CONGRESSIONAL TESTIMONY OF HEARING ON
THE VETERANS'S AFFAIRS DEPARTMENT MENTAL HEALTH CARE EFFORTS
BY PANEL OF EXPERTS FROM THE
U.S. DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
U.S. SENATE COMMITTEE ON VETERANS AFFAIRS
NOVEMBER 30, 2011

November 30, 2011

MURRAY:
Good morning! We will begin this hearing today on examining the barriers that our veterans our facing in seeking mental health care. We have a number of senators who are going to be joining us today. I am getting started a minute or two early. My Ranking Member, Senator Burr, will be here in just a few minutes. We are going to have votes in an hour. We have got two panels today and a lot going on, so we are going to go ahead and get started.
Today's hearing builds upon our July hearing on the same subject. At that hearing, the committee heard about two service members who even after attempting to take their own lives had their appointments postponed and difficulties getting through red tape in order to access the care that they needed. I know that, like me, many on this committee were angered and frustrated by their stories, and I am glad that today, we are going to have the opportunity to both get more information and answers on why these delays persist.
Today, we are going to be hearing from providers about the challenges that they face getting patients into care, including from Dr. Michelle Washington, who has been brave enough to come forward to give the true sense of the daily frontline barriers at our VA facilities. We will also hear about the critical importance of access to the right type of care delivered on time by qualified mental health professionals.
At our hearing in July, I requested that the VA survey their frontline mental health professionals about whether they have sufficient resources to get veterans into treatment. The results that came back to me shortly after that were not good. Of the VA providers that were surveyed, nearly 40 percent said that they cannot schedule an appointment in their own clinic within the VA mandated 14-day window, 70 percent said that they did not have adequate staff or space to meet the mental health care needs of the veterans that they serve, and 46 percent said the lack of off-hour appointments prevented veterans from accessing care.
The survey not only showed that our veterans are being forced to wait for care; it also captured the tremendous frustrations of those who are tasked with healing our veterans. That hearing also identified why discrepancies between facilities in different parts of the country including the difference between access in urban and rural areas, and it provided a glimpse at a VA system that 10 years into war is still not fully equipped for the influx of veterans that are seeking mental health care. The VA can and must do much better, and I am pleased to say that since I asked for the survey, they have taken some steps in the right direction. They have worked to hire additional mental health staff to fill vacancies; they have increased their staffing levels at the Veterans Crisis Line and Homeless Call Center; and they have made (inaudible) directors accountable for more standards of access to care. These are positive steps, but there is much more to be done as we will undoubtedly see today.
You know, just yesterday, before this hearing, I looked through the most recent statistics on PTSD that VA had provided my office, and they really showed what all of us know. This problem is not going anywhere. As thousands of veterans today return from Iraq and Afghanistan, you can see the number of PTSD appointments steadily rise each quarter. With another announcement yesterday of 33,000 troops coming home by the end of next year from Afghanistan, the demand for care will only swell. This should not come as a shock to the VA and it should not cause the waiting lines for care to grow, especially at a time when we are seeing record suicides among our veterans. We need to meet the veterans' desire for care with the immediate assurance that it will be provided and provided quickly. We can't afford to leave them discouraged, that they can't find an appointment. We can't leave them frustrated. We cannot let them down. We need to fix this now.
The VA has had a decade to prepare. Now is the time for action and for effective leadership. I look forward to hearing from all of our witnesses today and I hope that this hearing is another step to increased accountability of our efforts to provide timely mental health care.
I do want to mention that Lloyd and Andrea Sawyer who testified at our July hearing are here today, and I want to thank them for all they have done to help us understand this challenge. Even after coming before this committee, they are continuing to have trouble navigating the system.
I understand that Dr. Schohn has been personally working to help them get pass some of the barriers and I want to thank you, Dr. Schohn, for your help on this, but I think that they continue to highlight for all of us the continuing issues with the VA mental health care and a challenge that this committee is going to continue to pursue and to follow, and make sure that we are taking care of the mental health needs of our soldiers who are returning home and who have been home for some amount of time.
We have two panels this morning. We are going to have a vote at 11 o'clock which will interrupt the committee and a number of challenges to get through, so I am going to turn it over to my Ranking Member, as soon as he is ready for his opening statement. I would ask any other committee members to try and keep their statements short. But before I turn it over to my Ranking Member, I understand that it is his birthday today. Senator Burr.
(LAUGHTER)
Welcome. I am glad you are spending it with all of us. I am sure you have other ideas, but we are glad you are here with us today. So, Senator Burr, if you want to go into your opening statement.

BURR:
Thank you, Chairman Murray. It is good to have you back. I wish the outcome of the Supercommittee has been different, but I know that on both sides, the members committed a lot of hours to try to complete their process and it shows how daunting the task is. I thank you for the kind birthday remarks, but I have now reached the point where I enjoy this versus the alternative, but I'd just as soon might count the numbers as they add up.
I want to thank you for holding this important hearing today to examine the barriers that veteran face in receiving the mental health services from the VA. Welcome, all of our witnesses. It is insights from people like you that help this committee truly do our oversight duties.
As you know, this hearing is a follow-up to the July 14th mental health hearing where serious issues were raised by two of our witnesses, Andrea Sawyer and Daniel Williams, about problems assessing appropriate VA mental health care. VA told Daniel and Andrea and husband, Lloyd, that they would have to wait months to see a provider. Then when Lloyd was finally able to get treatment from the VA, we were told there was no coordination of care among his providers.
Unfortunately, their stories are not unique. I continue to hear from veterans about the problems they run into trying to get mental health care.
As the chairman mentioned, after the last mental health care hearing, she requested the VA conduct a survey of the mental health care providers to try to get to the root of the problem. The results of the survey confirmed what we already knew. Some veterans have a very difficult time in getting an appointment scheduled.
This is simply unacceptable. The men and women of the Armed Forces suffering from the invisible wounds of war deserve better. So, today, we'll again look at what is causing these problems, why they have not been fixed, and more importantly, when veterans will be able to get the appropriate and timely care that they need and deserve.
At a hearing in May, Dr. Zeiss indicated that the VA does have the resources it needs to meet the mental health care needs of our veterans. In fact, in fiscal year 2011, Congress appropriated $5.7 billion for mental health care services, a 25 percent increase over the previous year's budget and a 136 percent increase since 2006. What has VA been doing with the resources Congress has provided over the years?
Also, as VA's testimony points out, there has been a 47.8 percent increase in mental health staffing since 2006. Yet, in a VA Inspector General report, published earlier this year, the IG reported that only 16 percent of the sites they visited met their staffing requirements for mental health care.
Why haven't these staffing increases been effective? To top it all, VA's response to the survey was to put together an Action Plan to develop a plan to address the issues raised by VA clinicians. What is the plan of action that VA outlined? Focus groups, audits, and publishing yet more policy guidelines. The question is how does this help veterans in need of mental health services today? How does this action plan help veterans waiting to get follow-up treatment?
As Dr. Hoge will testify today, 70 to 80 percent of the patients diagnosed with PTSD can get better. Let me stress that -- 70 to 80 percent can get better if the patients are able to get care and continue with the treatment over the long-term. At VA, however, veterans may get their initial visit, but many are not able to get the ongoing treatments that they need.
What's really troubling is that the problems we'll hear about today are not different from what we discussed at the July 14th hearing. I had expected that four and a half months would have been enough time for VA to come up with solutions but it appears that is not the case.
As we'll hear today, aggressive steps must be taken and they must be taken now. And, if VA is not able to provide the appropriate care to veterans in a timely fashion, VA should consider sending veterans to someone who can help them promptly using their fee-basis authority.
Madam Chairman, I am confident today that this is not one you're not going to let get away from us. If VA believes that this is going to be a once a year topic of a hearing, let me assure you, it's not going to be.
The fact that we're four and a half months down the road, and the response is to do focus groups and to put out new guidelines, to me is unconscionable. Given the fact that every medical professional that has come before us says the most important thing is to get these service members into treatment, keep them in treatment for as long as it takes to take that disability and to drive it as close to zero as we can possible get it. My hope is that the Committee will recognize the fact that we have funded, and now it's a process of execution that we have got to seriously look at. I pledge to the Chairman to work side by side with her on this. I thank the Chairman.

MURRAY:
Thank you very much. I appreciate it. Senator Akaka.

AKAKA:
Thank you very much, Madam Chairman. I appreciate you and Senator Burr holding this very important hearing. I want to add my welcome to the witnesses and thank you for all what you have been doing for us, our veterans. Through the efforts of the VA and its many stakeholders, our country is doing a better job for caring for veterans. While we continue to improve educational benefits such as GI Bill and Job Training, and opportunities through legislations spearheaded by the Chairman, we must keep working to improve the mental health provided to our veterans.
Over the last decade, the men and women of our Armed Forces have greatly served in two wars. Now, it is our turn to look after them, to give them access to the care they need. Many of our men and women currently in uniform will be returning to the civilian world and seeking VA services in the coming years.
Hopefully, the stigma which once discouraged veterans in need from seeking mental health treatment will continue to decrease and they will be welcomed, increase in demand for these services. I know that Secretary's team has made strides and will continue to do so, but I have concerns as we all do, and as we look to the future and consider the capacity and projected requirements for mental health care, I think that this hearing is another vital step as we work to improve the services of veterans have earned and deserve.
I look forward to hearing our witnesses' testimony and how we are doing and how we might improve in meeting the needs of veterans and their families, and we will continue to look forward to working with our Chairman and this committee on this.
Thank you very much, Madam Chairman.

MURRAY:
Thank you very much. Senator Tester.

TESTER:
Thank you, Madam Chair. I want to thank you and Senator Burr for convening this hearing today. I want to thank the witnesses in this panel and the next panel. It is going to be a -- you know, the work we did before the Thanksgiving break was employment opportunities for veterans. I know that the Chairman is very proud and I am very proud of it, and this committee should be very proud of that work. Working together to get that done is important. This is another one of those issues that is going to require bipartisan effort to move forward because we have a steady flow of returning veterans to this country, the signature injury from those folks in Iraq and Afghanistan that deals with mental health. They need care and there are no ifs, ands, or buts about it. I can tell you that care can only happen if we work together as Democrats and Republicans, and policymakers and with the VA.
I think that the VA has made some strides, but not enough. They have hired a lot of folks in the mental health issue -- in the mental health arena, but because of the number of folks we have got coming back, because of the stigma I believe that is attached to issues that revolve around mental health, it is critically important that we work together.
If Senator Burr is correct -- if the response to the folks who come back with unseen injuries is to develop focus groups and guidelines, that ain't good enough. But if the response is to get more mental health professionals in the field, if the response is looking to the private sector when necessary to be able to contract out some of these services, if the response is to make sure that we have the VA facilities available to those veterans, if the response is making sure that we have vet centers around this country who were vets can talk to vets, then we're moving into right direction.
We have done a lot of good work on this issue as a committee. It continues to be a huge issue. It continues to be a big concern because I think it is most if you got docs up here and -- and a civilian, I can tell you that from my perspective if we can get treatment early we can help save a ton of money and improve quality of life for a ton of folks that deserve every benefit that we can give them because they put their lives on hold and their lives on the line for this country.
So, with that, I look forward to this hearing. I look forward to further hearings after this. Ultimately, in the end, I think that if we work together with the VA and amongst ourselves we can do a lot of good work and satisfy some of the needs that are out there.
Thank you, Madam Chair.

MURRAY:
Thank you very much. With that, we would -- we'd like to welcome our first panel. I thank all of you fro being here and for your testimony. We're gonna start with Dr. Michelle Washington who is representing the American Federation of Government Employees and then we will hear from Retired U.S. Army Colonel, Dr. Charles Hoge. Next, we will hear from Dr. Barbara Van Dahlen founder and president of Give an Hour, and finally, we will hear from Mr. John Roberts who is the executive vice president of Mental Health and Warrior Engagement with the Wounded Warrior Project.
So, we will start with Dr. Michelle Washington and just before she proceeds to her testimony I do wanna say how important it is for I, from this committee to hear from providers who are dealing with this issue firsthand. If we can't hear from their accounts, none of us is going to know what we need to do to improve the health for our veterans, and I expect that as always our witnesses will be treated appropriately. No one witness who comes before this committee or one of hearings should be treated unfairly just because they did the right thing in bringing us the issues and respond into this committee in telling us the truth so that we can make sound policy decisions.
So, Dr. Washington, we'll begin with you.
(AUDIO GAP)

WASHINGTON:
... and members of the committee. Thank you for the opportunity to testify before you on behalf of the AFGE. As a coordinator of PTSD services and evidence-based psychotherapy at Wilmington VA, my role is to provide specialty care to veterans with severe and complex PTSD, as well as new onset.
Due to chronic -- due to chronic short staffing at my facility and the inability to manage my patient's appointment based on their individual need, I am frequently frustrated in my ability to provide vet care. Why is working at -- by the way I worked at the VA, for me, it is very personal. My thought there was a Korean war veteran as well my uncle. My brothers are veterans, and my niece and her husband are both veterans and my nephew just recently returned from Iraq.
Timely treatment is critical for evidence-based psychotherapy including two methods I frequently use to treat PTSD. First, with prolonged exposures, the patient re-experiences rather avoid the trauma. The second approach Cognitive Processing Therapy treats PTSD as a disorder or non-recovery where we address erroneous belief about the traumatic events so that the patient can better process the trauma memory.
These treatments have been demonstrated to be highly effective in treating trauma to a limited number of sessions. But patients must be seen weekly during this treatment period is very difficult at my facility. When I determined that the patient is suitable for this type of treatment and motivated to receive it, I ask the scheduling clerks to book out 10 to 12 weekly appointments at regular time. Too often, I am told that the patient will have to wait as long six weeks for the first appointment. But after waiting that long, many patients lose the motivation for treatment or their PTSD worsens while they're waiting.
So, sometimes I find it better not to start evidence-based psychotherapy because the harm of waiting outweighs the benefit of a treatment. Also, because scheduling clerks are under great pressure to bring new veterans in within 14 days, they make one of my PTSD patient's regular appointments for a new patient appointment which hurts the effectiveness of my patient's treatment.
It is also extremely difficult to make timely referrals for ongoing mental health services. So, these patients stay on my caseload even though they do not specialty treatment any longer, this in turn further delays specialty treatment for veterans who could benefit from it. Even though the Uniform Mental Health Service Agreement and the PTSD Handbook clearly state that PTSD treatment should be reserved for veterans with -- with severe PTSD and complex cases and new onset, I am frequently assigned to patients with only minor forms of PTSD or only a history of PTSD with no current symptoms, and I have no means of referring them back to General Mental Health because they are booked solid. So, those patients stay with me indefinitely.
As long as scheduling continues to be driven by clerk pressured by management to make the numbers look good, and as long as mental health providers have little or no say about where and when to serve their patients, this will keep happening. The patients are also harmed by the pervasive shortage of primary care providers at my facility. Even though assignments of primary care provider is a pre- requisite to treatment to mental -- to a mental health provider and the DSM clearly states that you should rule out a medical condition first. Some of patients end up with me or in General Mental Health when they actually need medical treatment.
For example, Graves disease, a hyperthyroid condition sometimes mistaken for ADHD. Similarly, patients with dementia with Lewy body that include a symptom of visual hallucinations, HIV medication can cause a brief period of psychosis at the onset. When these patients are referred for mental health treatment without a comprehensive primary care assessment, the mental health provider is forced to carry out treatment without critical information. Also, the patient could then end up worse because his medical condition is not treated or he may receive antipsychotic medication he does not need.
The Wilmington VA has not filled a vacant primary care physician designated for OIF/OEF/OND veteran since March. As a result OIF/OEF/OND staff cannot get primary care appointments for these patients and no one is doing polytrauma consults, War Related Injury referrals or monthly treatment review of polytrauma veterans. When veterans cannot get appointments with the primary care provider, they sometimes end up in the ER to get their medication which is not the best way to treat them or the best use of resources.
The VA would also make better use of its resources by timely treatment. Research shows that patients get better -- more effectively get better at the outset with fewer mental health or medical services in the long run when they receive treatment early.
Another barrier to comprehensive care is the absence of a full PTSD treatment team. I developed and proposed a PTSD Clinical Team but due to lack of staff among other requirements, the program has not been implemented. Instead management creates the appearance of a team by counting staff located at CBOC.
What else? What I think would need help -- the medical conditions or mental health conditions. First, it was like be true that treatment teams that include regular meetings with mental health, medical and nursing. Panel sizes this for mental health providers which are long overdue, and we have been waiting several years for VA Central Office to establish parameters for maximum number of patients for each mental health provider to carry.
Finally, as I noted, mental health providers must have the say in when their patients need to be seen and to ensure that our patients receive integrated care, so all their medical and mental conditions are treated as a whole. That -- that good care, that good resource allocation and that's the way to get the most care for veterans in which is our goal every day.
Thank you very much.

MURRAY:
Dr. Hoge?

HOGE:
Good morning, Chairman Murray, Ranking Member Burr, and members of the committee, thank you for the honor of allowing me to be here today talk a with you about access which is a very critical issue and I kind of in my testimony -- my written testimony I sort of broaden the discussion a little bit to look at a little bit beyond appointment access and to consider other barriers to care and barriers to recovery because it's not just about appointments. We know that the majority of veterans and service members who need mental health care are -- do not come in initially or, you know, upwards of half come in to see us and -- and another half do not and then of those who come in a large percentage drop out of care after they -- they touch mental health care one or two times and then they drop out of care.
And there are varieties of factors. There are -- there are a variety of considerations and why this occurs. Some of which has to do with appointment availability or follow up availability. Sometimes, it has to do with negative perceptions of mental health care or -- or interactions within the, you know, within the -- at the first session in which the veteran felt as if their -- their needs were not met, and they leave care and it -- we've been -- I've been involved in studying stigma and barriers to care since the beginning of the war and one of the things that we learned more recently is that there are negative perceptions to mental health care that actually drive the utilization of services or drive the willingness to come in to see -- to see in the mental health clinic.
And that those -- some of those perceptions are actually stronger than some of the traditional stigma concerns that we've had from -- for a long time. Those are things that perceptions that mental health care doesn't work or that it's not gonna be effective for me either, but it's the last resort for instance are some of the things that veterans voiced.
In terms of -- I wanna echo a few of the comments that were made. Their treatment is 70 to 80 percent effective for -- for combat- related PTSD. If the veteran comes in to get care and receives sufficient number of sessions for recovery to occur and clearly early treatment, as Mr. Tester mentioned, is a very important factor in that. I also want to echo the comments that Dr. Washington mentioned about the importance of -- of integration with primary care because PTSD is really not solely an emotional or psychological condition. I really view it as a physical condition that affect -- has generalized health effect -- that affects the endocrine system. It affects the autonomic nervous system the part of the nervous system that controls automatic functions like heart rate, breathing, and so forth.
And so, a lot of veterans where there's a number of studies there showing that -- that veterans with PTSD have significantly higher rates of physical health problems in almost all categories of physical health problems compared with veterans without PTSD. And so, the coordination of care in primary care and having access both to mental health care within primary care and having good coordination of services with the primary care team is -- is really critical in the treatment of veterans.
Some of the other things that I've mentioned in my testimony have to do with destigmatizing PTSD -- combat-related PTSD by considering it from the occupational perspective and not always from the medical perspective and that is to understand how some of the -- some of the reactions that service members and veterans have after coming back from a combat deployment are in fact very adaptive for the combat environment.
So, many of -- many of the reactions that individuals have that we label symptoms were in fact beneficial and adaptive in the combat environment and talking about this way can sometimes help to reassure veterans that, you know, that they are not crazy and that -- that, you know, their -- their condition, their reactions have a physiological bases. There are not something in their head and that -- and that, you know, that -- that medical system is there to do something to help them with those physiological reactions.
The other thing that I mentioned in my testimony has to do with the importance of peer-to-peer support. I think that there is a real critical role because a lot of veterans are very reluctant to speak with civilians or including vet civilian mental health professionals who haven't been deployed and sometimes they need that veteran peer- to-peer connection in order to kind of encourage them to come into -- to -- to get the help that they need.
And finally, I just wanna put in a plug for research. There are a number of areas that where we could improve the research particularly in primary care interventions particularly in understanding more about why veterans -- why there is still a reluctance to seek care and --and -- and drop out of care, and -- and what specific interventions we might be able to do to improve retention and treatment.
Thank you very much.

MURRAY:
Thank you very much.
Dr. Van Dahlen?

VAN DAHLEN:
Thank you. Good morning. Chairman Murray, Ranking Member Burr and members of the committee, thank you for this opportunity to provide testimony regarding veterans' access to mental care through the Department of Veterans Affairs. It's an honor to appear before the committee, and I'm proud to offer my assistance to those who serve our country.
As a founder and president of Give an Hour, a national nonprofit organization providing free mental health services to our returning troops, their families and their communities, I'm well aware of the mental health issues that now confront our military and veterans community. As licensed clinical psychologist, who has practiced for over 20 years, I'm certain of the importance of ensuring that those in need are able to access effective care, care that fits their needs, care that fits their schedules, care that guarantees the opportunity to develop a relationship with the provider that they can trust. As a daughter of a World War II veteran, I share your commitment to ensure that all veterans in need of mental health services receive the care they deserve.
The Department of Veterans Affairs is the principal organization in our nation's effort to ensure that all of those who wore the uniform receive the mental health care they require but no organization, agency or department can provide all of the education, support and mental health treatment that every veteran and family needs. Indeed, I would argue that it is more helpful to those who served in their families to see numerous endeavors coordinated on their behalf so that they understand that our country, not just our government, supports them and is committed to their health and well- being.
Give an Hour is one example of a community-based effort designed to complement the work of a VA. We're honored to do our part. The idea behind Give an Hour is really quite simple, ask civilian mental health professionals to provide an hour each week of mental health support or treatment to any OIF/OEF service member, veteran or family member in need, free of charge.
Give an Hour provides mental health care and support to those who are active duty, members of the Guard, Reservists, veterans and their families, and we define family members as anyone who loves someone who has served since 9/11.
Our clients find their way to us through a number of channels. Many find us on the web and contact our providers directly. We have excellent relationships with other nonprofits and VSOs, all of which make regular use of our services. Further, we have very good relationship within the Department of Defense and often receive referrals from our colleagues there. And, although we do not have an official relationship with the Department of Veterans Affairs, we received many referrals from the VA.
Our mental health professionals remain in our network for at least one year. They are required to licensed, in good standing and to carry their own malpractice insurance. We've developed excellent relationship with all the major mental health associations. Our network includes psychologists, psychiatrists, social workers, psychiatric nurses, pastoral counselors, licensed professional counselors, substance abuse counselors and marriage and family therapists.
Give an Hour has over 6,000 professionals in our network. When every state and territory, our providers offer face-to-face direct care, they provide phone support to those who are unable to attend a session in person, and this month we began offering telehealth capability first in Virginia and North Carolina and then to the rest of our network in 2012.
Give an Hour providers offer a wide range of options with respect to available appointment, including evenings, weekends and home visits. In addition, they bring a wealth of treatment options and areas of expertise to their work. We know that one size does not fit all with respect to this population or any. Flexibility and treatment based on individual needs are critical elements if we are to successfully address the mental health needs of veterans and their families. There is no limit to the number of sessions clients receive and all of our services are free.
Give an Hour providers have reported over 42,000 hours of care, and we have reason to believe that many more hours have actually been given. Regardless, we are pleased that we can count $4.2 million in mental health services provided to those who have served our country.
Our capacity for providing cares has not yet been reached. We concurrently offer 6,000 hours of care each week to provide support, education, information and assistance. Our goal is to enlist 40,000 professionals to assist in these efforts so that someday we hope to offer 40,000 hours which translates to $4 million of mental health care per week.
Give an Hour is a virtual organization because we are not a bricks and mortar operation we have minimal overhead and are able to provide our services efficiently and inexpensively. We are current able to provide one hour of care for a $17.88. Give an Hour cannot provide all of the services that our veterans and their families need but neither can the VA. Working together, we have a much greater likelihood of ensuring that no veteran in need suffers or falls to the cracks of a poorly coordinated and overly burden system.
Thank you.

MURRAY:
Thank you very much.
Mr. Roberts?

ROBERTS:
Thank you Chairman Murray, Ranking Member Burr and members of the committee. Thank you for allowing me the time to come before you today on this important issue and provide testimony.
As the executive vice president of the Wounded Warrior Project, I interact daily with wounded warriors and not only am I the executive of WWP, former VA supervisor, but I'm also a wounded warrior myself that has struggled with PTSD since my injuries in 1992. Every -- every day I come across men and women who served this country -- their stories echo the story that I once told. They are very similar in nature. The stories have not changed from one generation to another.
Earlier this month, Wounded Warrior Project sent out a survey to our alumni who are warriors we served. We got 600 or I'm sorry, 900 responses back. Out of those 900, 60 percent of those individuals had attempted to obtain treatment through the VA. Half of those individuals have had difficulties getting that treatment and one out of three of those individuals got no treatment at all.
You know, these are real life individuals that have served our country proudly and are struggling to get the care that they need and they deserve, but I wanna share a couple of statements from three of those individuals. They have brought in written comments.
"I could not get an appointment for three months, and then they canceled and rescheduled three times. Once, I was able to see a counselor, I was told I could not get repeat care in a group setting more frequently than once a month, even though group counseling was not ideal for my situation. I was also told that they would not pay for me to see a private counselor, even though they couldn't fill my appointments at the frequency they said I required. That's when I gave up on VA health care. As a result, I put off getting treatment for almost two years until I got private insurance through a new job."
Second statement is in Columbia, South Carolina, "There is one doctor and two counselors. I've been off active duty since July 2011, and I've had one appointment for PTSD. There are short -- so short step just like trying to put a Band-Aid on an amputation."
And the last statement is, "While it would be great to have the ability to have more frequent visits than every two to three months, I'm actually limited -- limited to the frequency anyways due to the limited sick leave from work and the VA CBOC not offering evening counseling."
Now, stories like -- all the stories are different. They have very similar theme, and unfortunately, they're very troubling. Warriors may be able to get in for their initial appointment in Spring, but when a veteran who is struggling with PTSD, with depression, substance abuse and is coming to the VA for help and was told that the next available appointment is months away. Why are we surprised when somebody takes kind of loses hope and turns more desperate measures suicide for example?
Let me ask some questions. Why after 10 years do warriors have to struggle to get effective care for the signature wound of this war? Why haven't the undersecretary for health and the secretary move beyond measuring baseline access to initial mental health evaluations to systematically tracking access to sustain follow up care?
In fact, if leaders spent more times speaking with the veterans in their own clinicians, our whole system runs far deeper than even their data suggest. In that regard, we haven't -- why haven't those leaders instituted concrete remedial measures rather -- than offering so called "action plans" that promise nothing more than the possibility of future plans? And when will VA leaders actually enforce central office policies and end the disconnect between national directives and what has actually taken place in the medical centers across the country?
I recently spoke to a VA psychologist in a large urban VA Medical Center. He described the VA's ability to handle the current caseload as completely inadequate. VA has placed great emphasis on providing evidence-based mental health care to include sessions of cognitive behavioral therapy. The clinician I spoke with is trained in this technique and thinks it is effective for veterans with PTSD. Unfortunately, he's not able to provide this time-consuming treatment. This individual talked to me about working 10 to 12 hours a day just to keep up, so the veterans at that -- that he treats are not able to get that the treatment that they deserve.
This clinician operates a Crisis Center which currently has a waiting list for veterans who need care and then he indicated to me that there are other clinicians in his medical center that have caseloads up to 300 veterans, and I'm not the smartest math guy around, but I did little calculation and one doctor had 300 patients, never took lunch, phone calls, breaks, went to the bathroom or went to meetings. They could give 30 minutes a month to each patient. To me, I'm not the -- as I said I'm a civilian up here. I don't know if 30 minutes a month is actually adequate for quality care. I'll leave that up to the professionals.
These caseload levels result in many veterans being seen no more than every -- once every four weeks, and when they go to those appointments the sessions often are focused on medication management but not much of the needed therapy. The performance to management of medication may check the box and to fill access, timelines, standards, but this is not the type of care that will ultimately leave veterans to successfully manage their mental health conditions.
Meeting the medical benchmarks isn't good enough if the care of the warriors received is a poor quality. VA's recent action for improvement timeliness in mental health care does not reflect the urgency needed to address this situation. While the issue impacting access to care is complex, this is also a leadership issue. It's time to move beyond characterizing these issues as perceived challenges and acknowledge them head on.
VA's insistence on studying these issues is simply unacceptable. Veterans need a meaningful and aggressive strategy which the same way that they are currently tackling homelessness which is often a direct result of the underlying mental health issue. While there is a lot to be done, WWP has three recommendations. First, better utilize VA's Vet Centers and allocate more resources to those centers. Secondly, amount of meaningful peer-support program to help engage and retain veterans in mental health treatment. And lastly, utilize fee-based care in situations where VA resources did not allow a veteran to be seen in a timely manner.
VA officials speak of transforming the VA Mental Health Care System, but a real transformation must dramatically improve timeliness and access to effective quality mental health care. In our view, VA leadership has fallen short in meeting that challenge, short on urgency, short on the commitment, short on vision and short on action. We urge the committee to examine it more.
Thank you, Chairman Murray, Ranking Member Burr and the other members of this committee. Your continued oversight is essential in getting Secretary Shinseki and Undersecretary Petzel to embrace the challenge, too much is at stake to move forward as business as usual.
Thank you.

MURRAY:
Thank you very much, Mr. Roberts. I think every member of this committee agrees with you that we need an aggressive strategy and hopefully this hearing will highlight that, and our second panel will be able to really begin to talk to the VA about that. So, thank you to all of you.
Dr. Washington, I wanted to start with you. I am -- if I mention the survey that I requested of mental health providers really highlighted the disconnect between VA policies and practice the VA claims at about 95 percent of our veterans getting appointment within that mandated 14-day window. The survey for my VA staff found that only 63 percent of providers can schedule patients for mental health appointments within 14 days.
So, I wanted to ask you as a provider and talk and I'm sure you talked with other providers throughout the system. How often, have you and -- and those you talked to have been able to really schedule appointments for patients within that 14-day window?

WASHINGTON:
I would agree with probably the survey findings. It's fairly inconsistent, at very low numbers, meaning that they may be able to come in for the initial consultation which is of getting background information within the 14 days but then actually getting a face-to-face physical appointment to start actual therapy could be a month, six weeks usually.

MURRAY:
So -- so, the disconnect then could possibly be what that initial appointment actually is about.

WASHINGTON:
Yes, because initially when a consult is (inaudible) from usually primary care or individual self-referred, they come in and then we just get their background history and -- and it could be anyone who actually takes that, and so I think what's happening are sometimes they're counting that as the initial appointment when in reality it's really just getting the background information, getting their history versus an actual appointment to sit with a counselor to then determine what are good treatment plan will be for that person.
(CROSSTALK)

MURRAY:
Because I think most of us think when somebody is seen within the first 14 days, they're actually seen you or another provider who's beginning their treatment.

WASHINGTON:
That's not the case.

MURRAY:
But that counts under the VA's 14-day window?
(CROSSTALK)

WASHINGTON:
(Inaudible), yeah.

MURRAY:
OK.
Dr. Hoge, you recently wrote an article in the Journal of American Medical Association and found that very high percentage of veterans dropped out of their PTSD treatment, and you found that VA efforts that providing PTSD therapy is only reaching about 20 percent of the veterans who needed it. I'm really troubled by that finding that only about half of our veterans actually complete a full course of mental health treatment.
From you -- where you sit, what do wait times and scheduling problems play in veterans dropping out of care and not getting their full treatment?

HOGE:
I think that's one of many factors and -- and it's because there's not good research to really tell us exactly, you know, what -- how important that is versus other factors, but it is -- it is clearly a critical and important -- one of -- one critical important factor along with others and sometimes it's, you know, stigma, sometimes it's -- it's, you know, a -- you know, a sort of structural or physical barriers like transportation or distance from the treatment facility or appointment times, not being able to get appointment, you know, appointment times that can fit...

MURRAY:
That works for them.

HOGE:
... with work -- work priorities and so forth and then I've -- we've been -- I've been very interested recently in this sort of new domain of perceptions -- negative perceptions in mental health care. I was actually surprised of the recent research that has looked at that and -- and -- and the high percentage of individuals who report having negative perceptions in mental health care, not trusting mental health professionals, not feeling is that mental health care is not gonna be effective and so it sort of -- I don't know what to do about it exactly, but I think that it -- it -- it opens the question of you know, how do we better market mental health care.
And I think that some of the answers to that lie within the domain of integration with primary care, better peer-to-peer support because veterans are very responsive to their peers, in communication with -- with peers and -- and -- and family support also because the family is also -- is -- is critical often in -- in helping the veteran get into care. So, it's not just peers but family members.

MURRAY:
Well, I -- I think that the stigma issue that you talked about place into the wait time. If you're reluctant to call anyway and that's for help and then you call and you can't help right away or you can't get an appointment at the time that works for you that just place right into your own (inaudible) that this is not something that is acceptable.

HOGE:
I -- I agree completely, yeah.

MURRAY:
Dr. Van Dahlen, first of all, thank you for everything your organization has done and continues to do for our veterans in Give an Hour and a lot of other organizations play really an important part in making sure that our veterans gonna act. So, we really appreciate what you did. You mentioned that you don't have a relationship or you do have a relationship with DOD but not with the VA. What is the barrier in establishing the relationship with them?

VAN DAHLEN:
I don't really know. We've had many conversations and meetings but unlike with the Department of Defense where there is really and open as in an interest in toward collaborating with community-based resources. There's a -- that's clearly a belief in DOD that I have watched evolved over the last six years since founding Give an Hour that -- a recognition that we can't do at all from the military perspective, military organizations.
It has to be in coordinated effort in communities because many of these veterans go home to communities where there may not be a VA or vet center nearby, and so why not coordinate with the community mental health professionals whether they're -- it's fee-for-service or in our case mental health professional who don't want to be paid. They wanna give their time. So, Department of Defense seems to have moved in a -- a cultural way, in a perspective that we need to look at, and they're doing a lot of work, and I have not had that experience in conversations with the VA.

MURRAY:
OK, thank you very much. And I am out of time, so I have to go to my second round, but Senator Burr, I turn over to you.

BURR:
Thank you, Chairman, and I'm gonna be brief focus this with Dr. Washington, but I'd ask unanimous consent that all members be allowed the opportunity to send questions to our witnesses today as part of the record because I think we could spend the half a day here...

MURRAY:
Absolutely.

BURR:
... quite honestly.

MURRAY:
We'll do that.

BURR:
Dr. Washington, very quickly, what are you told when you raise the barriers that you have painted for us to your management? What did they tell you?

WASHINGTON:
They tell me we're working on it. We're developing a new blueprint for services and that's usually the response. There's nothing really substantive given to me other than they're looking at it. They are aware of certain things and then in some cases there is flat-out denial as there was an issue.

BURR:
Well, you -- you -- you testified that there are mental health physicians that at the Wilmington Medical Center have not been filled.

WASHINGTON:
Yeah.

BURR:
Let me ask you. In the last two years, how many positions have been filled?

WASHINGTON:
The exact number, I couldn't tell you, but I know some positions once they were vacated were then eliminated. So, the exact number of how many are left vacant...

BURR:
DO you have any idea right now how many are open and how long they've been opened?

WASHINGTON:
I couldn't give you exact numbers.

BURR:
OK.

WASHINGTON:
Yeah.

BURR:
Well, I think these are all things that will follow up in -- in -- in detail. Again, I think it gets a part of -- of what the level of commitment to structurally solve the problem, and I hear from each one of our witnesses the most disturbing thing is that appointments still are the most difficult thing for a veteran whether they -- they're seeking mental health treatment or primary care. The actual appointment is the toughest thing for them to accomplish. Forget the fact that it may only be for the purposes of collection of records, and I think the chairman and I will get into that with the secretary if in fact we'll get a little scam going on.
I thank the chair.

MURRAY:
Senator Akaka?

AKAKA:
Thank you very much, Madam Chairman.
Dr. Washington, first, thank you for testifying before us today despite your fear of retaliation enacting stronger protection so whistleblowers can't come forth without fear of retaliation is one of my top priorities, and I believe it is important to hear many viewpoints so that we can continue to improve your services we are providing to our veterans.
In your opinion, what are the top two priorities that should be addressed in order to better veterans who need mental health care services?

WASHINGTON:
I would say the top two from my perspective would be first of all getting them into care much more quickly that seems to me if I've said in my testimony that if you get them into services quickly and you get them in intensive services quickly, you can get the treatment -- they can get the treatment that they need and then they can go on with their lives because ideally -- I mean, that's the goal is for them to get better and to live their lives rather than having to come to the VA constantly for the rest of their lives.
So, it's definitely getting, you know, access to both mental health and medical care. Numerous of -- many numbers of my patients have extensive medical conditions because their PTSD was the result of a physical trauma as well. I've had people who have serious back injuries, and they are in chronic pain, and they are not able to get the medications that they need to treat those chronic condition or any other treatments without long delay.
So, I would say my top two things would be helping them to get quick appointments for both medical and mental health care.

AKAKA:
Thank you.
Dr. Hoge, left untreated, many health conditions can lead to an increase risk of unemployment, homelessness and suicide, stigmas prevent some from seeking to mental health treatment they need. This has been a huge problem over the years. DOD has also faced this issue but according to leaders I've spoken to the situation is improving. My question to you is this stigma situation improving amongst veterans? And can the VA deliver some of the DOD successes to help further breakdown the stigma in the veteran community?

HOGE:
I -- I think -- I think stigma has improved but -- but because that's not the whole story, it hasn't led to the -- the robust numbers that we'd like to see in terms of utilization services and access. So, it's not -- it's not the whole story, but there are clearly has been improvements and perceptions to stigma. I think that looking at things -- looking at PTSD for instance from the physiological and physiologic -- and physical perspective and -- and its relationship to combat physiology, how combat changes the way the body functions is important than destigmatizing this condition and treatment and also looking at it from the occupational warriors' perspective, so that when a veteran comes in for treatment or a service member comes in for treatment in DOD, and they sit down with the health professional or mental health professional, they're not automatically -- they don't automatically get the sense of they're being labeled as having a mental disorder when in reality their -- their body is reacting the way it's been trained to react in the combat environment. Did that makes sense? A little bit long winded response, but...

AKAKA:
Thank you.
Dr. Van Dahlen, you know, I want to thank you and your staff for all that you do to support the mental needs of -- of veterans. Your partnering with communities across the country to provide needed support is -- is to be commended. From your viewpoint, if there is one thing that we in Congress could do better to support the need to veterans and their families, what will it be?

VAN DAHLEN:
That's a big question. I -- I really do believe that the -- the answer, and there's some great efforts currently underway. The answer is in encouraging and that sometimes perhaps using the power of the Congress to push where it's not happening, integration, coordination and collaboration. That is the way we're seeing forward in many communities that we're now working in. There are some good efforts underway nationally to do just that, and it requires the VA, DOD and Department of Labor -- those agencies have critical roles in those communities, but it's at the community level because that's where people live.

AKAKA:
Thank you.
Mr. Roberts, part of the organization's focus is to ensure injured service members stay in connected with one another through both the peer mentoring and robust alumni program, and you mentioned peer-to-peer programs. How important is it -- is it to a veteran in your programs to be able to connect with other veterans to -- through VA programs?

ROBERTS:
In the survey, I mentioned when I spoke, we -- the biggest response we got back of what these individuals want, and what they think is effective for them is that peer support, and it is easier. I've run a program called "Project Us (ph) seasons 2007," which is basically a peer-to-peer recreational outdoor retreat with therapeutic aspect to it, and Loyd who is behind me -- Loyd Sawyer whose wife has testified on the 14th was a benefactor of that program, and I think Loyd can speak to the fact that being around other peers and being -- being able to talk openly and honest about what's going on back home, and how they're affected by this PTSD and how their families are affected makes a great impact on it.
And it also encourages many of them to want to get that treatment to get better because we do put peers that we've trained to being successful with their recovery. We trained them, gave them eight hours of training, put them into our programs, and they are out there basically to be that peer mentor for those young men and women that are still struggling.

AKAKA:
Thank you very much.
Thank you, Madam.

MURRAY:
Thank you.
Senator Isakson?

ISAKSON:
Mr. Roberts, thank you very much for your service to the country. Have you had an experience with the Federal Recovery Coordinator Program at VA that's been established in wounded warrior?

ROBERTS:
We have many experiences with them. Yes, sir.

ISAKSON:
Is it -- is it improving the coordination of care to veterans?

ROBERTS:
From the messaging I'm getting, yes it is -- it is improving.

ISAKSON:
I think to the credit that the VA's establishment of that program has begun to (inaudible) where understaff in terms of the ability -- the number that we need but is a step I think in the right direction.
Have any -- other of you had experience with the Federal Recovery Coordinator Program?
Dr. Van Dahlen?

VAN DAHLEN:
It is a positive experience for veterans who used -- who accessed that. So, I would say the same things as Mr. Roberts.

ISAKSON:
Ms. Van Dahlen or Dr. Van Dahlen, you'd mentioned the telemedicine or telehealth program you're initiating. Could you elaborate with regard to mental health how you deliver? What are you delivering? Are you delivering counseling? Are you delivering consulting? What are you delivering?

VAN DAHLEN:
Yes, we're -- we are using that capability to do all of the services that we are now providing and one of the things that -- that I'd like to -- to say is that what ways that I think organizations like ours can really work collaboratively with the VA is to have our professionals providing education information. To Dr. Hoge's point, the issue is to try to change the perceptions, change the stigma and change the expectations. If you harness the mental health professionals across the range VA community based, you can help put information out to communities to faith-based leaders, to schools about these issues, about the needs and about what's available.
So, in terms of what we're doing with the telehealth, we'll be providing direct service for folks in rural communities who cannot access a clinic or mental health professional. We'll be providing consultation to schools and to employers and to other primary care doctor, pediatricians who don't have access to mental health professional. So, we plan to use that technology. It's not the answer, but it's another tool to provide information, support and treatment where we can't live providers out to those areas.

ISAKSON:
Yeah, that -- that makes a very good point. We've got interestingly enough on the stigma issue which is a huge issue. It's also a huge issue on another national problem which is literacy and by delivering through -- via the internet web-based delivery of literacy training, we have greatly in our State of Georgia improved number of people coming in to learn to read and learn to -- to write because the stigma really when they're dealing with the computer versus the human being, and I would think telecounseling wound be somewhat the same thing.

VAN DAHLEN:
Was -- and actually there've been some interesting initial reports that this generation of service members because they've grown up with technology often feel more comfortable having that -- that telehealth conversation and so training some of the providers who are older then it's OK to engage in that kind of relationship, but I think we're moving towards, again, finding no one size fits all, but for this generation, I think that can be a very important tool to add.

ISAKSON:
I'm a little bit miffed with the fact that DOD is very engaging with your program and -- and veterans has been distant, I guess distant is the right word or not engage -- anyone?

VAN DAHLEN:
There have been, I would say, at the local levels. There have been some wonderful folks through the VA who found out about what we do and we work together. But on the national conversation, it's not happening yet, and hopefully that will come that's what we want. We were -- Give an Hour was built to offer those services in whatever way they make sense to assist the efforts with the VA and DOD. That's the purpose.

ISAKSON:
Madam Chairman, I think we ought to have an engagement with the VA on that very subject because if there are community-based free services -- mental health services to veterans with the number of veterans coming back from Iraq and from Afghanistan. We can use every professional available for our veterans in coordination that will be very helpful.
Thank you, Madam Chair.

MURRAY:
Thank you very much.
Senator Tester?

TESTER:
Well, thank you, Madam Chair, and I wanna thank all the folks who are testifying today. We'll start -- we'll start with you John. I wanna echo my -- thank you for your -- your service to the country and -- and incredible asset you are in this particular arena because you've been there, done that and obviously that's successful and -- and I think that your perspective is critically important.
I wanna talk about peer-to-peer for a second -- vet-to-vet. From your perspective you talked about the retreat that was done, there's program in Montana called "Healing Waters" who take fisherman out and do flyfishing and -- and it can, you know, it's a little different than what you visualized sit in the room and talking. But how -- how can we enhance peer-to-peer or vet-to-vet stuff and -- but more importantly how can VA enhance it?

ROBERTS:
I got to tell you. I -- most of my comments probably sound a very negative on the VA, you know, I was a VA supervisor. I'm very -- I know there are a lot of good people in that system that wants to do the right thing. One of them, Dr. Batres with the Readjustment Counseling Services actually partnered with myself on project as he -- when we started in 2007 and provided culturally competent counselors from the vet centers going on these retreats because it's a little bit of out of the box sitting in the room around, you know, circle with a bunch of chairs pouring out your feelings.
Those actually taking the counselors out being engaging with the warriors on an active level whether they were engaging, doing the activities, where there is physical or whatever we are doing and then at night having that trust built up where you could sit around the fire and just kind of talk about everything, and the individuals didn't know they are actually in a group session but they were, and I think it's being creative. I think it's engaging these warriors that are being successful.
Myself -- I'm very proud the fact that I -- I did overcome PTSD, and my wife is here. She could testify to how bad I was. It's like Andrea probably testified -- could testify how bad Loyd was or is and that impacts to families, and honestly, it's doing something more than my experience with the VA. I went for one appointment. I got screened, and the doctor sat me in a room, no military experience, had very short time to talk to me, didn't want to know what was going on, my marriage at that time was fallen apart, that I was self-medicating like men of the warriors I treat or I help today.
And quite frankly, he wants to teach me how to breathe, and I thank them and calmly left the room and never went back to treatment. I was lucky I had another marine reach out to me that I was injured with and kind of pulled me out of the gutter, and I think that -- it is a critical part of recovery process having that support and having those individuals that have been successful dealing with it and not every treatment is perfect.
You can't put (inaudible) a box and expect one treatment fit everybody. Personally, I'm not a medication believer that may work for others. You know, I can't what works and doesn't work, but I think it has -- the treatment has to be tailored to the individual, and they're gonna go through trials and errors. Sometimes things are gonna work and then they got -- if it doesn't work, they got to try something else.

TESTER:
Well, I can tell that -- I don't think (inaudible). I think the VA or bad people. They're doing the best I think the best they can do, but there are matters they can do better. But you -- you actually made some comments during your -- your opening remarks. I hope the VA can respond to access to follow up here the fact that we're medicating -- we're doing medication management. I mean the days of warehousing folks that have mental health problems should have been long, long, long gone, and I see that kind of structure there any abuse of medication made but (inaudible) would be the entire emphasis -- emphasis of -- of this visit.
I wanna talk with either one the two doctors in the -- in the private sector, and I don't know if you guys can answer this or not but -- but as far as highly qualified mental health professionals that are out there, the information I have guys is that there's not a lot folks out there -- not enough let's put it that way, and if that's your opinion, is -- do you have any ideas on how we can enhance as we get more highly -- highly qualified folks out there from your perspective being in the business.

HOGE:
The -- I mean, clearly, there is shortage of mental health professionals nationally that is -- and that, you know, there's also in DOD and VA and so, you know, more training of mental health professionals, you know, more programs to train mental health professionals might be a benefit. I think that there are ways also in the discussion for instance of peer-to-peer counseling to leverage the skills of mental health professionals in ways that -- that have partnerships with lay, peer-to-peer counseling that -- that may extend mental health professional.
And -- and so for instance -- it's -- if there may be ways to incorporate peer-to-peer mentoring and counseling into traditional mental health clinics within the VA structure within other, you know, DOD and other clinics, and so these -- so there -- there would be that short of going out and training and hiring more mental health professionals. There may be ways to extend the -- the treatment and -- and other ways through other types of professionals that -- that work with the mental health professionals.

VAN DAHLEN:
I would completely agree, and there are several programs now underway that Give an Hour is partnering with, that are peer-based programs, and what someone taught me very early on who is the vet who had developed the peer-to-peer, you know, peer-led, clinician-guided to have a clinician involved to assist, to provide the mental health information can really facilitate the -- the delivery of peer-to-peer support. So, that's one, and what we're finding in the communities, we're very involved in Fayetteville, North Carolina and the Hampton Roads areas Virginia in a community-based efforts.
The mental health professionals want to be trained, and so there are so many great tools the VA have many other DOD. It's working again collaboratively to create systematic program to offer that kind of training online, in workshops. It's out there. It's poorly coordinated. There are good tools, but they're not available, but clinicians want it. Our providers when we surveyed them they don't wanna join TRICARE. They don't wanna be paid, but they want training. They want the cultural information they need, the appropriate training to give the good services. So, they're there, but it's packaging them and providing them.

TESTER:
Thank you.
Thank you, Madam Chair.

MURRAY:
Thank you.
Senator Boozman?

BOOZMAN:
Thank you, Madam Chair, and we appreciate you all being here very much.
Mental health is just the inch problem. They waking out to I think county jails all over the country where you have people later on tried to commit suicide that -- that literally there is no room in the state hospitals. It's just that tremendous problem we can look suicide among our youth and then we have this significant problem among our military that are, you know, we've created problem, so, it's just something -- it's just a very, very difficult problem.
I'd like to talk a little bit more about the -- the peer-to-peer in the sense that -- that, you know, your testimony is such that -- that, you know, the marine helped you and, you know, where would you be without that. So, let's talk a little bit about how, you know, how we can do a better job of instituting that. I'm familiar with the Rivers to Recovery Program. They -- they -- we actually have a -- a Dog Training Bill, you know, in the sense that we have a lot of dogs that need to be trained, you know, using veterans to interact with that and you know, the fact that your carrying about something else.
I heard a story of a -- a guy that had amputations was lying in a hospital in a golf pro. I told him that he was gonna teach him how to play -- play golf, and the -- the guy was actually suicidal, laughed, you know, that thought inside sure enough is very frustrating because, you know, he could trust me without any problem at all.
Now, so, I think those are great things. The question is from your perspective, you know, recognizing that again this is not just the problem of the VA. I mean, we got, you know, this tremendous mental health problem going on throughout the country especially in rural areas which is a great concern. You know, much of our concern much of our country, you know, especially the national guardsmen, you know, counting small communities go back. They don't have the resources even being with their buddies, you know, it's not like being overseas or, you know, being dead (ph) or you come back as a group. These people come back, and they're just dispersed to small towns with their problems.
But I -- I guess what I would like is this is some suggestions most of the studies that we've seen are based on medication, and you know, where do we -- how do we think outside the -- the box perhaps and maybe do things a little differently.
Go ahead, sir.

HOGE:
If I can make a comment on one of the most healing components of what happens inside that mental health office -- mental health treatment office is narration. The ability to narrate the events that happened down range in combat and really talk through the details, connect with the emotions. Oftentimes, there's underlying issues of grief, for instance, in loss which have never been dealt with and just as one example, and there's some -- there is also some interesting data on that -- that narration as you mentioned that one size does not fit all.
Each individual, you know, each individual has a -- has a distinct way in which they need to go through their readjustment process, and sometimes there are some good data for instance on the written narration. There is some -- there is some very interesting data from European investigators working in -- with war-thorn refugee populations where they train lay counselors to go in and do narrative therapy -- life narrative therapy and achieve essentially equivalent results in -- in recovery from PTSD, and so I think that opens the door for narrative, you know, treatment strategies done by peer-to- peers. You know, lay peer counselors but supervise and coordinated and -- and -- and done in conjoint with -- in conjunction with traditional mental health professionals.
So, I think that would be one area that we could think outside the box among others. The other -- the other big area would be primary care, really integrating care within that primary care structure in a collaborative way.

VAN DAHLEN:
Another piece that we should put out here is we know from studies really excellent study that was done a few years ago by civic enterprises that our veterans and their families they volunteer at a higher rate. They come home, and they continue to serve. And I think we're not taking advantage of their desire to continue to serve to take care of their own. So, if you wanna think about -- sort of thinking outside the box, here we have a population that those who are coming through programs like ours, like the VA, like others.
If we, from the beginning, create the -- the almost an expectation but a need that they understand if they make it through then we want them to join an effort to become a peer-support person. I think we have a pool of ready-made folks who we can ask to engage in that kind of help for those who are coming behind them.

ROBERTS:
It's hard to argue with the -- both their comments. I think these young men and women do have still that service desire and once they do come through the recovery, and they are successful do wanna get back and wanna help others that are -- that are struggling still. I like the peer-facilitator group that has to be supervised. That's kind of a key that supervision is key...

BOOZMAN:
The marine that you mentioned?

ROBERTS:
... yes.

BOOZMAN:
What was his role? Is he a friend or an acquaintance? How did you come into contact with?

ROBERTS:
We served together. We're blown-up together, and he was actually, at that time, being successful in his recovery. I, at that time, was more severely injured and quite frankly struggling and not doing very well, and he happened to reach out to me and pulled me back up and got me on the right path and...

BOOZMAN:
Which would be harder to replace in a...

ROBERTS:
It's very hard to replace. I -- I had more trust in that individual than I did in a VA mental health clinician. So, yeah, there is a lot of trust built up and somebody I knew I could talk to and not be judged for what I was doing.

BOOZMAN:
Thank you, Madam Chair.

MURRAY:
Well, thank you to all of our panelists. I think your insight is very helpful to our committee as we continue to move forward on this critical topic.
I gave a number of Senators who wanna ask additional questions to submit them to you in writing and if we could get your responses that way, I'd appreciate it.
We do have a vote that's coming up shortly, so I wanna get our second panel up here and move to that, but again, thank you to all of you and with our second panel please come forward.
(AUDIO GAP)

MURRAY:
The vote has just been called, but the second panel comes up. I'd like all of us to go vote. We'll come back and then we'll hear the testimony and have a chance to ask question.
(BREAK)

MURRAY:
I'm gonna bring the committee back to order here. Our Senators will be returning, but I wanna get this panel started, and I appreciate everybody's patience.
I wanna welcome the Representative of VA, Dr. Mary Schohn. She is the director of the Mental Health Operations of the Veterans Health Administration, the Department of Veterans Affairs. She'll be testifying today and is accompanied by Dr. Zeiss and Dr. Kemp.
So, Dr. Schohn if you wanna go ahead and begin your testimony.

SCHOHN:
Chairman Murray, Ranking Member Burr and members of the committee: Thank you for the opportunity to appear before you today to discuss the Department of Veterans Affairs' commitment to providing responsive, accessible and effective mental health services that meet the needs of our Nation's Veterans. I'm accompanied by my colleagues, Dr. Antonette Zeiss, chief consultant for Mental Health and Dr. Jan E. Kemp, the National Mental Health Director for Suicide Prevention.
I also want to thank the first panel. We are pleased to hear the recommendations to improve VA's mental health services. We agree with their suggestions and in fact have begun implementing many of them. VHA takes seriously our responsibility for meeting the mental health care needs of veterans.
For the past several years, we have focused on enhancing this care by improving both the availability and quality of our services. As Chairman Murray noted in her October letter, we have written state- of-the-art policies, begun integrating mental health into primary care, and created groundbreaking new program to meet the needs of veterans.
Moreover, we have expanded our mental health staffing levels by almost 50 percent since FY 2006. During this same time, VHA saw 34 percent increase in the number of veterans receiving mental health care. To extend our reach to veterans in rural or hard to reach places, we have expanded and continued to expand the use of technology, including the use of telemental health in mobile F most recently.
We have recognized the essential role family members and friends to play in each veteran's personal support network to help spouses and other family caregivers address the many challenges associated with the transition from active duty. VHA has launched the Spouse Telephone Support Intervention, and we have implemented the coaching into care program to help family members in supporting veterans in accessing needed care.
VHA's efforts to improve mental health care has been many and yet we are aware that there are still much more for us to do. To this end, we have implemented a set of near-term actions and formed by the August 2011 query of field's staff requested by this committee, respondents to the query that perceived deficiencies and performance measurement in mental health staffing and expressed concerns about base shortages for mental health care.
They also mentioned adequacy of all services and the need to balance demand for C&P and IDES examinations with the delivery of mental health services. Our action plan addresses each of these areas of concerns.
First, we are auditing mental health scheduling practices and using the findings from these to improve practices. To ensure that appointments reflect veterans' need and scheduling desires, we are developing a team-based staffing model that enables VHA to carefully monitor mental health staffing levels at VISNs facility and to assess efficiency and failure across the system.
We have strength the performance measures to provide us with information beyond timeliness. We've added measures to assess three additional things, access to follow up care for veterans recently discharged from inpatient treatment, access to enhance care for veterans at risk for suicide and access to specialty appointments for the treatment of PTSD. We continue to reach out to providers for their perceptions and problems and solutions in delivering the best quality mental health care.
By the end of January 2011, we have -- we'll have completed 10 focused groups on providers to help us better understand the concern cited in the surveys and to follow up as needed. As more veterans seek and receive mental health care and VHA augments staffing to provide that care, we have encountered space challenges. We have upsized to update their facility base -- base plan to address these challenges in both the short and the long-term. VHAs -- of our capability for mental health services depends on primary care availability especially at our community-based outpatient clinic.
The undersecretary for heath has commissioned a work group to review and develop a system-wide policy for off-hours clinic time and to report I need findings by tomorrow.
In addition because C&P and IDES exams maybe for many veterans there first introduction to VA, we want to ensure a positive experience in timely access to care. To that end, VHA's Office of Mental Health Services and the Office of Disability and Medical Assessment have partnered to identify facilities highly impacted by these exams, and we've begun pilot programs to mitigate the issue.
We know that veteran demand for mental health care will continue to increase as our service members return from deployment and discharge from service. We have done a great deal to address these needs, and I promise you we will continue to do more.
I thank you for the opportunity to discuss our efforts. We are now prepared to answer any questions you may have.

MURRAY:
Dr. Schohn, I'm glad that the department has recognized the inadequacy of the waiting times and how they're measured in this pledge to hold our network directors accountable to their performance on these metrics but I want to ask you if you believe that facilities are gaming the system and not fully reporting wait time and wondered what you thought.

SCHOHN:
VHA does not condone gaming of any sort. I am not aware of particular facilities that are doing anything of that kind and if I were I would act immediately on finding that up. We are engaged in auditing to ensure, in fact that that is not happening, that is a requirement of the directive published by VHA in terms of auditing this on a regular basis, but we are conducting a special audit of mental health practices to reinforce that it should not be happening.

MURRAY:
Why do you think there's a disconnect between what the VA providers are telling us than what VA is telling Congress?

SCHOHN:
I believe the...
(AUDIO GAP)

SCHOHN:
... but it was mentioned by Dr. Washington is that patients are not having access to the evidence-based therapies in the way that we expect they should be. What we understood from the provider's survey was that providers were saying that there's access to the system but not necessarily access to those specific therapies in the time that they should occur and we are working on ensuring that that happens. We have recently put through a new information to the field and are working also through site visits and actually reaching out when we get evidence that that is happening to find way to solve the issues that Dr. Washington presented here today.

MURRAY:
And Dr. Zeiss, I wanted to ask you when you testified at the hearing for this committee, May 25th, I asked you whether the VA had enough resources to meet OIF/OEF veterans need to mental health care and -- and had resources weren't the problem? In light of what you have learned since last May, especially from own providers, do you standby that statement from me?

ZEISS:
I believe that we have unprecedented resources and that we have gotten them out to the field, and we have hired enormous number of staff, and at the time, I believe that they were adequate if use in the most effective way as possible. We continue to have an increasing number of mental -- mental health patients. We have looked at the FY '11 data and the numbers have again jumped from FY '10, and we are proactively predicting what kinds of increases there will be in FY '12, and we're working with the Office of Policy and Planning to ensure that those predictions are embedded into the actuarial model that drives the budget predictions.
So, I can say that we will be aggressively following all the data that we have available to ensure that we can make effective predictions at the policy level about the level of funding and level of staffing is that would be essential, and we will be partnering very closely with Dr. Schohn's office who are responsible for ensuring that those resources are used most effectively and the field are used specifically to deliver the kinds of care that we have...
(CROSSTALK)

MURRAY:
Or use (inaudible) do not believe its resources, that's the issue.

ZEISS:
I believe that we are at a juncture where we need absolutely to be looking at resources because of a greatly increase number of mental health patients that we're serving and some of that is because the very aggressive efforts we've made to outreach and to ensure that people are aware the care that VA can provide. The more we succeed in getting that word across and serving increasing number of veterans, the more you're absolutely right, we have to look at what's the level of resources to keep -- to be able to sustain the level of care that we believe is essential.

MURRAY:
You're looking at -- you're asking, I mean we need to have this information upfront now if we need more resources. I mean you just look the story up there of the thousands of people coming home. The people aren't getting served. The people were reaching out to and just feels to me like this is something we should know now. We've been 10 years into this.

ZEISS:
We believe that people who are receiving enormous amount of service from VA and we agree as Dr. Schohn has said that we need to focus and on some specific aspects of care particularly the evidence- based therapies, and we are working with Dr. Schohn who will be developing a very specific staffing model so that we can identify what are the levels of staffing that are available at specific sites and what is that (inaudible) care...
(CROSSTALK)

MURRAY:
Well, let me ask you specific question then.
Dr. Schohn, according to the mental health wait data provided to the committee by -- by the VA. Veterans of Spokane VA in my home state wait an average of 21 days for an appointment with psychiatrist with the maximum wait time for a psychiatrist being 87 days. Now, I've told that all of the psychiatrists at the VA in Spokane are booked solid for several months and that there are other places in the country that are far worse than that.
You mentioned that the VA is working to fill those vacancies, but the hiring process is very slow. What can the department do now to make sure that we are shortening these wait times?

SCHOHN:
In fact, there are efforts already underway in Spokane to improve hiring. There, in fact, the waiting time has decreased. There is a shortage and there is variability in our system in terms of ability. For example, to hire a psychiatrist in Spokane, one of the efforts that's being made is to use telepsychiatrist essentially to provide service from a site where there is a greater ability of -- to recruit psychiatrist and to use their services at the site where they're at and to then be able to provide services to Spokane for example, that the chief medical officer in Spokane has worked to ensure that coverage can come from other facilities within VISN 20 to ensure that the needs of the veterans in Spokane are met.
Those are the kinds of things that we're working on as we come across evidence then in fact there are shortages in some areas. We know that in some other areas, they are lots -- there are not shortages and that they maybe some surplus that can be used on those sites.

MURRAY:
OK. Well, let me ask you another question. There was a provision on using community providers for mental health services and the caregivers (inaudible) bill that was passed by Congress early this year. Could the peer-to- peer services -- and we heard from our first panel about how important assets to care and peer-to- peer services are. I am told that the department is very -- making very little progress on implementing that. Can you tell me what's holding that back?

SCHOHN:
We have made some progress. I'm going to ask Dr. Kemp to talk specifically to that.

KEMP:
As you are aware, most of our peer-to-peer services or a lot of our peer-to-peer services I should say are provided by the Vet Centers, which is an exceptional program that you're all very familiar with, and we endorsed and support. We've grown a number of Vet Centers. By the end of this year, we will have 300 centers across the country open and working in addition to the 70 mobile Vet Centers that will be open and traveling across the country.
So, I think we've made huge strides in providing those services to combat the veterans and their families across the country. We also have a contract which has been led out and is in the process of being filled to provide training to train more peer type support counselors where we're looking forward to that being completed. And we will get those -- those people up and going as soon as we're able to get them on board.
(CROSSTALK)

MURRAY:
OK.
(CROSSTALK)

KEMP:
We agreed with -- with the -- the intent of that legislation for lots of good reasons and we will continue to implement those services.
(CROSSTALK)

MURRAY:
OK. This committee will be following that very closely and before I turned over to Senator Burr, I just wanna say I'm really disturbed by the disconnect between the provider data and your testimony on the wait time issue and I'm -- I am going to be asking the inspector general to review that issue. I assume Senator Burr will join me in that and I would like all of your commitment to work with them to make sure we get the data.
(CROSSTALK)

KEMP:
Absolutely.

MURRAY:
Senator Burr?

BURR:
Thank you, Chairman. Dr. Schohn, how is it that given our -- can identify the need for flexibility in the delivery of mental health services but VA can't?

SCHOHN:
I think we agree with Give an Hour that we do need to have flexible mental health services. VHA in its uniform services package has had the policy that off-hours is required at all medical centers and large -- very large CBOCs since 2008. What we understand from the survey is that off hours have not always been available at the smaller CBO from a community based outpatient clinic. The policy group that Dr. Pretzel has just put together is addressing those issues and I have asked Dr. Zeiss to speak specifically to that.

ZEISS:
Well and let me just check on the question because you talked about flexibility and there are many aspects of flexibilities. Certainly one ...
(CROSSTALK)

BURR:
I'm getting credit for only one.
(CROSSTALK)

ZEISS:
... but Dr. Schohn.
(CROSSTALK)

BURR:
How about that? But I have yet to see one yet, so.

ZEISS:
Well, I believe as Dr. Schohn has been saying we do have flexibility in hours of service. What we've discovered is, in looking at the data, is that the initial requirement was for evening clinic. One evening clinic that leads to week and others as needed, and what we're finding is that the data suggests that what works much better for them is early morning hours and weekend hours.
And so the policy group is looking very carefully at that in terms of changing and creating even more flexibility than the original after hours policy. The Uniform Mental Health Services handbook that Dr. Schohn referenced also has an incredible array of flexible programs and defines a very broad range and flexible range of mental health services that you provide.
(CROSSTALK)

BURR:
Let me -- let me stop you there if I can. Let me -- let me just say I have a tremendous amount of respect for all of you. I mirror what you heard from other colleagues. I thank all the VA employees for what they do but the fact that you've got something in the book or you put out a guideline and believe that you can still come in front of this committee and say, "we've got it, it's written. It's right there." What we hear time and time again and I heard from Mr. Roberts in his testimony, there is no evening option in areas.
They don't exist. Whether your data shows that it's preferred to be in the morning or the afternoon, in (inaudible) bigger case, your guidelines says the evening and he said, he testified. It doesn't exist, so I -- I hope you understand our frustration and Dr. Schohn I wanna ask you if you would provide for the committee a detailed audit of how the $5.7 billion has been spent. And I'm not talking about breaking it down in $403 categories. I'm talking about for the committee a detailed description of how we spent that $5.7 billion in additional mental health money.
Now, let me just ask you, is Dr. Washington correct when she said the majority of the patient's seen in the 14-day window are there for the purposes of information gathering, not necessarily treatment and many are not seen by the healthcare professional. They are seen by a staff who are there to collect data.

SCHOHN:
That would -- that is not how the policy is written and that if happening ...
(CROSSTALK)

BURR:
Well let me ask -- I'm gonna ask it again, is she right or is she wrong?

SCHOHN:
I don't know about Wilmington I will admit. I would get something. I would certainly wanna follow up on because that is not the expectation of how services are to be delivered.

BURR:
Let me -- let me read you some comments that had been made today Dr. Schohn and you just tell me whether these are acceptable. Veterans have little access to followup care.

SCHOHN:
It is not acceptable.

BURR:
VA -- VA focuses on medication management.

SCHOHN:
That is no acceptable and we have a huge policy in training program to ensure in fact that veterans have access to evidence based psychotherapy.

BURR:
Can't fill appointments for the prescribed amount of time.

SCHOHN:
That I'm not totally clear what that means.

BURR:
I would take for granted that an attending has said that somebody with PTSD needs to have X amount -- a frequency of -- of consult, frequency of treatment and it should extend for X amount of time. Would you find it unacceptable if in fact the system was not providing what the healthcare professional prescribed them to have?

SCHOHN:
Absolutely. We do have a system set up in placed to actually monitor, if in fact this is not happening. We are concerned by reports that it is not happening in places. We have many evidences or places where it is happening but as we hear these reports we are concerned as you are and have developed a plan to go out and visit sites, to ensure that these things are happening and to make corrections when they're not.

BURR:
The inability to get appointments.

SCHOHN:
Same thing. We -- the VA is available to veterans. We want to assure that any veteran needing mental healthcare has access in the timing and standards that we think are important.

BURR:
Mental health treatment is trumped by new increase into the VA system.

SCHOHN:
Again, not acceptable.

BURR:
OK. These are all issues that exists with the current mental health plan at the VA. And I would only say to you that the one difference between what I heard from Give an Hour or any group that has been in that's focus on mental health treatment for our veteran and where the VA is, and I hope you won't take this the wrong way, is they're focus on outcome. And you're focus on process and as a policymaker, our commitment to our country's veterans are we're gonna get you better.
And we're sticking them in a system that they're the first ones that lose confidence in it, and we're sort of the last one, we're still debating. And I would say that maybe we need to look at how everybody else is looking at mental health within the VA and ask ourselves, if so many people find that substandard, if so many people have difficulty navigating it, would it suggest to us that the plan that we got is either not working or it's the wrong one.
It's troubling to me that you can have a natural profit organization like Give an Hour or any other one that's out there, that the VA is not aggressively reaching out to try and to utilize in some fashion to leverage, our ability to deliver care. Any comment on that?

SCHOHN:
I just like to clarify. I do -- the VA is recognized as the largest integrated mental health provider in the country and quite possibly the world. The GAO in the RAND study have recently shown that it is leading the private sector and other providers of health services in terms of mental health. We are concerned about the variability, and we are concerned about the stories that we hear where we're not living up to our aspiration.
(CROSSTALK)

BURR:
Well, we just sort of pluck in out of the United States, just the people that fall through the cracks and everybody else makes it.

SCHOHN:
I can address that. I can say they are -- that we do have evidence of patients being seen in a timely fashion of getting access to the care they require and again I am personally concern when I hear these stories about that not happening.

BURR:
I remember the last time and I can't remember whether it happen Chairman, in the last hearing but we had one that dealt with suicides. And VA highlighted the fact that -- that 24-hour hotline calls had increased and how successful that was. And my comment was that that's a demonstration that our mental health treatment doesn't work. And the fact that more people are considering suicide and calling the 24-hour hotline now, we look at things somewhat differently.
And maybe if you provide for us that detailed breakdown of how we spent this money, maybe the committee can glean some information and through our collective efforts, we can find how to tweak the plan or put the parameters in place that assure us that we're making progress but I think what the -- I don't wanna speak for the chairman but I think what she and I are saying is, these hearings are not gonna be six months apart from now on. They're gonna be much closer together.
We're going to get to a granular level of understanding of exactly the execution and I'm willing to do it facility by facility, by facility. So, the chairman may not ask you about Washington next time and I'm not gonna ask you about North Carolina. It won't be Spokane and it won't be (inaudible) but it maybe Mars Hill and I don't expect you to know where Mars Hill is but I -- I would expect that our confidence that we deliver care in a town of 3000 is as confident as we deliver care in a town of 3 million. And if we're not there yet which I don't think we are, then we got a long way to go. I thank you.

MURRAY:
Thank you very much Senator Burr. I am now going to turn it over to Senator Rockefeller who chaired this committee before and I'm going to turn the gavel over to him as well. I want the VA to know that I will be submitting questions for the record and as Senator Burr said, this is not a one-time shot hearing. This is something we both care deeply about. We're going to continue to pursue it and again we have many, many soldiers coming home. Many who are need to be accessing the system. This is a number 1 priority for all of us. Senator Rockefeller?

ROCKEFELLER:
I want your gavel.
(LAUGH)

MURRAY:
I knew you would.

ROCKEFELLER:
Why not. Thank you Chairman Murray. Do you know it should be easy to tell the truth. It should be easy to say that you're not satisfying the needs of veterans. That the policy says that you should be or that you are but that you in fact aren't and you know it. The way this should work, is that you should -- you should be able to tell us that it isn't working. That the policy says that -- that in fact it's not working.
Why do I say that? For two reasons: 1) As your testimony, are the three of you had been by vetted by OMB? Yes, I'm pretty sure the answer is yes but you understand -- you understand what that means to us. Why should we have a gulf between us? We don't for one minute doubt, in fact we rejoiced in the improvements that the VA system is making. The points about it being better than the public system than the private system and all of that, I think it's true but it's not -- it doesn't get all the veterans taken care of, which is the only thing that matters, is you're better by factor 7 than Johns Hopkins. It still doesn't matter if you're not taking care of the needs.
Now, there are things to be said in your defense. I mean the request for mental health from 2007 to last years have gone up by a factor -- I don't know -- it's 35 requests in 2006 to 139,000 among these recent veterans and that's just veterans from -- of the two ward. And so then somebody ask you, are people dropping between the cracks. And then you can't because OMB -- because you represent the Obama administration. I happen to think that (inaudible) is the best VA such we ever had, and I'd been on this committee for 26 years -- 27 years.
But things go wrong, things still go wrong. You can't grow fast enough. You've got budget problems. You're -- you're out hiring mental health counselors like crazy, thousands of them. You got a 150 VA centers across the country, maybe more, all kinds of Vet Centers and CBOCs and all the rest of it. And you don't make me unhappy if you say we're not doing what we should be doing. We're failing some people. Policy says we were not. OMB says we can't say anything to you and at some point, see that makes all of this system kind of a farce.
I believe in you. I trust you. What I wanna do is they will trust your words. What you wanna be able to do is believe in your words when you answer our questions. I don't think you can at this point because you get a -- you know VA is huge, 12 million people work for it, whatever it is, and so there's a chain of command. And if somebody gets out of the chain of command, there's all heck to pay. Well number 1, that's not what Gen. -- the way Gen. Shinseki looks at it. It maybe the way you're supervisors look at it, the way the -- your departmental bosses look at it but we can't have hearings.
We can't make progress at the rate that we should. We can't praise you to the extent that we should. We can't criticize you accurately to the extent that we ought to and what you want us do because you'll have a prescribed statement that you give and a prescribed policy that you have to stick with. And that's just not conversation, that's not progress. And see I trust you more when you tell me that we're not serving a whole block of -- forget about detox for the moment, I'm just talking about, you know, women who are uncomfortable sitting in -- in waiting room with men because they -- they're doing PTSD or whatever it is or sexual kind of problems and they're uncomfortable sitting in -- in a room with men.
A very logical answer that you can give me, say you know that's true and the reason for that is that we don't have enough rooms in which to be able to split them up, so that they can have their privacy. And that -- you would say that hopefully only if it were true but my guess it probably is true because the -- the rush to attention under Chairman Murray and ranking member Burr about the general problems of veterans is just -- has exploded in this committee in the last five, six, seven, eight, nine years. It's exploded. We wanna help. You know, one of the reasons that I'm sort of glad that super committee didn't succeed is because you all are protected in the sequestered process, and you weren't in the -- in their process.
Now, I'm not saying they would have done any (inaudible), I just don't know but I just wanna hear the truth. Otherwise, we're not having a hearing. We're having a -- you're holding up your end of the bargain. We're trying to be tough questionnaires, you're trying to be touch answerers, and nothing is substantially accomplished from it. That's a deep, deep frustration, not just with you, the Commerce Committee and the Finance Committee and the Intelligence Committee. Senator Burr and I are on that. It's the same thing -- it's the same thing. People -- it tends to be less on intelligence because that's in the room where nobody can listen, including any of the bosses.
And so people tend to tell more truth there but we need to have that -- we need to have that. I wanna trust you. I do trust you but it pains me when I feel that can't answer the way you really wanna answer because you're not in the VA because of the money. You're not in the VA because it is a hobby. You're in it because you wanted to do good and therefore anything that stands in your way about doing good, you should rebel against. Now, that's a naive statement. You know, everybody in the VA turns into whistle blower but darn it -- I mean if you look at the coal mines in West Virginia, you can't whistle blow, so people died. If you whistle blow, you get fired, not by all companies but by a lot of them. You get fired.
How you get paid about $61,000 a year to be a coal miner. Well that's about five times more than you can make in anything else within a 100-mile radius of where you probably live. So, you don't take on the system and if nobody takes on the system, then, you know, you don't see progress. I got around that -- I got around that and Senator Burr might be interested in this. I will stop talking eventually.
(LAUGHTER)
But I had, you know, but -- but look what I had to do to get around it. I knew I wasn't going to get any legislation on mine safety. Let's just talk about, make that into whether it's PTSD or -- or mental health. I knew I wasn't going to be able to get legislation. So, I went to the chairman of the Security and Exchange Commission, Mary Schapiro and I said what would happen if you put up on your website quarterly reports on the -- the investment enticements that your -- and your profits and losses and earnings ratio and all the kinds of in financial information because you use that because you're trying to get people invest in you.
And in a very easy maneuver, she said, well from now on as I ask her to and she said she'd do it. You also had to publish all of your violations of mine safety and that's what happening. Coal mines don't like it. MSHA doesn't like it because sometimes MSHA is not doing the job themselves. So, the coal mines -- the coal companies say, well it's MSHA's fault and maybe it is MSHA's fault. I don't care so long as the truth comes out and in this case so long as investors can make a wise decision about whether to invest in that company or not.
We're going to do the same thing on another major problem having to do with cyber security but going around, let's say the process (inaudible) we can't get it done. So, we're having a horrible time trying to be helpful to you. Don't make it harder for us to be helpful to you by not telling us how we can be or saying I'm much more interested in what isn't working than I -- what is working because I assume that you're all doing a much better job than was true before, just because the whole part of the VA has risen, you know exponentially, impressively, amazingly.
And on all front, you know with all kinds of new pressures on them because of people coming back from Iraq and Afghanistan and the rest of it, and all the women's problems and mental health problems, and suicide problems, everything all at once, and then there's no money. Nothing wrong with you telling me that. We're not doing what we could because that I'll believe and that makes me in turn wanna help you.
But if you say our policy won't allow that which is the same thing as saying it won't allow it but it's happening. If you tell me that the policy won't allow that but it's happening, then I wanna help you even more because you are being fair and square with me. It's all I wanna say.

BURR:
The chairman recognizing me?
(CROSSTALK)

ROCKEFELLER:
Of course I do.
(LAUGHTER)

BURR:
I -- I thank my good friend. Just a couple of quick follow ups if I can. Dr. Schohn, oral testimony from the July 14th period, a deputy undersecretary Schoenhard said he wanted to "personally follow up with Andrea Sawyer and Daniel Williams to learn more of their story and what we can learn." Did you know if he followed up with them personally?

SCHOHN:
I do not. I did follow up with them personally.
(CROSSTALK)

BURR:
Did he ask you to follow up with them.

SCHOHN:
He asked me to follow up with them personally.

BURR:
OK and -- and what policy changes resulted from those conversations?

SCHOHN:
I don't believe policy changes have resulted from the. Again, I think the issue from my perspective is not about the policy. I think the policies are fine but I think to the point that I'm hearing is the implementation of the policy. So how we are following up is to ensure that the policies are implemented as they are intended to be. And we are in fact working ...
(CROSSTALK)

BURR:
Are you convince today that we still got an implementation problem?

SCHOHN:
I am.

BURR:
OK. That same hearing during an exchange with the chairman on reorganization of VHAs Mental Health Office, Dr. Arana said the plan was to get out into the facilities and "much the way the OIG does with an underground visits." Dr. Arana indicated he wanted to "deploy this effort very strongly over the next six to eight months" and wanted to come back and highlight the progress. How many sites had been visited?

SCHOHN:
We have visited one formal site. In terms of piloting the site as a program, we have scheduled the additional site visits that we had intended for this year. After discussion with Dr. Pretzel, we are speeding up our timeline in terms of doing the site visits to more facilities.

BURR:
And I'm reading something into what Dr. Arana said to us that I shouldn't have deploy this effort very strongly over the next six to eight months. Is -- is one site deploying strongly?

SCHOHN:
My understanding about Dr. Arana's comments was not specifically around the site visits. My office was started at the end of the March and the plan and ...
(CROSSTALK)

BURR:
Let me -- let me read you the quote again and I quote, Dr. Arana said the plan was to get out in the facilities, "much the way the OIG -- OIG does with underground visits."

SCHOHN:
And I think that is certainly intended. The timeline for making it happen I do not believe he intended to face six to eight months.
(CROSSTALK)

BURR:
He said very, very strongly over the next six to eight months.
(CROSSTALK)

SCHOHN:
Right. The six to eight months I believe referred to the set of followup actions that we had intended to pursue of which the site visits was something that was at ...
(CROSSTALK)

BURR:
Is it not important enough to do the site visits?

SCHOHN:
It's totally important to do the site visits.
(CROSSTALK)

BURR:
Why would -- why would we have only done one?

SCHOHN:
It's important to do them correctly. As I mentioned, my office was started at the end of -- at the beginning of -- the end of March, the beginning of April with the intent to set up a system to ensure implementation of the uniform services package. We have done developing the processes ...
(CROSSTALK)

BURR:
So, it took us nine months to set up the plan to determine how to gauge whether we're following the guidelines or not? That -- I mean I got -- you got to put things in layman's terms I think. Senator Rockefeller just -- just I think covered very eloquently that, shoot us straight.
(CROSSTALK)

SCHOHN:
Yep. It has -- it has taken -- we have to set up the right process for doing it. We wanna make sure that we're looking at the right thing. We have set up and implement a health information system, so that we have data going out there that we can validate and assure what's going on. We have been working with other parts of VA to ensure that we're doing these site visits in a way that's reliable and believable. Of concern to us is that in fact and to address your concerns, is that we are able to give you information that we believe is valid. We think that is an issue and we wanna make sure that we're doing it the right way.
(CROSSTALK)

BURR:
You know -- Senator Rockefeller has been on the committee a lot longer than I have. He has been around a lot longer than I have, come to think of it.
(LAUGHTER)

ROCKEFELLER:
Thank you.
(LAUGHTER)

BURR:
But since day 1, the first hearing the issue was raised, different administrations, so this crosses all lines. The issue that was raised was can't get appointments. I mean we can study the hell out of this but until we put a person on the phone, the job is whatever you do, get this person an appointment. It might be vicarious first, make sure they get an appointment. Accommodate their schedule, ask them how many doctors they see at the VA facility, try to schedule all appointments on the same day. Don't make transportation reason that they couldn't come back and get follow up.
We still don't do that. It's still does not happen and the only thing I'm pleading with you today is don't over-analyze this. This is not rocket science. The private sector figures out how to schedule appointments, deliver care, help people get better everyday. And in areas of the VA, we do it extremely well but it's typically one where they're inside the facility. We're not relying on them contacting us. They're in the room, they're not having a call for appointments. There's a floor nurse and physician that's in charge of them and we do a pretty good job. We rate number 1 hospital in the world but I'd be willing to bet if we got rated on everything else. We might be the largest but we're certainly not the best and if you did not win on customer satisfaction, I would be willing to bet we came in last.
One last question, on July 14th hearing, did you testify that VA was in the process of "developing a comprehensive monitoring system that looks all of the issues, implementing rates, combining the data into one place for all, so that VA can red flag barriers or gaps that exist quickly based upon VA's available data. This package will be finished by year's end." We're a month away, is it going to be finished?

SCHOHN:
Absolutely, in fact we've already started deploying it and we've been working with all of our business in terms of looking at the data and developing plans where there are problems and issues that is part of the whole site visit process, and we are fully on board with. I had the schedule.
(CROSSTALK)

BURR:
I hope you put into your equation your answer to a lot of issues today. We've got an implementation problem. I would hate six months from now to come back and to have your package out there, identifying deficiencies, barriers and the answer to be, what was -- you know, we've got an implementation problem. We were able to detect it but we've got an implementation. It's the right plan, it's just we got people that are implementing it wrong.
That excuse ain't gonna work anymore, so again I thank all three of you for your service to our country's veterans. I think everyday the VA tries to fulfill what their core mission is, I do question. I'd be very candid. I do question whether when we think about the 24 hours ahead of us, whether we see the human face of that veteran first. If we don't, then we're misguided, whether it's you or whether it's me from a policy standpoint but I thank you for being here. I thank the senator from West Virginia.

ROCKEFELLER:
And the thanks is very mutual. I think we've covered things here. I guess I just end up, one of my least favorite word in the English language is something called matrix. And a lot of people at the VA live by matrixes and you've got to be able -- in another words that's -- you were just asked a question by Senator Burr is meant to be done in a month and you said it's gonna be done. And I take -- take you at your word but matrixes can also really mess things up because they can -- they can cause people to rush. They can cause people to overlook things. They're not thinking things through carefully enough.
There's no way that I'm gonna win on the matrix issue. The VA is going to be ruled by matrix and obviously you can't have a large organization without real sense of control. And you can't have people going around saying all kinds of different things or can't you. If it's in front of Congress, I think you can and I think you should. I do use this OMB thing a lot which I'm not picking on you. I used it a lot because I know darn well that people -- and because of -- I also know that people who are giving the testimony and I know they don't believe the word they're saying but that's what they have to say because OMB changed their thing to make it, you know, contort.
And so, just take away the message that we enormously care about you. We enormously believe in you, that you're doing extraordinary work. You're accelerating faster than anybody except the new dot com world I guess and then make a lot of money doing that and you don't.
And the truth will set us all free because it allows us to fight for you, because we believe in everything that you're telling us. And the fact that you can't get people who needs to the next 24 hours as Senator was referring to, you've got 55 people and one small place that need attention in -- in the next 24 hours and your doctor gets sick or that we brought thousands of mental health professionals in, is amazing to me.
I don't know where you them because I thought there was a scarce everywhere but I'll believe you because I -- I wanna believe you but allow us to ask the questions because that's the way we work together well. It's not your job to like us. Nobody else does, so why should you.
(LAUGHTER)
But it's our job to support you and your mission. That's our job, the only job and so make it as easy as possible by always telling us the truth. Thank you and this meeting is adjourned.
________________________________________
List of Panel Members and Witnesses PANEL MEMBERS:
SEN. PATTY MURRAY, D-WASH. CHAIRWOMAN
SEN. DANIEL K. AKAKA, D-HAWAII
SEN. JOHN D. ROCKEFELLER IV, D-W.VA.
SEN. SHERROD BROWN, D-OHIO
SEN. JIM WEBB, D-VA.
SEN. JON TESTER, D-MONT.
SEN. MARK BEGICH, D-ALASKA
SEN. BERNARD SANDERS, I-VT.
SEN. RICHARD M. BURR, R-N.C. RANKING MEMBER
SEN. JOHNNY ISAKSON, R-GA.
SEN. ROGER WICKER, R-MISS.
SEN. MIKE JOHANNS, R-NEB.
SEN. SCOTT P. BROWN, R-MASS.
SEN. JERRY MORAN, R-KAN.
SEN. JOHN BOOZMAN, R-ARK.
WITNESSES:
MICHELLE WASHINGTON, COORDINATOR OF PTSD SERVICES AND EVIDENCE BASED PSYCHOTHERAPY, WILMINGTON, DEL. VA MEDICAL CENTER
RETIRED ARMY COL. DOCTOR CHARLES HOGE
BARBARA VAN DAHLEN, FOUNDER AND PRESIDENT, GIVE AN HOUR
JOHN ROBERTS, EXECUTIVE VICE PRESIDENT, MENTAL HEALTH AND WARRIOR ENGAGEMENT, WOUNDED WARRIOR PROJECT
MARY SCHOHN, DIRECTOR OF MENTAL HEALTH OPERATIONS, VETERANS HEALTH ADMINISTRATION

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