bring us back to acknowledging that the
    larger context that we are all here to do is make sure our
    veterans are getting the best care possible. Our administration
    has fired veteran staff. It has removed the inspector general.
    We are here talking about spending less money in our budgets
    for the veterans, and we are wasting a lot of that on
    unnecessary expenditures that we have the ability to control.
        I just hope before this committee sends anything to the
    floor that my colleagues and I can work together to address
    this head on and ensure the administration is allowing us to
    inspect things, but also that we are making sure that our
    veterans have access to the best possible care, and that our
    policies reflect that. Thank you, Madam Chair. I yield back.
        Ms. Miller-Meeks. Thank you, Ms. Dexter. The Chair now
    recognizes Dr. Morrison for 5 minutes for any questions she
    might have.
        Ms. Morrison. Thank you, Madam Chair. I appreciate the
    discussion brought forward in this hearing about the importance
    of access to treatment for substance use disorders. It is
    imperative that we care that the care that we offer our
    veterans comes from providers with a demonstrated ability to
    deliver high quality evidence-based care.
        My experience is one of the millions of physicians that has
    trained in a VA facility gave me a firsthand introduction to
    the uniquely specialized care that the VA is able to offer our
    veterans. Achieving the goal of quality while preserving the
    specialized care VA offers requires intentional investment in
    VHA facilities that provide substance use disorder care and
    continual reflection on how providers are meeting veteran
    needs.
        For over 150 years, VA has been committed to providing
    residential care for veterans in need of additional structure
    and support. In 2022, VHA served over 300,000 veterans with
    substance use disorder diagnoses. Thank you, Doctors, both of
    you for being here today.
        In the spirit of understanding the progress VA's made in
    substance use disorder treatment, I have a couple of pretty
    straightforward questions for you, and they really are just yes
    or no questions.
        The first one, has utilization of residential substance use
    disorder treatment programs increased over time?
        Ms. Llorente. Just to clarify, in direct care, community
    care, both?
        Ms. Morrison. Both.
        Ms. Llorente. Short answer is yes.
        Ms. Morrison. Would you agree, Doctor?
        Ms. Llorente. Absolutely, yes.
        Ms. Morrison. Okay, thank you. Next question is, has
    increased capacity in VA's substance use disorder treatment
    programs led to improvements in your ability to provide the
    intensive medical treatment veterans, especially underserved
    groups, increasingly need?
        Ms. Llorente. I would like to ask Dr. Wiechers to answer
    that question.
        Ms. Wiechers. Sure.
        Ms. Morrison. Yes or no.
        Ms. Wiechers. Yes.
        Ms. Morrison. Okay, thank you. Then, last question. Would
    you characterize the educational training and staffing level
    requirements within VA's substance use disorder treatment
    programs to be consistent across your program sites?
        Ms. Wiechers. Yes.
        Ms. Morrison. Okay, thank you very much. VA's commitment to
    developing a cohesive continuum care is indispensable to
    achieving successful outcomes for veterans that find themselves
    at various stages of treatment for substance use disorders.
        I urge my colleagues to recognize the importance of
    supporting the residential substance use disorder treatment
    infrastructure within VHA, investing in expanded VA program
    capacity, and standing against tactics that would undercut
    treating our veterans with the dignity they so rightfully
    deserve. Thank you, Madam Chair. I yield back.
        Ms. Miller-Meeks. Thank you. The Chair now recognizes
    herself for 5 minutes. I would also urge my colleagues to
    recognize the care that comes in the community. The reason why
    the MISSION Act exists is because patients were not getting
    care. Veterans were not getting care. They were not getting
    access. They were waiting. They were dying. They were
    committing suicide. They were overdosing. They were dying of
    fentanyl poisoning.
        As a matter of fact, in this very hearing room when we had
    a hearing on residential care and substance use disorder, prior
    VA officials admitted that they did not think that residential
    care or substance use disorder residential care fell under the
    MISSION Act. It did not matter if the patient waited 30 days,
    100 days, or a year. They still were not going to refer them to
    community care because they did not feel it was under that--
    fell under the MISSION Act. This is the VA's own words.
        Dr. Llorente, and I am an ophthalmologist. Not only have I
    worked at VA facilities, not only was my uncle--you know, six
    of the eight kids in my family are veterans. My father is. My
    husband is. My grandfathers are. My uncle was in a residential
    facility at the VA for his entire life when his ship went down
    in the Pacific in World War II. I have done substance use
    disorder and helped to change policies at the State level.
        When a veteran is assessed needing urgent residential care,
    how long do you think they should wait? Are you confident that
    every VA facility applies this same timeline and criteria to
    get that veteran placed, or referred to the community without
    delay?
        Ms. Llorente. Thank you very much for that question. First
    let me say that the national policy is very clear and is
    applicable across the country. The fact that there is
    variability, and a lack of standardization is a problem. There
    is no question about that.
        Ms. Miller-Meeks. If the standard is present, then that
    means the culture is not permitting the standard to be met.
    Because the committee continues to hear that policies governing
    residential treatment and community care referrals are
    interpreted differently depending on where a veteran seeks
    care, how is the VA going to ensure that policies are followed
    uniformly?
        Ms. Llorente. Thank you very much. The Secretary has
    initiated a review.
        Ms. Miller-Meeks. This would be Secretary Collins?
        Ms. Llorente. Yes, ma'am, has initiated review of policies,
    directives, staffing, organization, structure of multiple
    aspects of the direct care system, as well as multiple aspects
    of the community care system.
        In order to be able to begin to answer the questions that
    you are asking in general, and these are generalities, when you
    have policy and it is just not being carried out, there are
    common reasons for that. Some common reasons is that a policy
    may not be clearly written. The policy may have broad subject
    to interpretation features. It may be that we have simply not
    adequately trained the frontline staff.
        There are a whole list of other reasons in between those
    things. Those are the things that we need to address because
    those are interfering with our ability to provide the access
    that veterans needs to have. It is creating barriers, and in
    some cases it may be creating additional administrative steps.
        Ms. Miller-Meeks. Dr. Llorente, as I mentioned, we have
    programs like the Gordon Fox Parker Suicide Prevention Grant
    Program. We have buddy systems within our veteran service
    organizations that help veterans to navigate some of these
    things.
        I realize that you are a recent addition, although you have
    cared and done mental health and substance use for a long time.
    How do programs like the Gordon Parker Fox Suicide Prevention
    Grant Program help veterans access mental healthcare services?
        Ms. Llorente. Is that a question you might be able to take
    Dr. Wiechers?
        Ms. Wiechers. Sure. The Fox Grant Program provides grants
    to community organizations for helping to engage veterans that
    do not engage directly with our VA health system. It really
    helps to fill that gap in providing access out in the
    community. There are partners out in the community helping
    engage veterans to reduce their risk for suicide.
        They can also grant--participants can also access care
    through VA when they have become part of one of the programs
    with the grantee.
        Ms. Miller-Meeks. Let me just say that, you know, I think
    that our VA healthcare system, although I do not utilize it as
    a veteran, nor does my husband, I want to save that for the
    veterans who have most in need and need that access to care.
        Nonetheless I think, you know, our Veterans Administration,
    our hospitals, our programs do a very good job, but they are
    not always there. It is those gaps that we are trying to fill
    and these partnerships, whether they be in the private sector
    in other avenues that we are trying to make sure veterans have
    access to care.
        I think we all want the same thing. I think to continually
    denigrate a provider that is outside the VA, just like
    continually denigrate the VA itself, both of those attitudes
    are inappropriate and wrong because as we have already said, we
    want the highest quality, most effective care.
        Sometimes that is at the VA hospital. Sometimes that is in
    the community because if you cannot get access to care, it does
    not matter how high the quality is. It does not matter how
    effective the program is. If you cannot get access care, you
    have no care. Given that I am in a rural area, our veterans
    like to have access to care when and where they can get it.
        With that, Ranking Member Brownley, would you like to make
    any closing remarks?
        Ms. Brownley. I would. I would indeed. Thank you very much.
    I would just like to say that I agree with my colleagues across
    the aisle that we must ensure that any veteran who is ready to
    seek assistance can be treated unequivocally.
        I am worried that treatment will not be available with the
    clinicians who have either been fired or cannot be recruited.
    We are already understaffed. We need a fee schedule, so the
    community providers will conform to industry norms. We need to
    weed out bad actors and not fire very capable employees within
    the VA.
        For the record one more time, I will say I support
    community care and community care is a critical partner to VA.
    We have got to get it right. I will yield back.
        Ms. Miller-Meeks. Thank you very much. I am again going to
    remind this committee as we did several weeks ago that over the
    4-years of the previous administration, there was an increase
    of $126 billion to the VA, an increase of 80,000 employees, 57
    of those full time, 23,000 part time. That as we have heard
    from Secretary Collins, healthcare workers were exempt.
        With that, I would like to thank everyone for their
    participation in today's hearing, and for the great discussions
    we have had on this important topic. I would especially like to
    thank our witnesses and Ms. Jarrott for her very moving
    testimony today, and for having the courage to come forward. I
    want to thank both of our witnesses from the VA, some of whom
    may be new to this process for being here today as well.
        Today's hearing reinforced what we have heard time and time
    again. While there may be very good care to excellent care at
    the VA, veterans do not struggle because the VA lacks funding
    or resources. They struggle because they continue to fall
    through the cracks of a bureaucratic system that is bogged down
    in inefficient processes and inconsistent standards.
        Veterans in crisis cannot afford to wait. I know this
    firsthand and personally. I look forward to working with
    Secretary Collins and the VA to break down barriers preventing
    our veterans from accessing the lifesaving care that they so
    desperately need in their moments of crisis, be it at a VA or
    be it in a community.
        The complete written statements of today's witnesses will
    be entered into the hearing record. I ask unanimous consent
    that all members have five legislative days to revise and
    extend their remarks, and include extraneous material. Hearing
    no objection, so ordered.
        I think the members and the witnesses for their attendance
    and participation today. This hearing is adjourned.
        [Whereupon, at 4:45 p.m., the subcommittee was adjourned.]

    ?

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

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Missy Jarrott

        I'm Missy Jarrott, of Savannah, Georgia, and the Mother of Landon
    Holcomb, who tragically lost his life 10 months ago. I'm very grateful
    for your invitation to share my son's story which is condensed due to
    limited time.
        Thank you Chairwoman, Miller-Meeks, and Ranking Member Brownley,
    and all of the members attending today.

        ``If soldiers are going to die, it needs to be at the attempt of an
    enemy, NOT a lack of effort and unorganized antics by the VA. The VA is
    killing our soldiers''

        My son, Landon, who served as an Air Traffic Controller Navy
    Veteran (NAS Jacksonville) several years ago, was struggling to find
    mental health help in a system that completely failed him. Like many
    Veterans, he reached out to the VA for help and support. His first
    consultation with a Provider was on December 4, 2023, however the VA
    did not provide a follow-up visit until April 10, 2024. Landon had
    scheduled visits between this timeframe, however, unfortunately, the VA
    canceled multiple visits denying him the chance to see a Provider who
    specialized in medicine management. Landon tried and tried to keep his
    head up that the VA would follow through. He was experiencing anxiety,
    insomnia, restlessness and mood swings. Landon knew that he needed a
    mood stabilizer. ``Mom, I'm struggling.'' After four unsuccessful
    months, he began to unravel with all of the canceled appointments. He
    became hopeless in the System. He was very emotional. On April 10, he
    visited the Savannah VA Mental Health team who determined that he
    wasn't under distress. Landon said the visit was a ``checklist'', and
    he explained that he had been asking for a psychiatrist (medicine
    management). He was hoping for a better outcome and knew that this
    meant another delay in getting the help he critically needed.

        ``Those that smile the brightest might be fighting a war within''.
    Landon was fighting.

        He came by to see me after this visit. At this point, family and
    friends became involved in searching for a psychiatrist and to no
    avail. We took it upon ourselves to call psychiatrists in the Savannah,
    Bluffton and Hilton Head SC areas. They did not accept military
    insurance, take new patients or charged $300/hr. More stress. Landon
    made numerous calls himself. (Play VOICEMAIL here) On April 19, he
    received a call from the Charleston VA for a Zoom appt. scheduled for
    May 3. He did not make that appointment and passed away on May 2. The
    unthinkable happened. Landon was found in the restroom of a restaurant
    on Hilton Head Island. He had fentanyl in his system. To numb his pain,
    he thought he was taking oxys. Landon did not plan to leave us! He was
    not suicidal. The hopelessness of canceled appointments, feeling
    abandoned and not taken seriously and the emotional spiraling ended his
    life.
        Landon was buried at the Beaufort National Cemetery in SC with U.S.
    Naval Honors on May 13. He leaves behind two beautiful teenagers, a
    loving family and many loving friends. He was a True Patriot who loved
    his country. Help just didn't come soon enough. Mental health is real.
    It can't wait! All Landon asked for was a mental health appointment for
    medicine management. He raised his hand over and over.
        In memory of my 39 year old son who could ``light up a room with
    his infectious smile'', let his voice ``be heard from Heaven above''
    and on behalf of the Veterans who struggle every day....let's be
    reminded to ``Never leave a soldier behind''. These are our children.
    This is why I'm here today.

        How many more testimoneys is it going to take ``for change''. How
    many?

        May God bless our military serving all over the world and may God
    bless our Veterans and all military families.
    GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

                      Prepared Statement of Michael Urban
    GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT

                   Prepared Statement of Shankar Yalamanchili

        Good afternoon. Chairman Bost, Ranking Member Takano and
    distinguished members of the Subcommittee Thank you for having me here
    to testify this morning. I am honored and privileged to be here and
    serve the country. I am Dr. Shankar Yalamanchili, my friends and
    colleagues call me Dr. Chili. I'm a psychiatrist with over 20 years of
    experience in working to improve mental healthcare efficiency and
    accessibility. I'm testifying here today to discuss how we can improve
    patient care while increasing efficiencies in mental health services in
    Veteran's Affairs Hospitals by allowing the VA to contract with private
    physician groups, when appropriate.
        After completing my residency and fellowship in psychiatry, I began
    working at the Veterans' Affairs (VA) hospitals in Montgomery and
    Tuskegee in 2005. While working there, I became frustrated with the
    inefficiencies that were interfering with my ability to treat patients,
    so I transitioned to Community Mental Health Centers. These centers
    allowed me the flexibility to improve operations, although financial
    mismanagement later destabilized the system. Through my experience in
    both systems, I recognize the national scale of these financial and
    efficiency issues and the effect on proper patient care. This led me to
    create sustainable solutions that would improve patient care while
    making the system more efficient.
        Today, I lead River Region Psychiatry Associates (RRPA), a multi-
    state psychiatric practice designed to bring care directly to patients
    where they live, rather than having to travel long distances. At RRPA
    and our owned outpatient delivery system, Ally Psychiatry, we emphasize
    a holistic approach that focuses on treating patients' underlying
    issues and thoughtfully incorporating families, when necessary, to
    develop manageable and successful treatment plans. In 2024, Ally
    Psychiatry now operates in 51 clinics across nine states, employs 68
    physicians, over 150 nurse practitioners and physicians, which allows
    us to see over 115,000 patients.
        RRPA's inpatient presence spans 55 inpatient facility locations
    across 7 states (specifically Alabama, Tennessee, Missouri, Georgia,
    Mississippi, South Carolina, and North Carolina), in hospitals,
    emergency departments, jails, community health centers and more. In
    2024, RRPA managed more than 1,000 inpatient facility beds, served more
    than 48,000 patients (about twice the seating capacity of Madison
    Square Garden), and completed more than 400,000 patients (about half
    the population of Delaware) visits/encounters.
        Our doctors also provide the highest qualities of care. We provide
    professional ethics and new innovation training, we have high standards
    for different levels of care (intake, crisis treatments, and then
    stable patient continuing care) and we believe in holistic care that
    uses the newest technology and engages families, rather than simply
    prescribing unnecessary medications. We also rigorously comply with all
    of the State and Federal regulations and standards. If we are not
    providing excellent patient care, we won't succeed.
        Unfortunately, the one area where we are not able to expand our
    patient care and services is where it is needed the most - VA
    hospitals. It is critical for U.S. veterans to have stable and
    qualified healthcare providers. An estimated 41 percent of veterans are
    in need of mental health care programs every year, and the VA provided
    over 1.7 million Veterans mental health services in 2024. Mental health
    issues and suicide among veterans are prevalent and complicated
    problems to sufficiently address, but we need to be more proactive and
    provide consistent treatment. Roughly 17 veterans die by suicide each
    day, according to a 2022 report by the VA and fewer than 50 percent of
    returning veterans in need receive any mental health treatment.
        Mental health services are just one area where patients are
    struggling to receive timely and consistent care. In general, VA
    hospital average wait times can be anywhere from a few days to a few
    months for needed care, and then appointments are often canceled at the
    last minute. Congress and the Administration recognized the need for
    more providers and they implemented the CHOICE Program, now VCCP, which
    provides opportunities for veterans to seek care from private, non-VA
    or Department of Defense doctors through ``community care'' providers.
    This allows veterans who need services not offered by the VA
    automatically or veterans who live in a State without a full-service VA
    facility, such as New Hampshire, Alaska, or Hawaii. However, the
    current system does not allow VA hospitals to contract directly with
    private physician practice organizations to address situations where
    veterans are underserved or forced into the lengthy waits by the VA due
    to staffing shortages and physician availability. Additionally, while
    the Community Care Network's (CCN) intended benefit of faster care,
    more access, and patient choice, are often undermined by red tape,
    payment issues, and poor coordination. Veterans end up waiting longer,
    juggling providers, or getting denied care, while private doctors are
    frustrated and leave the network. As the Committee heard yesterday,
    there can also be issues with consistency in patient data between
    community care and the VA. By allowing VA hospitals to partner with
    physician staffing groups, they will be able to provide enhanced access
    to consistent, reliable, and continuing quality care for our veterans
    and consistency in patient data. This will, in turn, extend
    availability from big cities, and provide some relief to CCN networks,
    to bring these critical services to the smaller rural communities in a
    timelier manner.
        Improving the health and well-being of our veterans who have served
    this Nation requires a collaboration between public and non-profit
    mental health providers. It is imperative that we increase the
    availability of mental health services and professionals for all
    veterans, and I believe that practices like mine can help achieve this.
    This includes encouraging more community-based services AND allowing
    private physician groups to provide services to the VA.
        In addition to the long wait times due in large part to shortage of
    key staff at the VA, which result in delays in care, there are also
    high overhead expenses. While the VA has met their own hiring
    initiatives designed to increase the number of inpatient and outpatient
    mental health providers, they continue to face challenges in hiring
    adequate mental health staff to meet the full demand for services (GAO,
    2015). The GAO cites pay disparities with the private sector,
    competition between VA medical centers (VAMCs) to fill positions,
    lengthy hiring processes, a lack of space for new hires, a lack of
    sufficient support staff, and a nationwide shortage of mental health
    professionals as reasons why the vacancies are going unfilled.
    Practices like mine can help solve these issues.
        When comparing the current state of the VA mental health workforce
    with private enterprise health groups, significant improvement in both
    patient care and efficiency is seen. For example, private health groups
    can staff a VA hospital so that twice as many patients can be seen, and
    that there are doctors available Monday-Friday, with weekend
    availability, and on-call 24 hours a day. Importantly, when hospitals
    contract the doctors out, there is a decreased per-patient cost of
    treatment while maintaining quality, value-based care and a decrease in
    the overall infrastructure costs while working with existing VA best
    practices and meeting VA quality metrics. In my practices, we use all
    the tools at our disposal. We evaluate patients using assessment tools
    in addition to talking to patients and their loved ones and previous
    providers because understanding past failures is essential to therapy
    going forward. We utilize community resources including religious
    institutions and groups such as AA, Alzheimer's foundation, and disease
    specific associations, and we empower patients to sustain lifelong
    stability with focus being able to get back to work and relationships.
    No one's disability should define them. Finally, all of the doctors in
    our practices train and collaborate with each other.
        We must improve where and how our veterans receive care and ensure
    that it is scalable, affordable, and patient centered. While veterans
    Community Care Programs may work well for very specific, targeted
    treatments over short durations of time, the gap remains for the
    sustainable and chronic care treatment model, which requires a higher
    level of continuity of care than can currently be offered through
    Community Care Networks, especially in the mental health space.
        To decrease cost to taxpayers, and improve efficiency and access to
    care, we propose that the VA ALSO contract with local private
    enterprise providers who can see VA patients in their clinics. The
    existing Community Care Network model is designed to meet episodic
    (time-limited) problems and short-term needs. While important, this
    leaves a gap specific to chronic care, which requires a higher level of
    continuity of treatment than can currently be offered through Community
    Care Networks. That is why we also propose a permanent public/private
    partnership that utilizes the resources of the VA with defined support
    from private enterprise (e.g., private practices). Support models can
    be tailored to meet the needs of individual VA facilities and
    communities.
        This is not without precedence. There are currently two pilot
    projects underway in three states that could serve as models for a
    program. First, there is a VA-Private Telehealth Partnership Pilot in
    rural Montana and Alaska where VA facilities are sparse. Under this
    project, funded through the VA Office of Rural Health (ORH) grants and
    CARES Act telehealth expansion funds, the VA contracted with private
    telepsychiatry groups to deliver care via VA-provided telehealth
    platforms. The result has been that Veterans were seen faster and often
    in non-clinical community settings (like local libraries or community
    centers) with VA-trained facilitators. Wait times went from 60+ days to
    under 14 days for mental health appointments and there was high
    satisfaction among veterans, especially those hesitant to visit VA
    clinics due to stigma.
        In Texas, under a State grant, several private psychiatric groups
    were brought into VA's Community Care Network, but the difference was
    they received dedicated liaisons and fast-track credentialing from the
    VA. A shared portal was created for scheduling and communication,
    avoiding usual CCN bottlenecks. This resulted in 80 percent faster
    referral-to-appointment time compared to standard CCN clinics and
    providers stayed in the network longer due to faster reimbursement and
    reduced paperwork.
        I can also envision a model where the VA continues to manage robust
    inpatient services, while then transitioning veteran's outpatient care
    to an identified partner who has established a care network in that
    market/region. To ensure a seamless care transition, the partner
    practice would utilize the VA's EMR while managing the patient's care.
    This will allow for seamless patient health information management
    including collaborating with VA care management teams.
        It would also be possible to have the private enterprise partner
    provide facility enterprise coverage for the VA community. This
    potential solution would make access to care easier and improves the
    quality of care for the veteran community while driving down the cost
    of that care as funded by the taxpayer and increasing its all-around
    value. VA contracting with local, private providers who can safely,
    securely, provide quality service based on VA quality measures in areas
    where there are provider shortages could be game changing for
    vulnerable Veterans. We will see our valued veterans in our clinics
    closest to their homes along with the rest of the community. Utilizing
    our existing efficient practices in place we can see a thousand more
    encounters per provider per year. This could be a $50,000 reduction, on
    average, in cost per provider per year, in my opinion.
        The public/private partnership model is mutually beneficial to both
    physicians and patients. These models I presented could reduce costs by
    20 percent-30 percent while expanding patient capacity by the same
    margin and outperforming traditional VA and community mental health
    systems. At RRPA, we have found that when hospitals contract with us,
    there is also a 20 percent reduction in emergency department visits, a
    25 percent decrease in inpatient length of stay, and a 15 percent
    reduction in readmittance. As a private company, we're not successful
    if the patient care and efficiencies don't make a meaningful
    difference.
        We strongly support the VA's mission to best serve veterans who
    have borne the battle with honor, and it would be our privilege to help
    improve their mental health care.

                      Prepared Statement of Maria Llorente

        Chairwoman Miller-Meeks, Ranking Member Brownley, and other Members
    of the Subcommittee. Thank you for the opportunity today to discuss the
    provision of residential substance use disorder (SUD) treatment through
    VA's Mental Health Residential Rehabilitation Treatment Programs (MH
    RRTP) and community care residential treatment programs. Joining me
    here today is Dr. Ilse Wiechers, Deputy Director, Office of Mental
    Health, VHA.

    Introduction

        VA's MH RRTPs are a critical component of VA's broader efforts to
    address the needs of Veterans with substance use concerns. The MH RRTPs
    provide care within specialized SUD residential programs, referred to
    as Domiciliary SUD programs, as well as across the full MH RRTP
    continuum, which includes programs for the treatment of posttraumatic
    stress disorder, general mental health concerns, and services for
    homeless Veterans. In fact, more than 95 percent of Veterans served
    within the MH RRTPs have a SUD diagnosis, and all programs provide
    treatment for SUD either as the primary treatment or concurrently with
    other services.
        Innovation has been a priority within MH RRTPs, focused on ensuring
    the provision of high-quality care that is responsive to Veterans'
    needs. For example, in 2012, MH RRTPs moved quickly to implement
    procedures to prevent fatal overdoses with the first Culture of Safety
    Stand Down launched in November 2012 and the introduction of naloxone
    as a critical tool. VA also established clear expectations to support
    access to life-saving medications for the treatment of opioid use
    disorder.
        The enactment of the VA Maintaining Internal Systems and
    Strengthening Integrated Outside Networks Act of 2018 (VA MISSION Act
    of 2018) (P.L. 115-182) further transformed the landscape of Veteran
    care by expanding access to community care options. This law expanded
    access to eligible Veterans to elect to receive care in the community
    in certain situations. In October 2020, VA developed the MH RRTP
    Standardized Episode of Care, which made it easier for VA to order
    residential treatment in the community. This has led to significant
    growth in the number of community programs providing residential
    treatment and the number of Veterans receiving this care. To help
    maintain high quality care for Veterans, VA requires residential
    community care providers to maintain appropriate credentials, such as
    by Commission on Accreditation of Rehabilitation Facilities or by Joint
    Commission.

    Improvements in MH RRTP

        In the past few years, VA has expanded MH RRTP care. As of March
    25, 2025, there are more than 260 MH RRTPs across 125 locations of
    care, with more than 6,600 operational beds. These programs provide
    integrated, concurrent treatment for co-occurring SUD and mental health
    treatment needs, ensuring comprehensive care for Veterans. During
    Fiscal Year (FY) 2024, around 32,000 Veterans utilized VA's MH RRTP
    care with just over 25,000 receiving care at a VA-operated facility and
    the remaining Veterans receiving care from community providers.
        During Fiscal Year 2024, 97 percent of Veterans served across all
    MH RRTPs, had an SUD diagnosis, and more than 92 percent had a co-
    occurring SUD and mental health diagnosis. Recognizing the importance
    of ensuring access to residential SUD treatment, VA has increased
    access through the addition of new Domiciliary SUD programs with four
    programs opening in 2024 and additional programs expected to open this
    year. VA's commitment to providing timely access to care is evident and
    has been a priority focus area over the last several years. During the
    first quarter of Fiscal Year 2025, 70 percent of Veterans were admitted
    to VA Domiciliary care within 20 days. The average wait time for
    Veteran admission for VA MH RRTP in Fiscal Year 2024 was 17.1 days.
        VA also emphasizes the critical role of community care in expanding
    access to residential treatment. When Veterans are eligible and elect
    to receive such care, referrals to community providers help address
    gaps in specialized residential treatment programs that may not be
    available within VA. By leveraging both VA's continuum of programs
    within regions and programs in the community, VA ensures that Veterans
    can access residential treatment as close to home as possible. On
    average, Veterans must travel 150 minutes or more to receive this
    specialized care, whether through VA or community care.

    Leveraging Community Care to Maximize Access

        Increasing access to community care is a significant component of
    VA's strategy to ensure Veterans have access to the care they need. The
    VA MISSION Act of 2018, its implementing regulations, and subsequent
    laws and policies have facilitated this expansion by allowing eligible
    Veterans to receive care in the community. For VA to continue to meet
    the growing need for MH RRTP care, we acknowledge that changes are
    needed to VA's current access standards. As a result, VA was proud to
    support the Veterans' Assuring Critical Care Expansions to Support
    Servicemembers (ACCESS) Act of 2025 before the full House Committee on
    Veterans' Affairs on February 25, 2025, while ensuring the offsets or
    additional appropriations are provided. We are committed to working
    with Congress and other stakeholders to reduce barriers and improve
    access to the care Veterans have earned.

    Conclusion

        We want to thank the Committee for its continued oversight. This
    concludes my statement. We would be happy to answer any questions you
    or other Members of the Subcommittee may have.

                           Statements for the Record

                                  ----------

         Prepared Statement of American Academy of Physician Associates

        Dear Chairman Bost, Ranking Member Takano, Subcommittee Chairwoman
    Miller-Meeks, Subcommittee Ranking Member Brownley, and Members of the
    Committee:

        On behalf of the more than 168,000 physician associates/physician
    assistants (PAs) throughout the United States and the more than 2,500
    PAs currently employed full-time by the U.S. Department of Veterans
    Affairs (VA), the American Academy of Physician Associates (AAPA)
    thanks the Committee for your commitment to ensuring veterans have
    timely access to urgent mental health care, substance use disorder
    treatment, and residential rehabilitation treatment programs. AAPA
    appreciates the opportunity to submit comments for the record on the
    Committee's March 25 hearing on Breaking Down Barriers: Getting
    Veterans ACCESS to Lifesaving Care.
        PAs are licensed clinicians who practice medicine in every
    specialty and setting at the VA, and throughout America. PAs diagnose
    illness, develop and manage treatment plans, manage their own patient
    panels, and often serve as a patient's primary healthcare provider. PAs
    practice medicine in every State, the District of Columbia, and all
    U.S. territories. Scope of practice for PAs is determined by their
    education and experience, State law, facility policy, and the needs of
    patients. Studies reinforce that PAs provide high-quality care, and
    patients have consistently indicated high-levels of satisfaction with
    PAs, comparable with care delivered by physicians.\1\ Patients have
    also already demonstrated confidence and trust in the PA profession by
    indicating the type of health professional who provides care is less
    important than when they obtain access to quality care.\2\ The VA is
    also the largest employer of PAs.
    ---------------------------------------------------------------------------
        \1\  Hooker RS, Moloney-Johns AJ, McFarland MM. Patient
    satisfaction with physician assistant/associate care: an international
    scoping review. Hum Resour Health. 2019 Dec 27;17(1):104.
        \2\ Dill MJ, Pankow S, Erikson C, Shipman S. Survey Shows Consumers
    Open To A Greater Role For Physician Assistants And Nurse
    Practitioners. Health Affairs. 2013 Jun; 32 (6).
    ---------------------------------------------------------------------------
        PAs at the VA are critical to the Committee's work toward better
    access to care. We agree with the goals of the Veterans' Assuring
    Critical Care Expansions to Support Servicemembers Act of 2025 (ACCESS
    Act) to reduce bureaucratic barriers to access to care for veterans,
    and with Chairwoman Miller-Meeks's emphasis on VA's goal of there being
    ``no wrong door'' at the VA for veterans seeking care.
        However, language in the ACCESS Act may inadvertently overlook the
    importance of the increased access to care PAs can provide.
    Specifically, Section 203, Improvements to Department of Veterans
    Affairs Mental Health Residential Rehabilitation Treatment Program,
    includes the following among the assessments of providers' quality of
    care delivered required of the Secretary of the VA:

          (3) the ratio of licensed independent practitioners per
    resident;

          (4) the rate of completion of training on military
    cultural competence by licensed independent practitioners...

        AAPA recommends that ``licensed independent practitioners'' be
    replaced with ``licensed practitioners'' to ensure that these
    assessments of quality do not inadvertently exclude PAs. In other
    contexts, some hospital administrators and personnel have been confused
    as to whether PAs were included among those professionals who
    authorized to order certain care due to the word ``independent''
    appearing in regulatory language. However, the term ``licensed
    independent practitioner'' is a phrase that is not used in the Social
    Security Act or commonly used in any Federal statute. ``Independence''
    is not a measure of a healthcare professional's educational
    preparation, competency, or ability to provide quality medical care.
    Eliminating this term, which has limited the ability of PAs to deliver
    needed care to patients, supports patient access to care, moves further
    toward a team-based healthcare delivery model and recognizes the need
    to fully utilize the healthcare workforce.
        In fact, the Centers for Medicare and Medicaid Services (CMS)
    removed this confusing language in a 2019 regulation which also
    prompted the Joint Commission to make the same change to conform with
    CMS.\3\
    ---------------------------------------------------------------------------
        \3\ AAPA. Joint Commission Removes ``Licensed Independent
    Practitioner'' Term from Restraint and Seclusion Standards. 2020.
    ---------------------------------------------------------------------------
        AAPA thanks the committee for the opportunity to submit this
    recommendation and for your ongoing dedication to the health of our
    Nation's veterans. We are committed to working with Congress to advance
    our shared mission of improving access to health care for veterans. If
    we can be of assistance on this or any issue, please do not hesitate to
    contact Tate Heuer, AAPA Vice President, Federal Advocacy, at
    theuer@aapa.org.

      Prepared Statement of National Association for Behavioral Healthcare
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