    [Senate Hearing 119-246]
    [From the U.S. Government Publishing Office]

                                                        S. Hrg. 119-246

                     MEDICATION MANAGEMENT IN VA HEALTHCARE
    =======================================================================

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                DECEMBER 3, 2025

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                  __________

                   U.S. GOVERNMENT PUBLISHING OFFICE
    62-271 PDF            WASHINGTON : 2026
    =======================================================================

                     SENATE COMMITTEE ON VETERANS' AFFAIRS

                         Jerry Moran, Kansas, Chairman
    John Boozman, Arkansas               Richard Blumenthal, Connecticut,
    Bill Cassidy, Louisiana                  Ranking Member
    Thom Tillis, North Carolina          Patty Murray, Washington
    Dan Sullivan, Alaska                 Bernard Sanders, Vermont
    Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
    Kevin Cramer, North Dakota           Margaret Wood Hassan, New
    Tommy Tuberville, Alabama                Hampshire
    Jim Banks, Indiana                   Angus S. King, Jr., Maine
    Tim Sheehy, Montana                  Tammy Duckworth, Illinois
                                         Ruben Gallego, Arizona
                                         Elissa Slotkin, Michigan

                         David Shearman, Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                                December 3, 2025

                                    SENATORS

                                                                       Page
    Hon. Jerry Moran, Chairman, U.S. Senator from Kansas.............     1
    Hon. Richard Blumenthal, Ranking Member, U.S. Senator from
      Connecticut....................................................     7
    Hon. Tommy Tuberville, U.S. Senator from Alabama.................    11
    Hon. Mazie K. Hirono, U.S. Senator from Hawaii...................    12
    Hon. Tim Sheehy, U.S. Senator from Montana.......................    14
    Hon. Angus S. King, Jr., U.S. Senator from Maine.................    16
    Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......    18

                                   WITNESSES
                                    Panel I

    Alyssa Hundrup, Director, Health Care, U.S. Government
      Accountability
      Office.........................................................     2

    Julie Kroviak, MD, Principal Deputy Assistant Inspector General
      in the role of Acting Assistant Inspector General for
      Healthcare Inspections, Office of Inspector General, U.S.
      Department of Veterans Affairs.................................     4

    Erin Fletcher, Psy.D., Warrior Care Network Director, Wounded
      Warrior Project................................................     5

                                    Panel II

    Ilse Wiechers, MD, MPP, MHS, Acting Deputy Assistant Under
      Secretary for Health for Patient Care Services, Veterans Health
      Administration, U.S. Department of Veterans Affairs accompanied
      by Thomas Emmendorfer, Pharm.D., Executive Director, Pharmacy
      Benefits Management (PBM) Services.............................    21

                                    APPENDIX
                               Opening Statement

    Hon. Richard Blumenthal..........................................    31

                              Prepared Statements

    Alyssa Hundrup, Director, Health Care, U.S. Government
      Accountability
      Office.........................................................    37

    Julie Kroviak, MD, Principal Deputy Assistant Inspector General
      in the role of Acting Assistant Inspector General for
      Healthcare Inspections, Office of Inspector General, U.S.
      Department of Veterans Affairs.................................    57

    Erin Fletcher, Psy.D., Warrior Care Network Director, Wounded
      Warrior Project................................................    63

    Ilse Wiechers, MD, MPP, MHS, Acting Deputy Assistant Under
      Secretary for Health for Patient Care Services, Veterans Health
      Administration, U.S. Department of Veterans Affairs............    71

                           Submission for the Record

    Letter dated November 13, 2025 from Ranking Member Richard
      Blumenthal to Secretary Douglas Collins, U.S. Department of
      Veterans Affairs...............................................    87

                            Questions for the Record

    Department of Veterans Affairs response to questions submitted
      by:

      Hon. Jerry Moran...............................................    91
      Hon. Richard Blumenthal........................................    95
      Hon. Mazie K. Hirono...........................................    98
      Hon. Jim Banks.................................................   102

    Office of Inspector General, Department of Veterans Affairs
      response to questions submitted by:

      Hon. Margaret Wood Hassan......................................   105
      Hon. Bill Cassidy..............................................   106

                           Statements for the Record

    American College of Clinical Pharmacy............................   111

    American Legion, Dr. Marie Black, Health Policy Analyst,
      Veterans' Affairs and Rehabilitation Division..................   115

    American Psychiatric Association.................................   121

    Fleet Reserve Association, Theodosius Lawson, Director,
      Legislative Programs...........................................   124

    Grunt Style Foundation, Derek Blumke, Veteran Impact Fellow......   128

    Honorable David J. Shulkin, MD, Ninth Secretary, U.S. Department
      of Veterans Affairs............................................   140

    Jewish War Veterans of the USA (JWV), Kenneth Greenberg, National
      Executive Director.............................................   143

    Navis Clinical Laboratories, Anthony Hayes, Chief Growth Officer.   146

    Senseye, Inc., David Zakariaie, Chief Executive Officer..........   150

    Veterans of Foreign Wars of the United States (VFW), Meggan
      Coleman, Associate Director....................................   154

    Veterans Strategic Solutions, John Spagnola, President...........   161

      Attachment: VA's Informed Consent Form for Opioids.............   166

                             MEDICATION MANAGEMENT
                                IN VA HEALTHCARE

                                  ----------

                          WEDNESDAY, DECEMBER 3, 2025

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 4 p.m., in Room
    SR-418, Russell Senate Office Building, Hon. Jerry Moran,
    Chairman of the Committee, presiding.

        Present: Senators Moran, Tuberville, Sheehy, Blumenthal,
    Hirono, Hassan, and King.

                 OPENING STATEMENT OF HON. JERRY MORAN,
                   CHAIRMAN, U.S. SENATOR FROM KANSAS

        Chairman Moran. Good afternoon and welcome. I know that
    Senator Blumenthal is running a few minutes late, but on his
    way, and I assume that we'll have a number of our colleagues
    join us. We have a vote at 4:30, so we'll have to figure out
    that circumstance as well.
        I appreciate our witnesses joining us today and for the
    important work that you all do to support our veterans and
    their families. As we know, our Nation owes veterans the
    assurance of receiving safe, high quality, and effective care
    through the Department of Veterans Affairs. This includes
    making certain that the medications that are being prescribed
    are designed to support their recovery from trauma, pain, and
    mental health challenges, and are being paired correctly with
    the right support system. This responsibility is central to
    this Committee's mission, and it is the focus of today's
    discussion.
        Recent reporting by The Wall Street Journal has raised
    concerns about the use of multiple central nervous system
    medications among veterans, often referred to as ``combat
    cocktail.'' These stories raise the question of how widespread
    these practices are, their origins, how the VA is addressing
    this issue, and what VA's oversight and accountability
    mechanisms are in these instances. Medication is critical to
    the overall care and well-being of many veterans and nothing
    from today's hearing should suggest that veterans should
    hesitate to seek treatment or that evidence-based medications
    are unsafe or unwelcome in any way.
        Over the past decade, the VA has made significant progress
    in reducing opioid prescriptions through promoting safer
    options, expanding programs that support holistic health, and
    implementing new oversight measures to identify high risk
    medication combinations. This hearing, however, provides an
    opportunity to assess progress, discuss effective strategies,
    and identify gaps that still remain. Veterans deserve the trust
    in the system, and that's exactly why we're here today.
        This includes understanding how the VA trains clinicians,
    monitors prescribing practices, and implements policy to make
    certain veterans have access to non-medication options like
    therapy, pain management, and community programs, along with
    discussing whether private sector models or technologies can
    offer insights and ultimately help the VA to better serve
    veterans.
        Today we'll hear from VA officials who oversee prescribing
    practices and mental health policies across the system. The
    goal is simple: simply want to understand the scope of this
    issue and determine what steps the VA and Congress can take to
    guarantee that veterans receive safe, effective, and
    personalized care. The men and women who have served our Nation
    deserve nothing less.
        As I indicated, Senator Blumenthal is expected to join us
    shortly and we are going to proceed with the first panel.
    Testifying on the first panel today, which is on my sheet the
    second panel, is Dr. Julie Kroviak, Principal Deputy Assistant
    Inspector General for the Healthcare Inspections, U.S.
    Department of Veterans Affairs; Alyssa Hundrup, Director,
    Health Care at U.S. Government Accountability Office; and Erin
    Fletcher, Wounded Warrior Project.
        I appreciate our witnesses willing to testify, and we'll
    begin. Ms. Hundrup?

                                PANEL I

                                  ----------

       STATEMENT OF ALYSSA HUNDRUP, DIRECTOR, HEALTH CARE, U.S.
                    GOVERNMENT ACCOUNTABILITY OFFICE

        Ms. Hundrup. Chairman Moran, Ranking Member Blumenthal, and
    Members of the Committee, thank you for the opportunity to
    discuss our work related to medication management at VA.
        My testimony today covers various related GAO report
    findings and recommendations. Effective medication management
    is essential to ensure veterans receive safe and comprehensive
    treatment. This is particularly important for veterans
    experiencing mental health conditions, which have been a
    persistent and growing issue. Many veterans also live with
    chronic pain, often because of injuries from their military
    service.
        Veterans may receive medications such as antidepressants or
    mood stabilizers, as well as opioids for pain management. Some
    veterans have multiple chronic and mental health conditions,
    which may necessitate the use of numerous medications,
    increasing the risk of polypharmacy. If managed improperly,
    polypharmacy can lead to adverse health outcomes or even
    overdose or death. As such, it is critical that VA ensure it is
    offering effective treatment, including medication as well as
    non-pharmacological options such as therapy to reduce the risk
    of negative outcomes.
        In 2019, we examined VA providers' treatment plan decisions
    for veterans with mental health conditions. We found veterans
    received a range of treatments including talk therapy, one or
    more psychiatric medications such as anti-anxiety or anti-
    depressants, or a combination of the two. At that time, VA did
    not have guidance on or monitor providers' documentation of
    required treatment options in the plans. So, we made two
    recommendations to address these issues.
        Since then, VA agreed with and took action to implement the
    recommendations. Specifically, VA providers are now required to
    record mental health treatment plans as separate easily
    identifiable documents in medical records. The plans are to
    clearly show what treatment is being provided, the different
    treatments that were considered, and whether any changes may
    need to be further considered going forward.
        VA also developed an approach for monitoring the
    consideration of different evidence-based treatments, including
    both the prescribing of medications and therapy options. With
    this approach, VA is in a better position to ensure providers
    are considering all available options and providing the most
    appropriate treatment to each veteran. Importantly, with this
    information, VA is also in a position to evaluate the
    prevalence and appropriateness of polypharmacy and minimize the
    risks that it can bring including overdose or death.
        Additionally, we've examined issues related to VA's
    implementation of its Opioid Safety Initiative. At the time of
    our report, VA had reduced opioid prescribing rates, but we
    found VA did not consistently follow some risk mitigation
    strategies, such as conducting annual urine drug screening or
    requiring informed consent for long-term prescribing. We made
    recommendations to address these issues and VA has implemented
    them.
        For example, VA created a planning tool for primary care
    providers related to reviewing and documenting each of the risk
    mitigation strategies in veterans' medical records. With this
    tool, VA can better ensure providers are following the
    strategies. In light of the very serious risks that opioids
    pose, including addiction and overdose, it is critical that VA
    ensure it is maintaining careful oversight of prescribing so
    that it is done in a safe and effective manner.
        Lastly, the availability of mental health services is
    especially important for service members transitioning out of
    the military as this is a particularly vulnerable time. The
    transition period can bring stressors related to housing,
    employment, and family reintegration, and these veterans are
    susceptible to mental health conditions. In our 2024 report,
    examining mental health services for transitioning service
    members, we found VA and DoD identified a number of helpful
    touch points such as pre-separation counseling, but the two
    departments have not assessed the effectiveness of their
    collective efforts, and we recommended they do so.
        VA has also agreed with this recommendation and stated that
    it will coordinate with DoD to establish a plan of action to
    implement it, including identifying any gaps in services or
    duplicative efforts. It's important for VA to take action to
    address our recommendation, and we will carefully monitor the
    steps that VA takes going forward.
        Addressing our recommendation will help to ensure that
    departments the are most effectively offering mental health
    services to service members and veterans as they readjust to
    civilian life. This concludes my prepared statement. I'd be
    happy to answer any questions that you may have. Thank you.

        [The prepared statement of Ms. Hundrup appears on pages 37-
    56 of the Appendix.]

        Chairman Moran. Dr. Kroviak, welcome, and thank you for
    your testimony.

      STATEMENT OF JULIE KROVIAK, MD, PRINCIPAL DEPUTY ASSISTANT
      INSPECTOR GENERAL IN THE ROLE OF ACTING ASSISTANT INSPECTOR
        GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR
              GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

        Dr. Kroviak. Chairman Moran, Members of the Committee, I am
    pleased to testify about the oversight conducted by the Office
    of Inspector General regarding VA's medication management
    practices.
        A fundamental healthcare activity is a medication
    reconciliation process involving providers, patients, and their
    caregivers, that ensures they are aware of all medications that
    patient is prescribed and taking, including over the counter
    and supplements.
        Medication reconciliation required by VA can be time and
    labor intensive, but it helps verify that patients are taking
    their medications as prescribed, and that each medication's
    risk and potential side effects are understood. It can also
    reveal or prevent duplicative treatments, contraindications due
    to allergies, and potentially dangerous drug interactions.
        Medication reconciliation is most critical during care
    transitions, such as when a patient is discharged from a
    hospital, moves between different levels of care, or receives
    VA and community care. For those patients with chronic or
    difficult to treat conditions including mental health
    conditions, the risk of polypharmacy, being prescribed multiple
    medications, is real, but it does not always mean a patient is
    receiving poor care.
        Veterans are at higher risk for psychotropic polypharmacy,
    that is, being prescribed more than two medications that affect
    mind, mood, and behavior. This can occur because of their
    distinct military experiences that lead to complex and
    treatment-resistant mental health diagnoses.
        The OIG has noted deficiencies in medication management in
    several of our reports on VA healthcare. We uncovered non-
    compliance with required processes for patients being
    discharged from acute mental health care settings. For example,
    only 37 percent of electronic health records at the
    Philadelphia VA included clear discharge medication
    instructions, which are essential to prevent medication errors
    post-hospitalization, and ensuring continued recovery.
        Patients must also be educated on potential risks
    associated with their prescriptions. Many anti-depressants, for
    instance, carry ``black box'' warnings due to their increased
    risk of suicidal thoughts, particularly in young adults. One
    tragic case reviewed by the OIG revealed serious deficiencies
    when a young veteran who ultimately died by suicide was
    prescribed an anti-depressant without being educated on the
    risks, and was not provided timely follow-up care to evaluate
    responses to this new medication. This case highlights the
    critical value of patient education and timely follow-up care.
        In addition to challenges with safe prescribing within VA,
    the OIG is concerned with safe prescribing for veterans
    receiving community care. A significant, troubling area remains
    the oversight of opioid prescriptions written by community care
    providers. VA is required to ensure community providers review
    and acknowledge VA's Opioid Safety Initiative (OSI) guidelines.
    However, we found inadequate oversight of VA's third-party
    administrators' certification that community providers reviewed
    these guidelines. When community providers are not even aware
    of VA's expectations for safe opioid prescribing, VA cannot
    guarantee the safety of those veterans referred to the
    community for chronic and acute pain management.
        Our review of the VA Eastern Kansas Health Care System
    highlighted further inadequacies in coordination and oversight
    of medication management involving community providers. Among
    other issues related to patient safety for veterans referred to
    the community, we found incomplete documentation verifying safe
    opioid prescribing practices and a lack of documented
    medication reconciliation by community providers.
        In conclusion, VA's dedicated clinical staff work
    tirelessly to provide high quality care tailored to each
    veteran's needs. Such care can involve multiple treatment
    modalities and medications. Patients and caregivers must be
    empowered to manage their care with accurate medication
    instructions and understanding of treatment expectations and
    knowledge of potential side effects for each medication.
        The OIG is committed to independent oversight. Our teams of
    dedicated medical professionals are uniquely positioned to
    assess and drive meaningful improvements in the quality of care
    delivered by both VA and community providers. Chairman Moran,
    Ranking Member Blumenthal, and Committee members, I am happy to
    take any questions you may have.

        [The prepared statement of Dr. Kroviak appears on pages 57-
    62 of the Appendix.]

        Chairman Moran. Thank you, Doctor. Erin Fletcher, welcome
    again. Your testimony will be received.

       STATEMENT OF ERIN FLETCHER, PSY.D., WARRIOR CARE NETWORK
                   DIRECTOR, WOUNDED WARRIOR PROJECT

        Dr. Fletcher. Thank you. Chairman Moran, Ranking Member
    Blumenthal, and distinguished Committee members, thank you for
    today's hearing and for the honor to join you on behalf of
    Wounded Warrior Project and the warriors and families we serve.
        Our vision to foster the most successful, well-adjusted
    generation of wounded service members in our Nation's history,
    brings with it the responsibility to identify, address, and
    serve the mental health needs of veterans who reach out for
    help. In our most recent Warrior Survey, 77 percent of warriors
    reported PTSD and more than half presented with moderate to
    severe PTSD symptoms at the time of the survey. Nearly two in
    three reported one or more mental health conditions, and for
    many of the warriors we support, mental health challenges can
    be worsened further by poor sleep, chronic pain, and feelings
    of isolation.
        Recent reporting about polypharmacy has highlighted how
    overmedication can be one of the many challenges veterans face
    on their road to recovery. Poor access to therapy, canceled
    appointments, and stigma can also frustrate even those who are
    most motivated to find care. But there is reason for hope and
    we can frame strategies for improvement around stopping
    overmedication, increasing access to care, and embracing
    innovation. Regarding overmedication, recent research has shown
    that 28 percent of post-9/11 veterans receiving VA mental
    health care, met criteria for central nervous system
    polypharmacy.
        One way to help reverse these trends will be for Congress
    and VA to continue their investment in precision medicine. By
    moving beyond one-size-fits-all care, precision medicine
    enables more accurate decisions that improve outcomes and
    reduce unnecessary or ineffective treatments. Congress helped
    launch VA's initiative for precision mental health to identify
    and validate brain and mental health biomarkers, and translate
    those findings into improved clinical care for veterans. With
    consistent support and funding, as well as expansion to
    consider low level blast injuries, this initiative can
    transform the way medication can supplement evidence-based
    therapy.
        Increasing access to care will help move away from what
    some veterans observe to be a medication first approach at VA,
    in which prescriptions are offered before therapy or without
    consistent access to evidence-based treatments. But as our
    country is struggling with training enough providers to meet
    increasing demand for mental healthcare, we can broaden our
    perspective on access. Veterans increasingly express interest
    in non-pharmacological and complementary therapies to
    supplement their clinical treatment. Mindfulness, yoga,
    acupuncture, Tai Chi, and other integrative approaches provide
    coping skills, stress reduction, and support between therapy
    sessions.
        Congress and VA can help extend more access to approaches
    like these by renewing commitment to VA's whole health program.
    Even with over 100 whole health locations, availability still
    widely varies across VA facilities. Without a consistent
    centralized implementation model, many veterans remain unaware
    of available resources or encounter barriers in accessing them.
    Moreover, capacity constraints and frontline clinical treatment
    make access to these services even harder to obtain. These
    barriers can lead veterans relying solely on pharmacological
    interventions.
        Last, innovation can help set new strategies to ensure
    veterans have access to evidence-based treatment. Forward
    thinking approaches to case management are one area where we
    can drive change. We found success with offering veterans
    regular touch points to reduce frustration, ease confusion, and
    help them stay engaged while they navigate the clinical system.
    In a VA context, one example that we have found extremely
    effective is the post-9/11 Military2VA (M2VA) Case Management
    Program.
        This Public-Private Partnership (P3) model allows VAs to
    place liaisons at certain partnership sites as veterans
    complete specialized treatment within the community. For
    example, VA liaisons are onsite at our Warrior Care Network
    academic medical centers where veterans receive intensive
    outpatient care. The VA liaisons help veterans obtain VA
    medical records, schedule follow-up appointments at VA after
    discharge, and serve as a direct point of contact should the
    veteran have questions about their VA care in the future.
        At these sites, 90 percent of participating veterans return
    to VA for ongoing care, which is evidence that structured,
    proactive, and collaborative transition support helps prevent
    veterans from falling through the cracks and help maintain
    gains achieved in treatment.
        In conclusion, I'd like to recognize that VA is our biggest
    and most important partner in helping veterans access the care
    and support they need. It is critical that we give VA the tools
    it needs to succeed, and with Congress's help, VA has made
    progress in recent years to reduce over prescriptions, improve
    oversight, embrace innovation, and strengthen its mental
    healthcare system. We are hopeful that the challenges being
    discussed today will be the focus of even more effort to ensure
    that veterans receive the best possible support when seeking
    mental health care.
        Thank you for this invitation to testify and I welcome your
    questions.

        [The prepared statement of Dr. Fletcher appears on pages
    63-70 of the Appendix.]

        Chairman Moran. Thank you very much.
        Before we go to questions, let me turn to the Ranking
    Member Senator Blumenthal for his opening statement.

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

        Senator Blumenthal. Thank you. Thank you, Mr. Chairman, and
    my apologies for my lateness. I'm going to put my statement in
    the record. But let me just thank you and thank the witnesses
    for being here today.

        [The opening statement of Senator Blumenthal appears on
    pages 31-33 of the Appendix.]

        Polypharmacy often is a symptom of long wait times for care
    or other factors that may result in multiple medications that
    conflict with each other or cause damage to the individual.
    Insufficient clinical capacity, fragmented care and lack of
    accessible alternatives to medication may lead to overreliance
    or mismanagement of pharmaceuticals. And unfortunately, what
    we've seen is longer waiting times for access to care.
        Reports indicate that there is a serious deviation from
    VA's commitment to evidence-based veteran-centered mental
    healthcare. And I have written to Secretary Collins about it.
    I'm going to put that letter in the record as well.

        [The letter referred to appears on pages 87-88 of the
    Appendix.]

        The VA has lost a lot of its staff, which could account for
    those delays, and it needs to be in the position to have the
    resources to restore its mental health care network. And let me
    just say finally, by way of this introductory statement that,
    Dr. Fletcher, I was concerned that the VA has instituted a
    copayment for holistic treatment like yoga, fitness classes,
    meditation, whole health coaching that allow veterans to rely
    on treatment other than just medication. And I think that is
    really counterproductive.
        So, I look forward to our questions and again, my thanks,
    Mr. Chairman.
        Chairman Moran. You're welcome, Senator Blumenthal. Let me
    begin with a broad question to each of you. In part, what
    precipitated this hearing was the reporting from The Wall
    Street Journal that highlighted troubling examples of veteran
    medication experiences. From each of your perspectives, how
    closely do those cases align with what your office or
    organization is seeing and where do they differ?
        In other words, tell me whether what you see is what is
    reported in that article and what we should know about that.
    Start with you, Ms. Hundrup.
        Ms. Hundrup. Thank you. So, in our work, we had found
    there's a number of factors that influence providers' decisions
    to prescribe. They ranged from the resources at a medical
    center, to complexity of the conditions, the comfort level with
    prescribing, as well as the availability and the types of
    treatment. So there's really a lot that can influence it.
        At the time of our work, which was based on fiscal year
    2018 data, so it's a little bit dated, there were 37 percent of
    veterans with at least one mental health condition that were
    prescribed a psychiatric medication, either alone or in
    combination with therapy. And focusing on those with PTSD,
    veterans taking two or more classes of medications ranged from
    32 percent for those seeing a primary care provider to upwards
    of 61 percent for those seeing both primary and specialty care
    providers.
        Now, as has been stated, polypharmacy in and of itself
    isn't necessarily problematic. So in preparation for this
    hearing, we were looking to see if there was updated data on
    where the VA is in terms of polypharmacy. Again, not to say
    that polypharmacy alone is bad, but it does increase risks.
    Updated data were not available. So I would encourage the VA to
    make those data available and it is worth examination.
        What we did recommend is making sure the treatment plans
    have clear identifiable information so that they can monitor
    that and see where there are risks and mitigate those risks,
    such as if a provider is doing a lot of prescribing and you see
    a lot happening, you can look into that and see if that is
    appropriate to make sure that they're mitigating any risks or
    taking action if that may be the case.
        Chairman Moran. Is that a suggestion so that we could
    compare what takes place at the VA with other healthcare
    providers?
        Ms. Hundrup. Well, just to have a number to update where we
    are, you know, a lot has changed since 2018. So just to
    understand veterans, for example, with PTSD or other mental
    health conditions, what kinds of prescribing is occurring, what
    kinds of classes of psychiatric medications are they getting?
    For a while there was a lot of concern about opioids in
    combination with benzodiazepines. I know that had been reduced
    greatly and that was something that the VA made great strides
    in. But where are we today? Has that continued to decrease? I
    think some of these allegations in the article, we just don't
    have the data, so we don't know. So I think the first order of
    business is really seeing updated data.
        Chairman Moran. Fresh data. Okay, thank you. Doctor,
    anything to add or suggest?
        Dr. Kroviak. I was actually quite disappointed in the
    article. I think it is devastating to read about the patient
    experiences. Those are real. Yes, I found the article
    disappointing. The cases were devastating. The patient
    experiences are real. But what I didn't, and I wouldn't expect
    to have seen in the article is what the medical record showed,
    what the provider and healthcare team, what their response
    would've been, and how they supported the patient. These were
    complicated patients. It's easy to understand that from reading
    the article, that VA treats very complicated patients.
        I was also very disappointed that the suggestion is that
    the VA providers are handing out medications to avoid providing
    adequate care. That's not what we've seen. We've been in every
    facility, CBOC, Vet Center, CLC; this is not what we're seeing.
    We are seeing compassionate, dedicated providers managing
    incredibly complicated patients.
        Chairman Moran. Great to hear. Thank you. Dr. Fletcher?
        Dr. Fletcher. Yes. Thank you for the opportunity. So what
    we hear from the warriors we serve is that they often encounter
    medication recommendations before therapy is offered or even
    accessible. And so we know this doesn't happen everywhere, but
    we've heard it consistently enough that it suggests an
    opportunity to increase access to first line psychotherapies
    and more shared decision-making in the treatment planning
    process.
        Chairman Moran. Is what you're saying different than what
    Dr. Kroviak was saying?
        Dr. Fletcher. No, I think there's a lot of similarities. A
    lot of similarities, yes.
        Chairman Moran. Senator Blumenthal.
        Senator Blumenthal. Thank you. Dr. Fletcher, to what extent
    have waiting times for mental health appointments been due to
    diminished staff, and I'll ask the same question of our other
    witnesses as well?
        Dr. Fletcher. Thank you for that question. So what we've
    heard, again, from the warriors we serve is that they are
    experiencing access to care difficulties and that can create
    problems. We know that warriors with the best outcomes have
    access to evidence-based treatment, are well-informed about the
    medications that they are taking, and again, are active
    participants in the treatment planning process.
        Senator Blumenthal. Dr. Kroviak?
        Dr. Kroviak. Yes, we are aware of shortages in mental
    health providers and access to care within mental health and
    health in VA. That's not unique to the VA healthcare system.
    So, the wait times we're seeing in VA are also reflected in the
    wait times that veterans are experiencing when being referred
    to the community. So, it is a much bigger problem than just VA.
        Senator Blumenthal. It's not unique. But what is maybe
    unique, certainly unusual to the VA healthcare system, is that
    it is discouraging talented mental health professionals from
    coming to the VA through policies of furloughs and firings.
    Would you agree?
        Dr. Kroviak. So, I will say through our cyclical reviews,
    where we go out to facilities not for cause, but to try to get
    a feel for culture and quality of care practices, we are
    getting more feedback that morale is going down because of the
    uncertainty within the Federal Government. So yes, while they
    aren't participating in the DRP or didn't participate in the
    DRP or other programs, clinical staff were exempted from that,
    but they are still losing clinical staff because of morale.
        Senator Blumenthal. Morale going down means----
        Dr. Kroviak. Correct.
        Senator Blumenthal [continuing]. That fewer talented and
    skilled professionals are going to come to the VA or stay,
    they're going to be leaving if morale----
        Dr. Kroviak. Yes, I have to say, these are discussions we
    have with leaders. We are not asking them to validate the
    data--they're just sharing in a conversation the concerns at
    the local level.
        Senator Blumenthal. Did you have anything, Ms. Hundrup?
        Ms. Hundrup. I would just quickly echo what Dr. Kroviak
    said about the nationwide shortages applying to both VA and
    inside as well as outside. Also, it is important to distinguish
    between care within VA and outside care. For the VA, there is a
    timeliness standard for care in a VA facility. They don't have
    that for receiving care in the community, which means that VA
    is limited in its understanding of how long it's taking for a
    veteran to be seen in the community or what the challenges are
    or how best to address them.
        And we do have an outstanding recommendation for VA to
    establish a timeliness standard, which would help give us more
    information about the differences. And of course, timeliness of
    care is an access to care issue because the longer a veteran
    has to wait can exacerbate health issues. Thank you.
        Senator Blumenthal. And of course, The Wall Street Journal
    article the Chairman referred to a little while ago, ``Combat
    Cocktail: How America Overmedicates its Veterans'', I think
    indicates that the care for them, mental health care or other
    kinds of care is really important to prevent the overmedication
    that often results from the cocktail of pharmaceutical drugs
    that may be prescribed sometimes wrongly or inadvertently. And
    I wonder if you can say Dr. Fletcher, whether there should be
    stronger safeguards oversight to prevent that kind of problem?
        Dr. Fletcher. I thank you for that. What we hear from our
    warriors is that they want to spend more time with their
    providers. They want to fully, you know, process through their
    trauma, their symptoms. They want to be informed about the
    medications that they're being prescribed. We know that
    consistent follow-up increases chances of treatment adherence
    and treatment compliance. Consistent follow-up allows providers
    and veterans to identify medications that may not be working
    properly, avoid symptoms, you know, side effects that become
    too uncomfortable. That consistent oversight is important to
    successful clinical outcomes.
        Senator Blumenthal. Well, again, my time is about to
    expire. Let me just say that I appreciated both the OIG and the
    GAO findings, which I think are tremendously important. Just as
    one example, 33 percent of VHA facilities were not in full
    compliance with requirements to have a pain management team.
    That seems like a really basic failing. And again, you can't
    have pain management without the personnel to do it. And I
    think unfortunately, the VA is sacrificing that tremendously
    important capability. Thank you, Mr. Chairman.
        Chairman Moran. Senator Tuberville.

                         HON. TOMMY TUBERVILLE,
                       U.S. SENATOR FROM ALABAMA

        Senator Tuberville. Thank you, Mr. Chairman. Thanks for
    being here. Good to see you all. Very important issue. We have
    a lot of problems in my State of Alabama with overprescribing
    at times. Doctor, you and Ms. Hundrup spoke about enhancing
    oversight at the VA and medical management related issues,
    especially a better hold on medical professionals accountable
    for overprescribing harmful medications. Do we have a plan for
    that? Both of you, could you all answer?
        Dr. Kroviak. So, ultimately, the plan is VA's, but what our
    oversight work has shown that a lot of critical leaders in the
    VISN, which is a body that exists to oversee the facilities, do
    not have defined roles, and responsibilities, and clear lines
    of authority. So, VA has a plethora of directives and policies
    that, you know, are based in evidence.
        However, it's the consistent application of those policies
    and practices where we find most of the issues that we report
    on. With structured oversight roles within the VISN, where
    leaders know what is their responsibility, it is written down
    and they own it, and that certain staff and procedures and
    practices, they are accountable to that leader can really help
    enforce--we feel it could really help enforce the more
    consistent application of these directives and policies and
    practices that they have plenty of.
        Senator Tuberville. Thank you. Ms. Hundrup?
        Ms. Hundrup. I would also, again, echo Dr. Kroviak. I think
    we have many similar findings and share the same sentiments,
    but I would just add that in our work, I think by having VA
    more clearly document the treatment plans that are in a mental
    health care plan and have them be easily identifiable as well
    as document what evidence-based treatment options were
    considered. Obviously, in many, many cases it's very complex.
    There's not a straightforward answer.
        There does have to be adjustments very specific to the
    individual that change over time. And these are complex cases,
    so you might have multiple medications involved. But by having
    that documented and clear in the record, it sets up VA to be in
    a position to monitor that. And they had committed to reviewing
    individual providers' plans, you know, a sample of plans on a
    biannual basis just to make sure. I think as Dr. Kroviak said,
    some of the policies are only as good as they're implemented.
        So, you know, I would be interested to see what VA is doing
    to continue to monitor and look for outliers and then take
    action with providers that may not have the best education or
    may not be making the best decisions for their veterans.
        Senator Tuberville. Do you all think we should have
    oversight on foreign manufactured drugs that we give our
    veterans? Is there any thought on that?
        Dr. Fletcher. Thank you for that question. I think where
    the Warrior Project we stand on this is, we want our veterans
    to be as informed as possible about the medications that
    they're taking. We want treatment recommendations to evidence-
    based research informed and prescribed in the safest manner
    possible.
        Dr. Kroviak. I don't have a specific comment on the
    oversight. You said meds manufactured over----
        Senator Tuberville. Foreign manufactured.
        Dr. Kroviak. Yes, I mean, again----
        Senator Tuberville. Which most of them are by the way
    anyway, I would think.
        Dr. Kroviak. Right. I mean, this whole medication
    reconciliation process that I've emphasized in my testimony is
    really more about the interaction between the prescriber, the
    provider, and the patient. I think that's where all of this
    sort of action has to happen to where everybody's on the same
    page. It's really outside of the VA to where the question
    you're asking would be, you know, put into play and absolutely
    I would not, you know, speak against increased scrutiny over
    the safety of the medications that we're buying and
    prescribing.
        Ms. Hundrup. I would just echo that. That's not something
    that I have familiarity with, but I think that's an important
    topic that VA should be closely looking at.
        Senator Tuberville. Thank you. I got 45 seconds. Ms.
    Fletcher, I hosted a field hearing in Montevallo, Alabama this
    spring talking about HBOT and psychedelic-assisted therapy. Do
    you think that expanded access through FDA approval of these
    types of therapies could and would help address the
    polypharmacy issue?
        Dr. Fletcher. Thank you for that question. I think that
    access and research into alternative treatments is something
    that a lot of the warriors that we serve would be interested
    in. We hear oftentimes that they're coming to us saying that
    they've tried more traditional therapies and are more eager to
    pursue the non-traditional therapies when they haven't found
    that success. But again, we would want these treatment
    recommendations to again, be based on patient safety and
    evidence-informed.
        Senator Tuberville. Thank you. Thank you, Mr. Chairman.
        Chairman Moran. Senator Hirono.

                         HON. MAZIE K. HIRONO,
                        U.S. SENATOR FROM HAWAII

        Senator Hirono. Thank you, Mr. Chairman. Thank you very
    much for the panel. So, we have millions of veterans, millions
    of veterans, and a rather large percentage of them have PTSD.
    And according to The Wall Street Journal article, nearly 60
    percent of VA patients with PTSD, and I don't know what that
    translates to into numbers, but they say that's over half a
    million patients. Are each of these veterans with PTSD supposed
    to have an individual treatment plan? I don't know who to ask
    this question to. Yes? No?
        Dr. Fletcher. Yes. I think that having an individualized
    approach to treatment yields better outcomes.
        Senator Hirono. I know. That's not my question, though. Do
    each of these, over half a million, let's just focus on the
    veterans with PTSD, do they each have a treatment plan and
    who's supposed to come up with a treatment plan for each of
    those veterans?
        Dr. Kroviak. If they're diagnosed with PTSD and being
    treated, then they are required to have a treatment plan that
    is created and monitored by their healthcare team.
        Senator Hirono. And Dr. Fletcher, you deal directly with
    the veterans of the two other panel members. So, do they have
    individualized treatment plans?
        Dr. Fletcher. I would say that that varies across veterans
    and across----
        Senator Hirono. I'm sorry, what?
        Dr. Fletcher. I would say that that varies. I can't speak
    necessarily for all of the veterans. We typically hear that
    when they're afforded the opportunity to have the access to
    this evidence-based treatment that it can be individualized,
    but it's not always.
        Senator Hirono. Well, when you think about the number of
    veterans we have and their medical needs and they go to VA,
    it's just astronomical. The needs are astronomical. And at a
    time when there have been pretty significant cuts to VA, which
    always had a shortage of providers. Isn't that true? I mean, in
    Hawaii they're always trying to hire people for the VA. So,
    there's always been a shortage. It's been exacerbated with this
    regime. Isn't that so? That shortage? Somebody?
        Dr. Kroviak. So, the OIG publishes a report annually on
    critical staffing shortages, and for the past 8 to 10 years, I
    can't remember exactly, but this year, yes, you are correct.
    We've noticed the most significant increases in those----
        Senator Hirono. So, at the same time as, I think Dr.
    Fletcher, no--GAO, I think you said that there needs to be yes,
    more oversight. And when you have the staffing cuts, etc.,
    who's supposed to provide the oversight that you are
    recommending? This is for Ms. Hundrup, am I pronouncing your
    name correct?
        Ms. Hundrup. Yes, that's correct.
        Senator Hirono. So, you say more oversight is needed, but
    there are massive cuts to VA. Who's supposed to provide the
    oversight for the medical care of the veterans?
        Ms. Hundrup. Right. I think that that's where there is a
    level of oversight to ensure, because as I mentioned, if you
    have a policy or requirement, it's only as good as----
        Senator Hirono. But do we? You're saying that they need
    more oversight, but there isn't more oversight. In fact, I
    would say there's less, because there are cuts. There have been
    cuts to the VA's capacity to provide care. So, what I'm seeing
    is that I commend you all for pointing out the needs, but how
    are the needs supposed to be met when the VA is actually making
    pretty significant cuts to an already strapped healthcare
    system, the biggest healthcare system in the country? I mean, I
    don't know how the veterans are supposed to receive the kind of
    care they need when there are cuts to the provider base.
        Ms. Fletcher, I was intrigued by your saying that veterans
    would like to have alternative kinds of care, and is that a
    fruitful avenue for us to support and pursue if we're not going
    to have all the mental health providers that are necessary, you
    know, non-traditional services? Are we doing something to
    provide those kinds of programs?
        Dr. Fletcher. I think that there is absolute value in
    pursuing research to support these alternative therapies. What
    we've typically heard, again, is most of the warriors that we
    serve are willing to avail themselves to the frontline
    treatments that are already available. What we hear is they
    seek these alternative therapies when what they've tried hasn't
    worked. And we always want--and so a commitment to innovation
    in mental health care is absolutely needed.
        Senator Hirono. Do you think that that is a fruitful way to
    go, but because the VA system lacks providers, especially I
    would say mental health providers, maybe primary care
    providers, but if we can create an environment where
    alternative kinds of support can be provided, is that a
    fruitful way for us to proceed? Dr. Fletcher?
        Dr. Fletcher. Yes, I do believe there's value in pursuing
    alternative therapies.
        Senator Hirono. Well, that may be one of the ways to go
    when we lack resources. Thank you, Mr. Chairman.
        Chairman Moran. You're welcome. Senator Sheehy.

                            HON. TIM SHEEHY,
                       U.S. SENATOR FROM MONTANA

        Senator Sheehy. Thank you all for coming today. Appreciate
    your commitment to this important cause. As a combat veteran
    myself, married to a combat veteran, I take very personal stake
    in all these matters and thank you for your commitment to the
    cause. You know, I think to respond to some of my colleagues'
    comments there, all the more reason why the community care
    model was introduced and is more critical now than ever, which
    is the VA has perpetually been underresourced especially in
    rural states like Montana, where you cannot have a VA clinic in
    every town.
        And when most towns are two to three hours apart, when it's
    a five-hour drive, from Plentywood to Helena, the expectation
    that a VA clinic will be available within reasonable driving
    distance in a negative 30-degree snowstorm, is unlikely. And
    taking advantage of the community care options and investing in
    community care, especially in our rural states, is just as
    important now more than ever.
        You made a great point today Dr. Fletcher, and I want to
    reinforce, and that's the alternative care model. That we're
    seeing so many veterans now flying to Mexico, flying to the
    Middle East, going to Turkey to get psychedelic treatment. That
    they're finding immediate relief from PTSD, from TBI. They're
    finding it to be safer, healthier, and far more effective for
    them and their families. And yet that type of treatment is not
    only not provided by the VA or our healthcare system at all,
    it's been stigmatized and in some cases treated as illegal,
    even though it's working far better.
        And I think whether it's acupuncture or dry needling or
    yoga, meditation, sleep therapy, or alternative psychedelics,
    we need to be open-minded about how we can adopt these
    therapies. And unfortunately, this isn't a knock on the VA, but
    the government is not inherently going to be an innovative,
    entrepreneurial, creative place. It's just not. It's opposed to
    the DNA of a government bureaucracy. And we shouldn't fight
    that. We should welcome that and say, outside groups like
    Wounded Warrior Project, like other nonprofit organizations can
    be those hotbeds of innovation.
        And we should be able to welcome those in and welcome their
    creative thought process. Because at the end of the day, it's
    about the outcomes, not the process. Veterans not victims,
    patients not bureaucracy, and outcomes over process. And at the
    end of the day, that's what we have to focus on. So, thanks for
    your comments there.
        Ms. Hundrup, I want to go back to a comment you made, I
    think it was incredibly relevant. I'd like your thoughts on
    that. You said, you know, no matter what the legislation or the
    policies are, if they're not executed properly, none of that
    matters. And I think that that is government in a nutshell at
    the end of the day. We can all pass laws, but if the people
    that we employ to enact those policies aren't the right ones or
    are not doing it properly, it's going to fail.
        This written informed consent law we're trying to pass, I
    think has broad support across the veteran, the nonprofit, and
    the healthcare industries, and in communities. I'd like your
    thought on should this pass, how we ensure that when it passes,
    if it passes, we enact it properly, and the outcome is what we
    want?
        Ms. Hundrup. Yes. I think informed consent is important
    because it's an explicit way to ensure the patient knows about
    the risks of the medications they may be taking. In the case of
    the Opioid Safety Initiative, we did find that the informed
    consent was lacking and recommended that VA take steps. In
    implementing our recommendation, they implemented a tool so in
    the medical record, there's a flag to show whether or not
    informed consent for long-term opioid therapy was discussed and
    signed by the patient.
        So, I would suggest perhaps a similar approach where in
    that medical record, if it is expanded to other psychiatric or
    other medications for informed consent, there could be a
    similar flag that in prescribing it, it blips up on the medical
    record and they can then have that discussion with the patient,
    including the date that that was had.
        Senator Sheehy. Do you feel the VA is currently structured
    to be able to effectively implement this rule should we pass
    it?
        Ms. Hundrup. I will acknowledge it's been a while since we
    looked at this, but I understand that tool was in place in
    their medical records. Now, I will acknowledge a lot is
    happening with the medical records right now and the
    transition. But should what we understood to take place when
    they implemented our recommendation in 2020 still be there and
    still be utilized. I think it's worth asking.
        I think my understanding is it could be a simple process to
    add that and that providers would be continuing to do that.
    I've not heard any cases where it has been lacking, but again,
    it's up to each provider in that medical record to document
    that for that individual veteran.
        Senator Sheehy. Now on its face, unrelated, but all things
    relate to this, do you think this is yet another reason why we
    must reemphasize electronic health records, linking DoD health
    records that have a seamless pass through to VA health records
    so we do not have to continue to waste billions of dollars in
    years and lives losing medical records from years in service,
    from combat injuries that have been meticulously documented by
    the DoD, and then we throw them in the trash and rebuild them
    from scratch for the VA, which takes years, missing treatments,
    missing symptoms, and failing our veterans.
        Is it finally time for us to have a DoD to VA health record
    that is seamless and there's no delay and there's no ledge that
    people fall off of?
        Ms. Hundrup. Absolutely.
        Senator Sheehy. Thank you.
        Chairman Moran. Senator Sheehy, you might want to tell our
    colleagues about the plan for a roundtable that you've asked me
    to conduct to have a conversation about a topic that you
    described in some of your questioning. So, next Tuesday at 2
    o'clock, you might tell us what you have in mind.
        Senator Sheehy. Thank you, Chairman. Yes, we're going to
    talk about our alternative treatment ecosystem. After I was
    wounded, I was privileged to undergo some processes at Walter
    Reed, which were eye-opening for me. A lot of the alternative
    treatments that we've talked about: psychedelics, sleep
    therapy, yoga, etc. But specifically, the availability of
    psychedelics and how we can bring those into the VA system,
    into the broader veteran healthcare ecosystem as we're seeing
    really a tremendous caseload of feedback from veterans and
    patients who've benefited from that treatment, very
    specifically, and come back and testify that these treatments
    are having an incredible impact on them, and the side effects,
    at least so far are minimal to negligible.
        So, thank you for giving me an opportunity to bring that
    up. It's going to be hopefully, a pretty insightful session.
    Thank you.
        Chairman Moran. You're welcome. Thank you for your
    leadership and interest in this topic and Committee. We have
    not invited every Committee member, but you're all invited. We
    invited everybody who's on this Committee that has been engaged
    in this psychedelic treatment aspect of pursuing policy, but
    anybody and all are welcome to come and it's next Tuesday at 2
    o'clock.
        Now, Senator King.

                        HON. ANGUS S. KING, JR.,
                        U.S. SENATOR FROM MAINE

        Senator King. Thank you, Mr. Chairman. I want to emphasize
    what Senator Sheehy just said. As I looked over my notes and my
    questions, it all comes back to decent electronic medical
    records. You talked about coordination with community care,
    good electronic medical records, coordination with veterans
    coming out of the Defense department, decent electronic medical
    records. And everything comes back to that.
        I mean, the overprescribing or prescribing polypharmacy
    where there's conflicts and danger, that's where you get--that
    won't happen if you have decent medical records. So, every
    practitioner that sees a veteran sees the same information
    about what they're taking, what they've been prescribed, what
    their history is, all that necessary background.
        So, the development of electronic medical records for the
    Department of Defense and the VA has been an absolute debacle.
    And we're spending billions of dollars, it's still not working.
    It's been tested. People don't like it. I've never understood,
    frankly, why we didn't use the same system that's already on
    the shelf for thousands of hospitals across the country. Why
    are we inventing a whole new system for these patients? But
    sorry about the speech, but Senator Sheehy provoked it, because
    he's absolutely right.
        A personal story. Just recently, I talked to an elderly
    friend, and in our conversation, I realized that she was much
    sharper and more engaged and with it than had been the case
    just a month or two before. And I didn't really think too much
    about it until I later talked to her husband who said she had a
    fall, she had a broken knee, she went into the hospital, her
    physicians looked at her prescription record and changed the
    prescriptions, and she's a different person.
        Nothing else happened other than taking her off certain
    drugs, putting her on others, and adjusting the volume, if you
    will. And so this was totally obvious, and all it was, was
    somebody seeing cohesively what the prescription record was.
    And I'm sure that's happening with thousands of veterans.
        One question I have is, this seems to be a prime area where
    AI could help. AI could tell you whether there are
    contradictions and problems. I mean, I think that's one area.
    Everybody's talking about AI and all the problems. But this is
    something where AI could quickly and instantly analyze. It
    would have every drug in the world and you put in, ``What would
    happen if this person is taking these three drugs and I
    prescribe this?'' It would give you an instant answer. Isn't
    that true? You're nodding. Nodding doesn't show up in the
    record. You have to say, ``Yes, Senator. That was a brilliant
    comment.''
        [Laughter.]
        Ms. Hundrup. Yes, Senator. That is not a topic we've looked
    at in-depth, but I do think you're absolutely right. And in
    terms of just even some of the record sharing, we do understand
    from VA in terms of them stating their intent to implement our
    recommendations that they do anticipate using medical
    technologies like AI. So, I think just to loop back to the need
    for oversight and the need for more people, I do think there is
    promise that AI could alleviate some of that.
        We're very early, and that's not something that GAO has
    looked at specifically, so I need to stop there, but I think it
    has a lot of promise.
        Senator King. One of my questions is, is there any part of
    the VA routine that involves an annual checkup of your
    medications? Is that something the VA does routinely? It seems
    to me that would be a useful tool.
        Dr. Kroviak. I can take that question. So, within an EHR,
    including the old CPRS that VA uses and the new Cerner record,
    when you prescribe a new medication, the software itself is
    taking that one medication against the list of medications a
    patient is already prescribed or against a known list of
    allergies the patient has reported.
        So, what you're saying is happening in even the most basic
    EHR function. The issue is an alert can pop up that describes
    the risk level of that interaction. So, the provider in that
    moment has to make a determination like, ``Yes, I know this
    risk exists, but I'm taking the risk because it's worth
    whatever outcome or treatment plan I've established.'' So, what
    you're saying is happening. It doesn't require new technology.
        Senator King. There are regular reviews of medication?
        Dr. Kroviak. Every time you see a patient, this medication
    reconciliation process should be happening between provider and
    patient, but the software that they're using when you enter a
    new medication will run it against the inventory of what's
    already being prescribed to make sure those interactions aren't
    happening that you're worried about.
        Senator King. And one of the things you mentioned was the
    possible lack of communication and coordination with community
    care?
        Dr. Kroviak. Yes.
        Senator King. That's correct? So, that's a gap we should be
    paying attention to?
        Dr. Kroviak. It's a massive gap that we've reported on
    frequently. There is a technological solution--one day when all
    EHRs communicate with each other. That's the ultimate solution.
    We are nowhere near that.
        Senator King. And there's no excuse for being nowhere near
    that in this day and age. But I deeply appreciate your
    testimony and I hope you'll follow-up as a result of our
    questions and what the Committee is after. Let us know what we
    can do to help. That's our job here. And you can be our eyes
    and ears in the field and say, ``Here's a gap. Here's a
    problem. Here's where either oversight by this Committee or
    legislation by this Committee could help to fill those kinds of
    gaps.''
        Thank you very much for your testimony. Thank you, Mr.
    Chairman.
        Chairman Moran. Senator Hassan.

                       HON. MARGARET WOOD HASSAN,
                    U.S. SENATOR FROM NEW HAMPSHIRE

        Senator Hassan. Well, thanks, Mr. Chairman and Ranking
    Member Blumenthal. And to our witnesses, thank you for your
    support of veterans.
        Ms. Hundrup, I wanted to start with you. As you highlighted
    in your testimony, veterans often experience hardships in the
    transition period where they leave the military and reenter
    civilian life. As you know, the GAO recommended that the DoD
    and VA's Joint Executive Committee, which oversees the
    coordination of healthcare and benefits between the military
    and the VA, assess the effectiveness of DoDs and VA's efforts
    to facilitate access to mental health services for these
    transitioning service members.
        So, can you discuss why it's important to make these kinds
    of assessments and how they can help lead to potentially
    improving the healthcare that our veterans are receiving during
    this critical time?
        Ms. Hundrup. Yes, thank you. So, in our work, we identified
    a number of helpful touchpoints across the transition
    continuum, which is 1 year before separation to 1 year after.
    However, there was often some confusion about which program
    they need to use or how it works. Sometimes a lack of
    awareness. Some of the programs we found were late. So, for
    example, there were two programs, Solid Start and inTransition,
    both noble programs with good intent, but they were identifying
    the veterans two to three months after separation, which is
    already very late in the process.
        Senator Hassan. Yes.
        Ms. Hundrup. And there was also potential duplication
    getting similar phone calls, which was just resulting in
    confusion on the part of the veteran maybe being overwhelmed,
    not knowing. So, not only was it late in the process, but
    looking across, there are a lot of different programs. I think
    each individually has, again, noble goals and provides critical
    services. But looking across, there was, you know, maybe some
    places that were a little too late.
        Senator Hassan. But as we look at assessing this,
    especially for mental health care, what is the value of this
    assessment in terms of mental health access?
        Ms. Hundrup. So, the value of this assessment will be to
    look across and identify the timing, whether there are gaps,
    whether certain things could be done earlier, whether, for
    instance, the Separation Health Assessment is supposed to have
    a mental health assessment that's not happening now.
        So, I think they could identify what is happening, where
    there are gaps, maybe there's overlap or duplication, and
    really look systematically across, which I think could result
    in some savings on the part of DoD or VA or both. And they can
    take those savings and shift them. So, services really coming
    at the right time in a clear manner for the veteran that are
    more understandable. So, I think it's going to result in a more
    cohesive, holistic approach.
        Senator Hassan. And I think that's, you know, critically
    important, as somebody who advocated it and worked on the Solid
    Start Program. The idea was day one of the transition, there
    would be these things in place, right? And that means that the
    organizations have to start planning before the veteran
    separates.
        Dr. Kroviak, let me kind of follow up in a way on what
    Senator King was just talking about, because one of the issues
    you've raised is medication management for veterans who are
    receiving community care. And you've discussed, it's really
    important that veterans who receive community care have their
    opioid prescriptions coordinated and monitored by the VA. The
    coordination and oversight obviously can be lifesaving for
    veterans struggling with pain and mental health conditions.
        In 2023, the Inspector General's office looked into VA
    oversight of community care opioid prescriptions and found,
    ``Gaps in care coordination documentation and the use of risk
    mitigation strategies for system patients receiving community
    care.'' In your testimony, you stated that two of the seven
    recommendations from that 2023 report still haven't been
    implemented.
        So, what problems remain in terms of ensuring the community
    care providers and the VA are working together to ensure that
    veterans, especially those who are being prescribed opioids,
    are getting the safest, best care that they can, and what can
    we do in Congress to help?
        Dr. Kroviak. Yes, so I think those two recommendations
    you're referencing are specific to that information sharing.
    And we have been working with IVC, which is the Integrated
    Veteran Care program office that runs community care. It is a
    struggle to ensure that communication and oversight of that
    effective sharing of information, and it will require likely
    changes to the contract, modifications to the contract that VA
    has with the TPAs currently. They are up to renew that contract
    in the coming year. They're taking our considerations and
    concerns very seriously, and we meet with them quarterly to
    discuss how we can move forward with ensuring these things
    happen.
        Senator Hassan. Well, let us know if we can be helpful in
    that way and urging forward.
        Dr. Kroviak. Of course. Thank you.
        Senator Hassan. I'm just about out of time, so I'll follow
    up in writing, but I continue to be really concerned about the
    issue of veterans, especially with mental health issues being
    given the right kind of follow up instructions about their
    medications when they're discharged. So, I'll follow up with a
    question in writing for you on that. Thanks, Mr. Chair.
        Chairman Moran. Senator Hassan, thank you.
        We have another panel and we have not yet called the 4:30
    vote, so we might be in good shape for the hearing to conclude.
    I'll quit talking to improve the chances, except I don't have
    time to ask these questions. But I'm very interested, Dr.
    Kroviak, in community care. And it seems like other Members of
    this Committee are. I don't know whether the problem--I
    suppose, because we don't have the information, the
    coordination. We don't know whether there has been real life
    problems for the veterans or whether it's lack of ability to
    demonstrate whether that exists or not.
        So, I'll follow up with my staff and you to have that
    conversation like, are veterans at real risk or we don't know.
    And it's not just a paperwork issue, I don't mean just, because
    records are important, information matters. And I'm interested,
    of course, in the Eastern Kansas report that you alluded to and
    want to hear more about that.
        And then I think it was you, Dr. Fletcher, that maybe said
    something about prescription first image. I want to know
    whether the prescription first image has a basis in fact, or
    whether it's just something that is said. And then also there
    is an impression that the VA has been successful in
    overprescribing opioids and I'd like to know the facts about
    that belief.
        And so those are the things I want to follow up and I'll
    ask my staff and you to have those conversations. I thank you.
    I knew if I did this, that Senator Blumenthal would think he
    was entitled as well [laughter].
        Senator Blumenthal. Just a really quick question which I
    neglected to ask before, Ms. Hundrup. The Wall Street Journal
    article says, ``Only 15 percent of veterans diagnosed with
    depression, PTSD, or anxiety are offered psychotherapy in lieu
    of medication according to a 2019 report by the Government
    Accountability Office.'' Is that percentage still accurate?
        Ms. Hundrup. Unfortunately, I don't have updated data on
    where we are with that, which is to my earlier point, as I
    think it's worth following up with VA since publicly available
    data on that are not out there.
        Senator Blumenthal. If you could follow up, I would
    appreciate it. But you know of no reason that that number has
    changed?
        Ms. Hundrup. I don't know that that would necessarily
    change, no.
        Senator Blumenthal. Thank you. Thanks Mr. Chairman.
        Chairman Moran. Senator Blumenthal, thank you. Thank you
    all very much for your testimony. Appreciate your commitment to
    this cause. And with that you are dismissed, quickly. And I
    welcome our second panel, quickly.
        Testifying today on the second panel is Dr. Ilse Wiechers,
    Deputy Director, Office of Mental Health, U.S. Department of
    Veterans Affairs, and she is accompanied by Tom Emmendorfer,
    Executive Director of Pharmacy Benefits Management, U.S.
    Department of Veterans Affairs.
        Thank you both very much for your presence and Dr.
    Wiechers, you are recognized for your testimony.

                                PANEL II

                                  ----------

        STATEMENT OF ILSE WIECHERS, MD, MPP, MHS, ACTING DEPUTY
    ASSISTANT UNDER SECRETARY FOR HEALTH FOR PATIENT CARE SERVICES,
      VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
    AFFAIRS ACCOMPANIED BY THOMAS EMMENDORFER, PHARM.D., EXECUTIVE
         DIRECTOR, PHARMACY BENEFITS MANAGEMENT (PBM) SERVICES

        Dr. Wiechers. Good afternoon, Chairman Moran, Ranking
    Member Blumenthal, and Members of the Committee. I am Dr. Ilse
    Wiechers, Acting Deputy Assistant Under Secretary for Health
    for Patient Care Services at the Veterans Health
    Administration. I'm joined today by Dr. Tom Emmendorfer,
    Executive Director of Pharmacy Benefits Management Services.
    Thank you for the opportunity to speak with you about how VA
    ensures safe, effective, and veteran-centered medication
    management, and to share our views on the three bills under
    consideration today.
        As a practicing VA psychiatrist for over 15 years now, I'm
    aware of the complexity of medication management for our
    Nation's veterans. Many veterans live with multiple chronic
    conditions like PTSD, chronic pain, and substance use
    disorders, which often require complex treatment plans.
        While multiple medications may be necessary, we recognize
    the risks of polypharmacy and are committed to reducing
    unnecessary or unsafe prescribing. VA has built a strong
    foundation for safe medication use through our national
    formulary and evidence-based prescribing practices. We use real
    world data, not market incentives to guide decisions.
        One example is our use of pharmacogenomics, which helps
    tailor medications to a veteran's genetic profile. This
    approach is improving outcomes in reducing adverse drug events.
    We have also made significant progress in opioid safety. Since
    launching our Opioid Safety Initiative in 2013, we have reduced
    opioid prescribing by 68 percent and cut concurrent opioid and
    benzodiazepine prescribing by 90 percent.
        Tools like the STORM--Stratification Tool for Opioid Risk
    Mitigation--dashboard help us identify veterans at high risk
    and coordinate care to prevent overdoses. VA has continued to
    make it easier for veterans to obtain the life-saving
    medication Naloxone. We distribute Naloxone widely: over 1.8
    million prescriptions to date, as well as providing overdose
    education to veterans and the caregivers. Naloxone is available
    free of charge to enrolled veterans in various forms. It can be
    accessed through VA pharmacies, mobile units, community events,
    and even by messaging care teams through the VA app or website.
        In addition, we are continuing to advance the Psychotropic
    Drug Safety Initiative or PDSI, a decade long quality
    improvement effort focused on safer prescribing of medications
    for mental health conditions. PDSI has helped reduce
    inappropriate use of benzodiazepines and anti-psychotics,
    especially among veterans with PTSD and substance use disorder.
        Despite these successful initiatives, we acknowledge there
    is more work to be done. That's why VA recently issued a
    request for information to identify innovative software
    solutions that can support individualized medication review and
    de-prescribing. This is part of our broader effort to address
    polypharmacy and ensure that every medication has a clear
    evidence-based purpose.
        Now, I will turn briefly to the legislation before the
    Committee noting that our full views are detailed in my written
    statement. VA supports the End Veterans Overdose Act subject to
    amendments. We agree with the goal of expanding access to
    Naloxone, but we are concerned about removing prescription
    requirements entirely. Prescriptions help ensure accountability
    and stewardship of government resources. That said, we've
    already taken steps to make Naloxone widely accessible,
    including permitting the use of standing orders or
    prescriptions for any veterans at risk of overdose. We remain
    committed to increasing the availability of overdose reversal
    medications like Naloxone to save lives.
        VA supports the Protecting Veteran Access to Telemedicine
    Services Act also with amendments. VA greatly appreciates the
    Committee's engagement and attention on this issue, as well as
    the willingness to discuss technical issues VA has identified
    with the bill. VA recommends amendments to ensure this new
    authority effectively addresses the two significant barriers VA
    has experienced and ensuring providers can furnish care,
    including prescribing controlled substances to veterans through
    telehealth, restrictions with the CSA--Controlled Substances
    Act--and within the CSA, and variability in state law
    prescribing requirements. A clear federal framework would help
    us deliver consistent care to veterans wherever they live.
        VA has concerns with the Written Informed Consent Act.
    While we support the goal of informed decision-making,
    requiring signature consent for a broad range of medications
    could lead to unintended consequences, such as a delay in
    access to care and increased stigma to mental health treatment
    that might deter veterans from accepting needed care. Our
    current policies already require completion of informed consent
    discussions and documentation in the electronic health record
    that is tailored to clinical risk.
        In closing, VA is committed to ensuring safe, effective,
    and veteran-centered medication management that helps improve
    the lives of our Nation's heroes. We're proud of the progress
    we've made, but we know there's more to do. We'll continue to
    refine our practices, expand access to innovative treatments,
    and put veterans first in everything we do.
        Thank you for your time and your continued support. We look
    forward to your questions.

        [The prepared statement of Dr. Wiechers appears on pages
    71-84 of the Appendix.]

        Chairman Moran. Thank you. Let me turn to Senator
    Blumenthal. We need to ask questions in light of the scheduler
    vote----
        Senator King. Mr. Chairman, I have to leave unfortunately
    for another meeting, but I want to compliment the department
    for the dramatic reduction of opioids prescribing. I think
    that's----
        Senator Blumenthal. I'm happy to yield to you, Senator
    King, if you want to ask.
        Senator King. No, that's all I wanted to comment. Thank you
    very much.
        Senator Blumenthal. Thank you. Let me ask Dr. Wiechers, I
    noticed that you are on the faculty at Yale, so you're familiar
    with our VA facility in Connecticut. And as you know, Secretary
    Collins has repeatedly stated that access to VA care has not
    been affected by staffing reductions. But the VA's own data, in
    my view, tells a different story.
        Wait times for new mental health appointments have
    increased sharply since January. In my home State, Connecticut,
    for example, the most recent data shows the current wait time
    for a new patient mental health appointment at the Orange VA
    Clinic in Connecticut, an outpatient facility specializing in
    mental health, is 208 days, nearly six months.
        Let me ask you, given these kinds of wait times, how does
    the VA plan to prevent overreliance on medication when veterans
    can't access these timely appointments and what steps are
    necessary to address this issue?
        Dr. Wiechers. Thank you for the question, Senator. I agree
    that access to timely mental health care is one of our top
    priorities. We continue to actively be recruiting and hiring
    mental health providers across the system. We are working to
    address the access challenges that you have noted. And it does
    vary from facility to facility.
        So, acknowledge that there are differences based on
    location, but we're doing work now to identify areas of ways we
    can improve our efficiencies so that our workflow and our
    ability to see patients and get them access quickly----
        Senator Blumenthal. You don't dispute the data showing
    those wait times?
        Dr. Wiechers. I acknowledge that there are wait times at
    some facilities that are beyond what our expectation and
    standard----
        Senator Blumenthal. I've also heard credible reports that
    some VA psychologists are being instructed to cap the number of
    sessions they can offer patients, even when in their
    professional judgments additional sessions are clinically
    necessary. I don't know how you justify that kind of practice.
        Dr. Wiechers. There is no cap on the number of
    psychotherapy appointments that a veteran can have. There's no
    national policy. That wouldn't be----
        Senator Blumenthal. So, you dispute that there are any caps
    that psychologists have been instructed to impose?
        Dr. Wiechers. We support the implementation of evidence-
    based psychotherapies. Many of those evidence-based
    psychotherapies are a course of treatment that occurs sometimes
    8 to 12 treatments, sometimes 12 to 20 treatments. The
    individual provider working with that veteran is the one who is
    determining that course of treatment and when it's appropriate
    to complete that work. But there is no cap set. There is no
    policy indicating a cap in the number of treatments available.
    It is a decision----
        Senator Blumenthal. So, the answer to my question is yes,
    you dispute that any instructions have been provided that there
    should be a cap imposed by psychologists?
        Dr. Wiechers. There's no national policy instructing to
    have a cap in----
        Senator Blumenthal. Well, were psychologist ever told they
    have to impose caps?
        Dr. Wiechers. I can't speak to what every individual
    psychotherapist across the country has been told by someone,
    but I can say that we don't have a policy that states that and
    that I wouldn't support it.
        Senator Blumenthal. Well, I would just tell you, I'm going
    to cut through the verbiage in the interest of time. We've been
    told by multiple sources that caps have been imposed on
    psychologists. So, if you're not hearing it, I think the VA
    leadership needs to do a better job of listening to the
    psychologists and others who are actually providing care. In
    the interest of time, I'm going to yield.
        Chairman Moran. Thank you, Senator Blumenthal. I'd suggest
    Dr. Wiechers, that you take Senator Blumenthal's commentary to
    heart and actually explore within the VA whether there's a
    policy or a written national policy, whether there's a practice
    that is limiting the ability for the treatment that the
    provider believes is necessary in some fashion. That makes
    sense to you?
        Dr. Wiechers. That does make sense to me. And Senator
    Blumenthal, I'd like to continue the conversation with you and
    your staff further so I can make sure I understand what you're
    hearing better.
        Senator Blumenthal. I would welcome that opportunity. And I
    just want to say this is not personal to you. I recognize you
    are not in charge of the VA healthcare system and both of you
    have long histories of service in the VA, which I appreciate. I
    thank you for your service and I know you have ultimately the
    goal of serving our veterans. And I want to be helpful to you
    in serving that goal.
        Dr. Wiechers. Thank you, sir.
        Chairman Moran. Dr. Emmendorfer, let me ask you maybe a
    question. I was able to attend the launch of the PHASER pilot
    program in 2019, I think it was. It was at the National Press
    Club, with Secretary Wilkie, and which introduced the idea of
    using a patient's DNA to prevent medication side effects and
    reduce the use of ineffective medications. I understand that
    program is successful. I'd like to have that confirmed and is
    now available in nearly every VA medical center.
        How is the VA training providers to use this? How is the VA
    integrating the results into the VA's electronic health
    records? Tell me about this program and whether it matters.
        Dr. Emmendorfer. Thank you, Senator, and I am happy to
    report that it is a success. As a matter of fact, earlier this
    week, we just learned that one more VA medical facility has
    implemented the pharmacogenomics program, and we expect the
    remaining seven VA medical facilities to implement
    pharmacogenomic testing by the end of the calendar year 2026.
        For the training, we have over 1,000 VA providers that have
    participated in the continuing education program on
    pharmacogenomics. And then we also have our Academic Detailing
    Services program, which has especially trained pharmacists that
    have conducted outreach with, I believe, around 7,000 providers
    to help promote pharmacogenomics. It's well integrated into our
    electronic health record, so it's part of the clinical decision
    support system.
        There's about 100 medications that are evidence-based with
    the pharmacogenomic testing. And so at the time of prescribing,
    the computer system, our electronic health record, will flag an
    alert on the pharmacogenomic testing, and that helps guide
    appropriate medication selection and therapy. So, we're very
    proud of the program.
        Chairman Moran. Tell me, as the layman on so many things,
    what does the DNA tell us? What does it indicate? What is it
    capable of indicating to avoid in the treatment of a patient?
        Dr. Emmendorfer. Yes, so it's helpful with the DNA because
    it will tell us as healthcare providers how we would expect
    that medication to behave when it's in your system and being
    metabolized by your body. And that information really helps us
    make that upfront selection of the medication. So, in the past
    where you may have to do some trials and then if the patient's
    trial on the medication wasn't optimal, and then you may have
    to taper and stop that medication and then try another
    medication. The pharmacogenomics takes that guesswork out
    upfront.
        Chairman Moran. Thank you. Senator Blumenthal, anything you
    want to cover before I----
        Senator Blumenthal. I would like to submit some additional
    questions for the record.
        Chairman Moran. You also indicated you had something to
    submit for the record, I think.
        Senator Blumenthal. I'm going to submit my statement and
    the letter that I wrote to Secretary Collins.
        Chairman Moran. Without objection.
        Chairman Moran. I'm sorry to cut this hearing short.
    Senator Blumenthal and I probably have access to more
    conversations with you, and I see you nodding your heads, and
    then we'll follow up with our staff to make sure that anything
    that we may have missed because of the vote is covered.
        Chairman Moran. With no other questions, I want to once
    again, thank you for your testimony. I thank our Committee
    members for their participation and for our audience. Each
    member has five legislative days in which to submit statements
    or questions for the record.
        Any Senator who would like to submit a question for the
    record to today's witnesses should do so in a timely manner.
    And likewise, I ask our witnesses to respond to any questions
    that they receive from this effort following today's hearing in
    a timely manner as well.
        And with that, our Committee hearing is adjourned.
        [Whereupon, at 5:18 p.m., the hearing was adjourned.]

                                A P P E N D I X

                               Opening Statement

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                              Prepared Statements

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                           Submission for the Record

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                            Questions for the Record

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 [all]