[Senate Hearing 119-246]
[From the U.S. Government Publishing Office]
S. Hrg. 119-246
MEDICATION MANAGEMENT IN VA HEALTHCARE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINETEENTH CONGRESS
FIRST SESSION
__________
DECEMBER 3, 2025
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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
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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
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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
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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
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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
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Prepared Statements
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Submission for the Record
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Questions for the Record
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Statements for the Record
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