[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.]
?
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A P P E N D I X
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Prepared Statements of Witnesses
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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
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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.
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\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).
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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\
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\3\ AAPA. Joint Commission Removes ``Licensed Independent
Practitioner'' Term from Restraint and Seclusion Standards. 2020.
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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
[email protected].
Prepared Statement of National Association for Behavioral Healthcare
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