and we're going to out of the recent elections that took place in louisiana we have two new members of our committee one democrat one republican democrat is don and the republican steve scully's don as you want to special election to fill the seat of a former member of our committee richard baker is district covers nearly all the baton rouge metropolitan area and surrounding parishes to the north and south don has had a distinguished career as an attorney and a member of the louisiana house of representatives and he has an extensive background in budget appropriation issues and i think that will be a valuable asset to our committee mr as you we are anxious to get you appointed to one of our subcommittees and we'll bring that decision after our caucus formally meets to the next committee meeting welcome don and i just want to say welcome or whatever you louisiana as a graduate of high school he attended louisiana state university where year and a degree in computer science and minored in political science he served in the louisiana state legislature for twelve years and worked as a systems engineer for a technology company in new orleans well in the state senate served as the chairman of the louisiana senate labor and industrial relations committee our new colleague brings to the committee both invaluable legislate experience and expertise in information technology which will be good for the for the committee so again i'd like to think like to welcome both and case you i'm anxious to hear you pronounce your last name to the sisco lease of louisiana to the subcommittee on economic opportunity i know that both members eager to get started working with these two very crucial subcommittees committees adopted a resolution and i think the chairman you'll back my time i think resolution to assign  we are scheduled to move today h r twenty eight eighteen and also twenty one ninety two returned late on tuesday and really never got a chance to get into the substantive nature of this bill regarding the ombudsman i spoke with mr show last night on the floor and i know my staff had had some concerns i want to work with  find the best way that we can work through this mr chairman and i know that in last year's defense bill the same something very similar was proposed to do an ombudsman and the house senate negotiators were able to work work these issues through  and i believe we were able to do that and had meetings this morning so i was not able to speak with you about this and so i appreciate you moving to withdraw and not market this bill and give us the opportunity to work through it thank instead of veterans advocates and the purpose of the ombudsman legislation would be to make sure there are people working for the veteran and there's a point of contact an unknown entity so we'll consider that in the in the future thank you mr b you already about coming to louisiana to look at some of the issues and we'll be happy to work with you to do that welcome and thank you mr commission the thank you mr chairman h r twenty eight eighteen the veteran epilepsy treatment act of two thousand and eight men's title thirty eight to establish the epilepsy centers for excellent in the department of veterans affairs congressman ed perlmutter from colorado has been a champion for h r twenty eighteen according to the v a there are currently eighty nine thousand veterans and rolled in the v a that have been diagnosed with epilepsy as we learn more about traumatic brain injury we are discovering that many of those who suffer from t b i may also develop epilepsy h r twenty eight eighteen as amended designates epilepsy center of excellence in the department of veterans affairs the centers will be colocated with the  centers the primary purpose of the centers will be to conduct research on the diagnosis treatment and long term effects including epilepsy development as a result of combat the bill also established the working with us and in particular with with mr miller this is a prime example of once again the committee works best when we work we work together and when we had the idea of doing six centers and sort  spread out around the country without utilizing the expertise of the poly trauma centers probably was the most prudent thing and it was also something that you recognized and so to bring that and utilize that capacity is a good thing it and  minds and the most comprehensive care is readily available so i want to thank you chairman show for your considerations in working with us on this bill and you're back thank you and the other comments house for those who came in late we have postponed action on h r twenty one ninety two to our next markup and without objection the committee staff is authorized to make necessary technical and conforming changes to all of the bills to the bill reported by the committee open o hearing on implementing the wounded warrior provisions of the national defense authorization act for fiscal year two thousand and eight and the committee will come to order on this on this hearing participation well thank you chairman filner and ranking member bill your appreciate the honor to serve on the veterans affairs committee and as well as my colleague mr cathy you who served in the legislature but specifically in the new orleans region many all the parishes in my district are adversely affected by hurricane katrina but our veterans hospital has been closed because of the damage that took on from  number of issues i want to work on that involve all veterans across the country but specifically the veterans in our region have been dealing with a number of extra problems because of the closure of that hospital and before the work and through those issues with you and the rest of the members of this chairman we thank you and we welcome as you to the committee i would thank the witnesses for being in on this hearing officially we count over thirty three thousand service members have been wounded in operation enduring freedom and iraqi freedom i think we all know that due to improvements in both battlefield medicine medicine and incredible evacuation procedures and transportation those who might have died in past conflicts are now surviving many with multiple serious injuries such as amputations for medic brain injury and of course post traumatic stress disorder we have seen a lot of publicity on this and   inability to predict all of this and have the resources in place to deal with it we are trying to catch up and do that the wounded warrior provisions of the two thousand and eight national defense authorization act were tended to do just that many of them require the department of energy affairs in the part of the fans to collaborate to improve the care and management transition of recovering service members the hearing today will explore the progress that the two departments have made in implementing these provisions thirty two warrior transition units have been established in the army to try to improve care management injured soldiers are now assigned a primary care manager nurse case manager in a squad leader to guide them through their recovery the rapid creation of these units appears to be excess however according to g a o several challenges remain including hiring sufficient medical staff in a very competitive market replacing temporarily borrowed personnel with permanent staff and getting eligible service members into those units in december of last year the v a in cooperation with the d o d and department of health and human services established the federal recovery coordinator program to coordinate clinical and non clinical care for severely injured and ill service members as of may of this year there were only six field staff members working with the eighty five patients at the three sites i want to look in today at how effective this program has been and how will be expanded to benefit more of our veterans as these veterans transition from the military health system to the v a system they face the difficulty of navigating through two different and cumbersome disability evaluation systems the current system is a source of stress and frustration for many veterans  last november both the odeon v a jointly initiated a one year pilot program to evaluate a streamlined evaluation system i hope they will be able to expand this program and today we'll hear how that's going we all know that post traumatic stress disorder p t s d and traumatic brain injury or t b i as are considered to be the so called signature injuries of this war according to a rand corporation report that came out last month or two months but a month and a half ago nearly three hundred thousand veterans of afghanistan and iraq are suffering from p t s d or major depression and nearly twenty percent according to their figures and which i will see i think is a low one  reported of probable traumatic brain injury during deployment by the way that three hundred thousand estimate which again i think is low compare that with the official casualty number of thirty three thousand and there is not just a minor discrepancy between the two figures i think we were going to have to ask the pentagon to to deal with these casualty figures in the far more i think realistic terms and we want to get your real feeling on that as we will hear many veterans are not getting the care that they need and deserve only forty three percent of those reporting a probable t b i have been evaluated by a physician for brain injury and only half of those who meet the criteria for p t s d or other major depression sought help from a position or mental health provider this is simply not acceptable and we have to do better again last year the department of defense established a center of excellence for psychological health and from out of brain injury and i want to see how the v a and the odio working together to conduct research in these areas develop  best practices certainly a point component to improve continuity of care is the development of an interim bearable electronic health record which would allow for the seamless transfer of medical information between departments i think we have made some significant progress toward improving care and transition but a lot of work needs to be done and that's what this hearing is about today so we look forward to informative hearing our first just want to say before we start hearing that no matter where we stand on the war and the war is a pretty divisive thing in this country and in the congress we are united in saying that every young man who come or woman that comes back from that war get all the health care and the seamless health care that they need in the benefits they have earned i will yield to mr bill you're the ranking member for his opening statement and the quick comments from the rest reports for a reason and i almost can't help but sense we're a month early with the hearing and i know that you're really eager to move out here but we have there are eight progress reports that were set forth in the in the defense bill section sixteen of the bill require g a o to provide an assessment of the implementation of the wounded where provision six months after enactment since that deadline is next month g a o is unable to provide this assessment because it's only recently began its review of the implementation provisions and it would not have been able to provide an in depth analysis for the committee did indicate that based on the initial assessment have not finalized a policy nor have they begun implementation of many aspects of the defense bills mandates while this is a concern i feel that it is really premature at this point to criticize the department's progress based on incomplete information submitted before the benchmark requirement therefore my counsel during this hearing will be provisions must be implemented with a sense of urgency sixteen months of passed since the washington post news story revealed some of the instances of inadequate housing of soldiers at the walter reed army medical center discharge process over the past fifteen years one commission and a task force report after another has called for measures to streamline the transition process but such changes have not been implemented therefore i was pleased that this year's defense bill contained these provisions that we had worked on together that amendment in particular we were able to focus on the use of the uniform separation exam and evaluation that could use for rating decisions the electronic fourteen is something we talked about for years and i'm glad they're finally moving moving toward that the real time access to veterans medical history by requiring electronic exchange of critical medical information between the need for this electronic exchange of medical records was amplified appalled that that was being done now obviously things were being done in transition of aromatic medivac but you know we talk about getting to the electronic medical record but we still have a long way to go so chairman  ask of you and i think that's what you've done here by moving out here today but we're going to come back and and hold them to the timelines on their progress report thank you mr bill you're i would just say we are in  sixth year in of the second longest war in american history and we are way late on these things not to early anybody want to just add any comments before we mr chairman thank you as a member from florida with my other colleagues we have a lot of veterans coming back from the war into florida it's one of the largest and fastest growing veterans population in the country and i think mr chairman as you pointed out this traumatic brain injury if i veteran suffers from that that in turn could create a high incidence of post traumatic stress syndrome so obviously members want to know what's being done to stand on their title seventeen of the wounded warriors acts specifically requires a secretary of the v a to develop an individualized plan to help rehabilitate and reintegrate back into our community service members who receive care at the v a for t b i the act also requires a v a to assign a case member for each veteran suffering from t v while also explicitly stating the family members of the veteran members of the veteran with b i should be involved in the development of this individualized plan this is good i'd like to obviously hear how that's progressing just as a side note mr chairman if in fact a person suffers traumatic brain injury and this causes post traumatic stress if we could through a blood test immediately on the field of battle or after the fact and comes back through a blood test determine if there is this traumatic brain injury that would indeed give us insight immediately and how to care for these individuals there is a company in my congressional district called banyan corporation that we have helped funded for many years to develop this blood test and they are on the cost now making this into a proud product that the military could carry into battle and actually toughest the blood samples of an individual to see if they have traumatic brain injury and that in turn would give us a head start on post traumatic stress and i say that i'm so obviously bragging about this company we've funded it over the last six seven years and there are real possibilities mr chairman my colleagues that this will be into a quantitative case and not into a qualitative case where we're trying to understand the veteran who comes back to fill out forms and things like that but we need this urgently to be able to help the veteran even though pete perhaps he feels there's no problem but this blood test is on the cusp of being into a device that can be manufactured so i look forward to the hearing and i think as i've pointed out in the title seventeen the v a has a heavy responsibility to integrate these individuals and to help the family members develop this individual plan so i look forward to the hearing and thank you mr chairman thank you we will start then the first panel important contribution to our standing of the issues mistake ochs will focus on the key findings on psychological cognitive injuries and missed a million we'll focus on the recommendations for addressing these injuries  viewer and distinguished members of the committee thank you for inviting us here today to present on the rand study invisible wounds of war it's an honor to be here my testimony will present the results of the study which was conducted independently of the d i d n b a and takes a broad perspective on three consequences of war post traumatic stress disorder p t s d depression and traumatic brain injury or t b i among service members returning from iraq and afghanistan my colleague terry two million will follow with recommendations for addressing these conditions since october two thousand and one approximately one point six million u s troops have deployed to these theaters at a pace unprecedented in history of the all volunteer force advances in both medical technology and body armor mean that more service members are surviving their combat experiences however casualties of a different kind are because beginning to emerge invisible wounds such as mental health and cognitive impairments resulting from deployment experiences first i'll discuss our findings relative to p t s d and depression our telephone survey representing all previously deployed individuals found substantial rates of mental health problems in the past thirty days with fourteen percent screening positive for p t s d and fourteen percent for major depression some specific groups previously understudied including the reserve component and those who have left military service may be at higher risk of suffering from these conditions but the single best predictor  d and depression is the number of combat traumas experienced while deployed only about half of those with current p t s d or major depression had sought help for mental health problems in the past year and only about half of those that thought care received a minimally adequate treatment the number who received quality care would be even smaller many barriers inhibit veterans from getting help from their meant for for their mental health problems including concerns about treatment leading to negative career repr questions and also concern that treatment might not be effective unless treated both p t s d and depression have wide ranging and negative implications that affect work family and social functioning including substance abuse homelessness and suicide that's early intervention is needed to help stem this cascade of negative consequences in dollar terms the costs associated with p t s d and depression are substantial we estimated costs incurred within the first two years after service members return home to range from four to six billion dollars our cost model assumes the status quo in which the minority of individuals with p t s d and depression actually get treatment and the minority of that care is acceptable quality of care if we assume high quality care goes to every person with p t s d or depression we see that by increasing treatment costs the societal costs are reduced by as much as two billion dollars in just two years for active duty personnel in particular personal and cultural factors impede the use of services as do structural aspects of services such as wait times and availability of providers we identified gaps in organizational tools and incentives that would support the delivery of high quality mental health care to the active duty population and she retired military who use tri care the v a prop provides a promising model for the d and quality improvement in mental health care however it faces challenges in providing access to veterans many of whom have difficulty securing appointments particularly in facilities that have been resourced primarily to meet the needs of older veteran improving access to mental health care for veterans will require reaching beyond the d o d and v a healthcare systems but it will be essential to ensure quality care in these systems i'm not going to turn to our results regarding t b i traumatic brain injury in our survey we found one thousand percent i during deployment although we don't know the severity of that injury or whether there whether the injury caused functional impairment of those reporting probable t b i while deployed fifty seven percent had not been evaluated by a physician for a brain injury in dollar terms we estimate one year cost for mild t b i or concussion to be about thirty thousand dollars largely due to productivity losses in contrast from moderate to severe cases costs are about ten times higher and are due mostly to mortality cost the medical science for treating combat related trial t b i is in its infancy research is urgently needed to develop effective screening tools as well as to document what treatment and rehabilitation will be most effective in terms of the service systems f gaps in access to services demming from core documentation of blast exposures and failure to identify individuals with probable t b i service members with more severe injuries it's a different kind of access gap lack of coordination across the continu care thank you for the opportunity to testify today and share our results additional research results are available in my written testimony and also available at veterans dot ran dot org thank you thank you very much  representative here and distinguished members of the committee thank you for inviting me to testify today is an honor and pleasure to be here my testimony will briefly discuss several recommendations for addressing the psychological and kind of injuries among service members returning from afghanistan and iraq the purpose of these recommendations is to close the gaps in access and quality for our nation's veterans but dr j cox described a report offers for recommendations that would improve the understanding and treatment of p t s d depression and t b i among combat veterans first our report recommends an increase in the number of providers who are trained and certified to deliver proven or what we call evidence based care there is a substantial unmet need for treatment of p t s d and depression among military service members following deployment both d o d and the v a has had difficulty  recruiting and retaining appropriately trained mental health professionals to fill existing or new slots with the possibility of more than three hundred thousand new cases of mental health conditions among iraq and afghanistan that a commensurate increase in treatment capacity is needed since there is already an increased need for services the expansion in train providers is already several years overdue with an existing shortage of mental health professionals in the us health care system more broadly this is become a critical pipeline issue such investment could be facilitated by several strategies including adjusting financial reimbursement for providers to offer appropriate compensation incentives developing certification prophecies to document the qualifications of providers and establishing regional training centers for joint training of d o d v a and civilian providers and evidence based care for d and depression our second recommendation is to change the policies that would encourage active duty personnel and veterans to seek needed care many service members are reluctant to seek services for fear of negative career rep or question policies must be changed that there are no perceived or real adverse career consequences for individuals who seek treatment except when functional impairment compromises fitness for duty such policies require creating new ways for service members and veterans to obtain treatment that are confidential off the record off base and during off duty hours currently information about being in treatment is available to command staff even though treatment itself is not a sign of dysfunction or poor job performance providing an option for confidential treatment has the potential to increase total force readiness by encouraging individuals to seek health care before problems accrue to a critical level third to close the gap in quality our study recommends delivering evidence based care to service members and veterans wherever and whenever they are served treatments for p t s d and depression very substantially in their effectiveness and while the most effective treatments are being delivered in some sectors of the care system for military personnel and veterans system wide implementation remains a problem the delivery of evidence based care to all veterans with p t s d or depression would pay for itself or even save money by improving productivity and reducing medical mortality costs with within only two years the v a is at the forefront of trying to ensure that evidence based care is delivered to all of its patients but it is yet to evaluate its best of these efforts across the entire system nor will the v a serve all veterans transformations are required to achieve this needed improvement in quality of care for veterans for example providers delivering treatment to veterans must be held accountable for the services they are providing tri care and the a could require that all patients be treated by therapists who are certified to handle the diagnosis orders of that patient and use varying payment systems to incentivize the delivery of evidence based care monitoring system should also be used to ensure quality and coordination of care our final recommendation calls for investing in research to close information gap and plan effectively for the future better understanding is needed of the full range of problems that confront individuals with post combat p t s d depression and t b i greater knowledge is also needed to understand who is at risk for developing mental health problems and who with small farm bill to relapse at the same time policymakers need to be able to accurately measure the cost and benefits of different treatment options so that fiscally responsible investments and care can be made a coordinated federal research agenda on these issues within the veteran population is sorely needed such a program would likely require resources and access of that currently devoted to p t s d and t b i through d o d and the v a and could extend to the end i h the substance abuse and mental health services ministration the c d c and the agency for health care research and quality addressing p t s d and depression as well t b i among those deployed to afghanistan and iraq should be a national priority but it is not an easy undertaking the prevalence of these injuries is relatively high and may grow as these conflicts continue and the long term consequences associate with these injuries if left untreated without evidence based care can be severe the systems of care available to address these conditions have been improved significantly but critical gaps remain system level changes across the entire u s health care system are essential if the nation is to meet not only its responsibility to recruit prepare and sustain a military force but also its responsibility to address service connected injuries and disabilities thank you again for the opportunity to testify today and to share our research findings and recommendations and thank you both very much mr snyder and if you have any questions you recognize treatment and that people need to be trained and that if i were today decided to quit this job and i wanted to become that kind of a trainer where would i go and how long would it take me that's an excellent question and we recommend actually we develop regional training centers that would offer this type of training and evidence based care currently at sparse in different locations around the country and we would need additional training centers also asked d cox who is trained in some of these evidence based therapies to comment i think one part of your question is who who can be trained and normally some degree of clinical training before you get training in evidence based treatments is required but that doesn't necessarily mean just psychiatry and psychologists and social workers marriage and family therapist there's many different people with degrees who would be ready to take up this kind of training and the d o d is rolling out a number of the training programs among residen and providers within their system so there's you know a number of different efforts to bring these kinds of treatments into the both the d o d settings and isn't one of the problems here we have a i mean my impression is we have lack of general mental health providers in this country anyway already right you do that and so if we're talking about is trying to take this pool that we think is an adequate for the country and get some of them to take additional training at these regional training centers in the specific treatment modalities for p t s d and the depression and because i think you're talking about we're still going to have the same shortage of providers or we don't we have a shortage of providers in the us now health care system that's why we identified it has a pipeline issue we do need to think about the pipeline of individuals going into mental health professionals professions as well as those paraprofessionals that dr j cox described and how they could be trained as well and these particular types of approaches we need to kind of think broadly because we need a large investment to get the required expansion as soon as possible one of the issues that comes up sometimes is that there is an interest to meet this ne  and having probably people that with quite limited mental health treatment background you know but who may have been better in some cells or had been in combat themselves i don't see anywhere in your writing that you're suggesting that we omit step one which is some basic background of education and clinical experience in providing treatment to patients and folks with mental health issues would you elaborate on that yeah i agree that there needs to be some basic baseline clinical training but there's also roles for other types of people in the treatment process we know that support and help with transitions is extremely important for reducing p t s d and depression symptoms so for instance in the vet centers that role of helping people work out their financial problems their employment problems their family problems is important as well and in addition there's some new models but integrate care for instance in primary care where the primary care physician can serve as sort of the the point of contact then would help decide which patients need to go into the more intensive psychotherapy approaches for instance and their primary care physicians can be trained to deliver the medications with psychiatric consultation not just so that individuals when have to see psychiatrists completely but could also work with their primary care physician one of the things that happens it seems to me with mental health services is a person goes to see you talk about this i think this to a person goes to see their mental health provider they spend time with them then they come out with their slip that says counseling or just something very be delivered you don't know what happened in the room the problem is it seems as it is that part of the issue it makes it difficult to evaluate what has been a fact they were not affected or if the person is being paid federal dollars is providing the kind of what you call evidence based therapy would you comment on that absolutely our health care system is designed on a reimbursement system that only ask providers to record the number of minutes that they saw the patients are now three suggests that we need to break down the black box of what's happening in these sessions and require accountability so it would be more informative for both evaluating the types of care that's being delivered as well as just to put this in perspective how many and this is question for each of you can answer separately how many if any of your recommendations were  that it's a different system of care that we're looking at by and large except for in terms of moderate to severe so i don't have an exact answer for you do you it's an excellent question and i think that we could look a little bit more closely at the specific provisions the entire u s health care system terms of the pipeline issues providers who are going into these professions is well as the systems that would need to be in place to ensure appropriate quality in terms of the evidence based care that's being delivered to the veterans so you're also talking about the private sector to absolutely that a number of veterans will be seeking care outside of the d o d and the v a health care systems in the private sector as well as the publicly funded health care sector maybe it's difficult for you to answer if you took the v a d o d and the private sector and you if you could rank them into your professional opinion in terms of the quality of mental health care and traumatic brain injury care   conscientiously monitoring and trying to enhance quality both for p t s d and depression the deity is rolling out a lot of programs but it's not yet monitoring the quality of those programs and the civilian sector i would say is behind both of them is that your opinion also that the veterans administration is way ahead of the private sector as well as d o d yes at the v a have a number of tools in place that they're using already as dr j cox described to increase the level of evidence based care that's delivered to its patients as well as to monitor and incentivize the delivery of that type of care d o d also has similar tools that they're now able to roll out the civilian sector while there are some models out there for decades the veterans health care systems as well as military health systems have led the field particular around the tree p t s d you probably heard my opening statement in which banyan corporation which is affiliated with the university of florida which i represent has done this research to depression so not during during  what does rand define as minimally adequate care for mental health conditions do the different policies and procedures among the services in v a impact the delivery of mental health care and t b i care if so in what way and does a public law one ten dash one eighty one address any of these issues you talk about the definition of minimally adequate care first we defined it in a way that's similar to the way researchers are doing in the civilian sector and that  is that if people reported having counseling or psychotherapy that they have at least eight sessions of psychotherapy that lasted at least thirty minutes each in the last year so really it's just talking about an amount of time in therapy and for medication that you  visited a doctor at least four times and stayed on the medication as long as your doctor wanted you to so it's again it's sort of a dose of therapy rather than talking about the specific type of therapy or the type of medication provided your remarks that society costs actually could go down by as much as two billion dollars if they received treatment earlier is that for the veterans themselves or is that include  their families the cost to society because of the families affected as well thank you for letting me elaborate a little bit on that the cost in our model included lost productivity at work both present absenteeism being able to function less well on the job lives lost to suicide and treatment costs directory we were not able to factor in things that we know exist like difficulty with family  members divorce substance use because there aren't good dollar figures to attach to those to be able to put them as assumptions into the model so really the gains with treatment have to do with increased productivity at work lead to alcoholism or drug abuse and they're incarcerated than that burdened put on to the cost of castration is put onto the county or state part of that cost incorporated in that as well know so that kind of cost is not incorporated just work productivity suicide and treatment costs and they're very conservative estimates because as you point out there's many other costs that we are aware of when you talked reimbursement and they can do a better job not only that it's about reimbursement that they're and an investment in research as well as in training and rolling out evidence based practice guidelines to train providers in the delivery of evidence based care as well as the use of tools that they have within the system such as electronic medical record that would enable them to kind of monitor care you'd mention that they were actually regional  and do you see a disparity between urban versus rural and getting the help that individual military or veterans need sure we recommend the establishment of regional training centers to train providers in this type of care it's not that they exist already and there is a lot of variation in accessibility of care between urban and rural areas those that may be further away from military installations and v a health care facilities will have greater difficulty in getting services in those types of settings and will turn to their community based setting in sector for care and that is why civilian providers would also need to be trained in delivering evidence based therapy as well as be trained in kind of the military culture and being sensitive to these special issues and treating military service members and veterans where would you suggest that these facilities would be located when you look at the demographics of our  that's a great that's a great question we are hoping to do some further work on that and i think there's some work underway also to actually map out where where service members and veterans are and where the facilities are and figure out the areas of need but we did not analyze that in th report in my last question is that when you look at the department of defense you look at the v a system and in what's happening out there in the private sector there definitely is a shortage d for those type of health care professionals as well as in the v a system but as the war winds down there probably be less need in d o d but more need actually to be a system have a look how those two over time and to look at the capacity that will be required in five ten years and where that capacity would be best placed we have heard anecdotally that there is a shifting of providers from our community based mental health doctors to either the d o d or v a now because they're hiring and so we're taking providers from what is an already shortage area and so that's why we identify this is a major pipeline issue for the entire u s health care system thank you very much you're recognized thank you very much i was wondering you talked about evidence by scare as in contrast to what we discussed you know some of the things that are going on the trip concerned about there have been some studies of it but really it's more diffuse supportive type of therapy without using the specific techniques that we know to be effective we have a whole section in our report that discusses the evidence based care offering the best that we know is available which offers higher recovery rates but is not perfect either you mentioned i think eighteen and a half percent p t s d and depression how is that in contrast to the just the general services t our sample everyone had been deployed but we had a group of people who had not been exposed to any combat exposures while deployed so no no experiences of loss or traumatic events and we found very low rates of  depression there one percent for p t s d and three percent for depression so that gives you an idea because i guess the other i think it probably is important to find that out and then to just the general population you know what what kind of depression in the general civilian population about seven percent will experience depression in the year and only about three and a half percent will experience p t s d and even the other problem that you mentioned was you know people not reporting you know the fact that they were having a problem can you talk to us about specific things that you feel like we can do a better job of to we asked service members what would get in the way of getting treatment and as we mentioned three of the top five barriers had to do with concerns about negative repercussions on career thirty got there yet i think you also said the right of reporting was about the same as the general population and i read that the rate of reporting  that service use was about the same as in the general population yes that's true we do have difficulty getting individuals with mental health problems in the civilian sector into care as well here though the types of barriers are very different in the civilian population it really has to do more with access and here everybody has access to some type of care and it's really about concern around negative career progression so that was a striking difference thank you very much mr chairman i yield back thank you for your testimony thank  you mr snyder would just like to physically look at that book if you would mind passing it around and if he doesn't pay for it we'll get back to we'll get him for thank you mr mitchell  mr hare thank the chairman i just have two questions mr million you mentioned in your testimony that slightly more than half of those that are suffering from p t s d and depression are receiving minimal minimum minimally adequate care can you describe what you mean by that and also what are the long terms of the long term effects of the inadequate care what might they be what are we looking at here sure  half of those who had sought care professional in the past year have received what we define as minimally adequate which really was about the amount of time they spent in either therapy or the number of times they visited the doctor so if they were getting medications it was four visits to a physician in the past year and taking the medication as long as they were recommended to if they were in therapy or counseling it was visiting a therapist for eight at least eight days that of thirty minutes in duration so this is really just a minimum a minimum dose of therapy without treatment or with under treatment we know that there are long term negative consequences with having p t s d depression and t b i including impairments in relationships homelessness increased risk for suicide problems   wherever in whichever sector they be offered the latest evidence based therapies and treatments that have been demonstrated through research to yield higher recovery rates so faster recovery as well as more time without symptoms improve the care that's a really good question there are a number of screening efforts underway and unfortunately you know there's some concern that service members and veterans don't want p t s d or depression diagnosis on on the record in their personnel file and so it's tricky to figure out a way to screen them in a way that you know will benefit them and get them into care without you know concerns about negative career over question i think the more that the military can do to encourage care to make it acceptable seen as a sign of strength to receive mental health treatment post deployment the more and more service members will be willing to seek out those services to symptoms when they're screened well the chairman has advocated for a long time and i completely agree with him that we ought to be screening everybody so that that person doesn't pass identify themselves as having a problem and then there's a whether or not that's go affect whether or not they're going to be able to dance and rank or whether it's going to affect them in their jobs so would you concur that that what we should be looking to doing is screen everybody that comes back in but no exceptions and also then monitoring them for a longer period of time because a lot of times as i understand it and i have a vet center close to my congressional district office a lot of this doesn't just happen in a matter of weeks or months it could be down the road plus you know that these are things that affect not just a service person but their entire family in that there are mandatory screenings post deployment and now three to six months after return but those again are imperfect and that service members might not be willing to admit to symptoms when screened they agree that long term follow up is necessary research is necessary to follow individuals over time and track and see how they're doing and particularly around traumatic brain injury where we know so little about the functional impairment the long term military encounters is likely to more likely to to cause symptoms p t s d or other mental health issues and the reason i ask this question is can we get to the point in which we know a cause for the symptoms so that we can attempt to eliminate the cause are there studies that show number of deployments length of deployment or physical or mental issues characteristics of a particular individual cause a greater propensity to to encounter p t s d so we were able to look at that in our study we have data on the kinds of experiences they had number of deployments length of deployments and we found a number of predictors of heightened risk for p t s d and depression including and listed versus officers marine and army versus navy and air force women and hispanics are at higher risk in our data we also have reserve and those who have left military service at higher risk length of deployment is related but the single best predictor is the number of combat traumas experience so if you control for everything together really it's that that drives the rates  p t s d and depression we that's a very common experience we only have about ten or fifteen percent in our sample who have not experienced anything like that while deployed particularly in these conflicts it's quite common to be exposed to an explosion or have a life threatening situation regardless of whether you're have a combat duty m o s or not and is the because of unwillingness to a fair amount of peer review and is is able for i think for the first time to kind of look across the different sectors have more than many of the prior studies focus on one combat unit for instance at a particular point in time and ours is a cross section of  a wide variety of individuals who've been deployed so that that offers something new and also we're able to complete confidentiality to everyone we interviewed so it's annoying to any personal record is are these traumas that are the  common denominator or are they things that are experienced by everyone and that's not the right word or they are the experiences that are common in military service such that they couldn't be eliminated  part of military service so you couldn't eliminate that depression the most common are things like having a friend seriously wounded or injured or killed having witnessing an accident or life threatening event personally experiencing those types of events so they're part your review of where we are structurally how we deliver services and this may be you may have answered this question with with mr michel's question is there a differential in services available and qualitatively in rural versus other settings are we are we shortchanging rural veterans there's why variability and the accessibility of services across the country and each of these systems we do know that those that have a harder time getting access to military installations or v a facilities will turn to community based providers where they could also get thirty seconds for mixed firing but this is one of the issues that i want to explore further i've had several meetings with kansas we have mental health centers that are really the public sector providing a middle health services and they tell me that they have the willingness and the desire to to treat veterans but have no particular relationship with them and so just structurally i want to see how we combine the department of veterans affairs and their outpatient clinics their hospital settings and vet centers with the community based services that are really what we have in rural america there is no vet center no v a hospital in the congressional district i represent there are community mail health centers and yet they would like the opportunity to better avail themselves and cooperate with them if you have thoughts about that i'd be glad to hear from you aside from the setting thank you very much like this german you mr chairman i would actually like to hear your response to mr moran's question i represent the entire state of south dakota and we have vast rural areas and i recently was in aberdeen south dakota in the northeastern part of the state visiting the community based outreach clinic where a to the rural veterans through the community based outreach clinics i do agree with mr moran that whether we have the box or medical centers we also have community mental health centers that are i think ready and willing to work with the v a could you specifically talk about anyone else if you did with seebach we did not do any specific analysis with the c b x however mental health clinics as well as private providers in our community setting do provide another avenue for veterans to get care and our recommendations would call for ensuring that even those providers be trained in delivering evidence based care so that wherever our nation's veterans seek care they can be afforded the best care available and that's consistent with what i've heard from veterans as well and veterans service organizations that concern that there is some specific training if indeed we are looking to contract with people outside of the v a system to provide that level of care a couple of other areas i'd like to follow up on based on your response to earlier question could you discuss why women are greater risk for p t s d and if there are any different barriers to women veterans getting access to care than what you found in many different theories about why that might be but it's not specific to the military life in terms of specific differences in barriers and such we haven't broken it out that way women only comprise about fourteen percent of the military force and in our sample that's the same so we aren't able to really break out the numbers we would like to look at that it's a very important question and look at the specific kinds of traumas they experienced all in addition to whether or not they experience military sexual trauma for instance but we have not done that in the study why appreciate your desire to want to look at that closer ms brown weight and i've introduced a bill specifically working with the disabled american veterans and others to address the issues of barriers to access to health care across the board for women veterans so we hope to continue to get more information not only in the provisions in our legislation we hope to advance but also in the work that rand another's will be doing  one other question as it relates to the avoidance issues and the stigma that we know continues to exist as it relates to servicemembers and and you know the civilian public as a whole seeking access to mental health care one of your recommendations is to quote change policies to encourage active duty personnel and veterans to seek needed care unquote so the v a has done a terrific job trying to get a grasp of this problem the d o d s rolling out these programs  but what specifically can you talk a little bit more about your recommendations as to who who carries what level of responsibility to seek the care and do the outreach to veterans to get them across  avoidance issues not just in the initial access to the care but then as you mentioned dr admitting to the sometimes during the treatment short we know that stigma is a problem in the general population but for military service members active duty in particular concerned about the impact that getting mental health care may have on their career were really quite paramount in terms of the barriers to getting health care so it required disclosures about getting mental health counseling or services policies that require that you report mental health counseling would be those that could be amended such that there would be no perceived or real adverse career consequences associated with getting mental health care tax anything that i just would add there is a concern about the large number of people who have separated from the military but have not yet crossed into the v a and that's a population that you know the v a is doing outreach efforts but it kind of unclear who is responsible for them that they may be seeking care from a variety of different sectors and we need to worry about how to draw them into care more effectively well that's a good point and one of the things that we've been working on with our subcommittee and the full committee is sort of that group that separated from service and what they also are now qualified for those in the national guard reserve separated for education benefits based on their deployment they may not even know they have those education benefits because we're not able to easily connect with them but certainly i think that the state adjutant general and some of our states have developed a good working relationship in which we're trying to share best practices to be able to not lose track of these veterans and allow them to fall through the cracks as we know th one access for rural veterans and specifically women women's care that we want it we're going to series of field hearings and also hearings here so those are two important house and senate and section sixteen eighteen we are asked that the secretaries of both of these departments work together to develop a joint plan and they're going to get to get that to us in in july now part of this joint planning between the two apartments what we wanted to focus in on is prevention diagnosis mitigation treatment and rehabilitation of the research on traumatic brain injury post traumatic stress disorder and comprehensive plan we wanted the assessment of current capability dedication of gaps in current capabilities and then the identification of the resources then we went with specificity and identified twelve elements that we also were but of this what we've done so you can be very helpful here is by saying ok based on your research in this and what we've done in the defense bill are we on the right track that's my question i would say that i think we are on the right track i think the increased attention and the investment in improving the services and the programs that are available on both and the v a with specific focus extend beyond these two health care systems there is a pipeline issue for the training of providers that go into these particular professions well beyond these two agencies there are also concerns about the level of care that is provided in the civilian sector in these community based settings as well and so one of our major conclusions is that these issues extend beyond the day and will require transformation and system level changes across the entire u s health care system i agree with you it's one of the reasons why we  and then whether it's a medical discharge or not a medical discharge and now they're out in the private sector contract based care whether it was an approved provider when you get into all these complexities and so i can i can concluded that three hundred thousand of the one point six million who served in iraq and afghanistan have symptoms of post traumatic stress disorder or major depression the three hundred thousand is that a possibility or a fact so that's that's a possibility that's an estimate based on our numbers we have we were able to use state of the art testicle technique to the deployed population and when you were doing your sampling obviously you were talking to service members and the diagnosis or is this actually my doctor says i have neither of those we actually assess all the symptoms so we asked them have you had trouble sleeping in the past thirty days have you had nightmares all of those questions that  being the doctor over the phone well there's standard surveys that are you that maps very well on to a clinical diagnosis so we use ones with good psychometric properties that map onto a clinician diagnosis with reasonable advocates is something that i would i would really like to see is tackle because i think that getting them into the system and having someone help manage it is critical and i would applaud the secretary peak and his staff for addressing that issue one of the things we've seen in the state of minnesota  of twenty two states that has got a veteran service officers that are used as the point of contact something we've asked for is what state of minnesota does with national guard soldiers they've captured all of them by the returning soldiers because they have that data and ninety nine percent of them and some of the every data seems to show that by capturing them early getting in the system early we see a lower occurrence of p t s d and some of these things which i think is a positive and i applaud them drunk as are some institutional barriers here hipaa laws those types of things of trying to get there but i but i agree that's the way to go the question i'm going to ask you is a bit subjective i know but i'm just trying to get at this you heard it from representing versus family mr moran i do like many of these wrapped up sprawling districts with very rural areas and the issue in these areas is not being able to go down and choose another provider there is simply no one that provides mental health care at all in the region forty percent of these iraq afghanistan veterans fall into that category my question to you is there was a lot of talk last year in the requirements we put in   is there anything out there that showing that that works is it a way to go is it is it is it a cost effective as well as an outcome based affective way to do this and there's a number of models like that that are under study but we don't have the answer  yet but there are things funded by and i for instance that are really trying to bring bring these kinds of services to people in rural settings using telehealth models and so we should know that in the coming years but there's not good evidence yet your advice would be just we need just wait and see as that comes out it and i mean i'm wondering if there's anything out there any other studies in any other way from the civilian sector that this type of you know tell if there is working i think these kinds of cognitive behavioral treatments that are the evidence treatments for p t s d and depression lend themselves well to internet based and therapist supported telephone services so i think there are models that could be begun to roll out sorry i missed your opening statements but i've been perusing them during other questions based on what you said about stressors in this tenure for v a compensation purposes should the v a use a broader definition of engaged in combat with the enemy that goes beyond infantry activity or direct participation in in an attack i'm thinking about the incoming rounds in the green zone where i slept last october where people never know when they hear a shell coming down or a rocket round coming down it's going to hit them or land right next door or for instance somebody traveling in a convoy in witnessing the vehicle in front of them being hit or civilians being hit we've heard stories of nightmares and depression and so on from people like this who themselves been engaged in what's conventionally called combat yes so the nature of  exposures on the battlefield has really changed quite dramatically with these particular conflicts because the risk is more dispersed and so we are seeing individuals who are not in typical infantry roles or military combat roles that are being exposed to traumatic events while they are deployed and so our data did show that the types of exposures that are predicting p t s d are relatively common in those who've been deployed that's good to hear because we have a bill that the  four four to six point two billion dollars over two years in two thousand and seven dollars that would seem to indicate that we don't know yet what the c p o estimate will be on this  productivity and other causes that you mentioned here i'm not asking for an answer that it's just i'm just interested that you're you're putting a number on treated p t s d that runs well into the billions of dollars regarding women's health and mental health what i've heard and not just from the services but from the service academies is that  women and women's experience in combat is not just the same type of trauma that men have but also the problems of sexual harassment and the change from an all male or mostly male force to only seventeen percent now but it's still the largest percentage of women i think serving ever in our country's history in our armed forces and that many of them when they come home can't or don't want to take part in a discussion group or an encounter  session with a bunch of guys who are veterans because their experience is so different is that something you can countered unfortunately we did not look at women separately in this in this study and we did not ask different questions of the women than the men so we don't have good data on to offer i would say vastly critical issue to try and understand the experiences of women to do that would require a different study than we did you would need to kind of over sample and look at much larger groups of women our study was designed to what limited knowledge i have of counseling and therapy in general my guess is that it would probably work to extent that it works for their milder cases of depression and p t s d but that for many veterans a lot of veterans i've heard testified before the committees or subcommittees or veterans in our district that i've spoken to they not only want to talk to a human being they want to talk to a veteran who who they feel understands them and having a voice on the other phone is helpful probably in some instances having somebody on the other under the computer screen i think is probably less helpful and unless it's dispensing medication or something like that which in some cases it may be appropriate as a temporary measure at least but  apologize that another homeland security committee let me just one brief question and then i'll go to when you go to the next panel but i want your data shows that you're indicating roughly of the eight hundred thousand have been gone to iraq and afghanistan that three hundred thousand might suffer from post traumatic stress that's a significant number from what we have been i don't recall the figure with i think the v a might have had a hundred thousand maybe potential so that's about a three hundred percent increase you have any comments well that's based on a survey that we did with representing the whole deployed force so it's a cross section of everyone that data has not yet been available and it's a cross section so it's how many people are currently suffering and an estimate then based on the whole deployed force we hear some people think that it's an underestimate as well the numbers come in around the same as many of the d studies so it's not our rate of eighteen point five percent is sort of corroborates the d o d s studies and is not vastly different to come again you say is that vastly different in terms of now do you know the approach that they're being  utilizing do to make that determination versus yours so the duties conducted a number of studies of specific groups of individuals at a particular point in time post deployment so for instance a brigade or a combat unit either one month or three months after they've gotten back and they've also found rates in the high teens similar to ours ok thank you very much thank you sir i thank you thank you both for your report has had wide visibility in this quoted and your overlap of with the team with the p t s d i mean that again is is ten times what the official casualty statistics from the pentagon i mean shouldn't these three hundred thousand be included in that do you think well they are an injury condition resulting from combat deployment and so it's a it's a different kind of casualty but yes they're very important numbers i mean again a three hundred thousand casualty figure versus a thirty thousand is very very different and i think you know we in america should understand what has happened there and that's a that's a significant number of casualties again i think it's on the low side you  told us about the scientific sampling and you had roughly two thousand or just slightly less than two thousand telephone interviews right that correct correct me point out one other thing which is that this is a cross section of a particular point in time so this is the number of people who we interviewed who said i'm currently suffering from p t s d or depression by virtue of the symptoms they endorsed there's more people who may have been suffering earlier when they got back from deployment and who may develop disorders later but i mean just as a brainstorming thing if one of the elements of depression was refusal to answer the phone i mean your thing is off road right i mean it's way under reported and i could see something like that occurring also the stigma and the screenings that you refer i mean could also apply to the telephone interviews that is people are smart enough to know if i say this it shows that i'm weak and so they even in the so called confidential setting which i doubt anybody would really believe you know in the telephone thing i certainly wouldn't say maybe under reporting their symptoms  i mean that's part of the whole problem that you referred to so that's why i think for a lot of reasons it's what it's just still even though it's ten times higher than the military would like to admit it still i think on the low side for some of those reasons and another member pointed out that i've been trying to talk about mandatory evaluations and i use that word different than screenings i mean you said there's mandatory screenings i'm not sure that's true by the way in terms of the guard and reserve units and those screenings as i understand it and tell me if you have a different understanding are usually self question itself administered questionnaires so there's no qualified provider there actually observing the soldier or exploring other things right i mean is that i might write on the internet correct we learned a lot about a lot of variability in the way that the screenings are being o and i think we have to say that there are no mandatory evaluations when i mean evaluation is spending an hour with a qualified mental health professional who could and you know we had one member for blood test there sca but there's also interviews and i think where we the best approach that we can do in the simplest thing is while on active duty mandatorily evaluate not screening all of the our soldiers because we're letting them out with p t s d and brain injury which as we all know causes enormous problems for themselves their families and their communities so that i mean that's and i and you know the v a always says well we we screen everybody who comes in well first of all not everybody comes in you know it's less than twenty percent probably and the screening and the v a will be able to answer this on their panel is a couple of questions from a admitted you know a clerk kind of thing and i mean if there's a and a psychiatrist told me there's fifteen for example predictor or predictors or factors in p t s d or sites they say suicide risk and if you're asking as they say i think as two questions you're not getting it hardly any of the risk factors that you ought to be getting to so i think we have a long way to go and i think your report has helped us because it's it's shown that you know the need is so great although i think it's even greater than you but and and i think while on active duty every soldier should be evaluated and the follow ups as you point out i mean is that the hidden  title of your thing that hidden is it that moon's the invisible wounds that clearly it there's it is both invisible because of denial there's invisible because a stigma there's and the but there's in of is invisible because it might not have i mean physiologically or whatever it manifests itself so we have to look at people three months maybe a year meeting and as you said maybe thirty years i mean we have to keep doing that but this this problem is a matter of life and death for so many individuals as you said so suicide several times in your answers i mean we're talking about significant numbers here and we have got to get at  that evaluations and your your work has helped us toward and i appreciate it if you have a chance for any last minute comments or words again we hear your expertise as well evident and we appreciate it so much thank testifying we call the second panel we have both the department defense and the veterans affairs department with us and we thank you we thank both departments as the ranking member said we're a little bit ahead of your official reporting period but given all the publicity on suicides on homelessness and others we thought we we needed as a service to our our veterans and our nation to know more about what's going on  representing the department offenses michael domingo's who is the principal deputy undersecretary of defense for personnel and readiness and with the v a as admiral patrick dunn the acting undersecretary for benefits a chairman good morning members of the committee thank you for the opportunity to update the committee today on v a s progress in implementing the wounded warrior provisions in the national defense authorization act i would like to thank the committee for its work in passing this important legislation and i am pleased to report v a and d o d are making demonstrably progress i am accompanied this morning by dr mccoy our chief patient care services officer for the veterans health administration and dr paul tibbets deputy chief information officer office of enterprise development in january v a awarded a contract for two studies on disability benefits the first study will examine the nature and feasibility of making long term transition payments to veterans undergoing rehabilitation the second study concerns appropriate compensation for loss in earnings capacity and information on potential quality of life payments the reports are due by august and will inform our efforts regarding disability benefits policies and procedures working on two handbook one for our federal recovery coordinator and another for transition assistance in case management of veterans the federal recovery coordinator handbook will guide the f r c s in the delivery of all needed programs and services to recovering service members and veterans the target date for completion is this summer v a completed a separate handbook on the transition assistance and case management of always better and in may of two thousand and seven and we will continue to review and update this handbook as necessary to chart a group comprised of special care managers to include all we have teams spinal cord line rehabilitation mental health trauma and others will be making recommendations in july for a system w approach to care management with emphasis on the coordination between programs this chart a group will also assist in the development of v a policy for care management we are currently piloting a single joint  examination process for service members from walter reed army medical center national naval medical center at bethesda and malcolm grow medical center and rolled in a disability evaluation system a senior oversight committee will be briefed in july regarding the expansion of this proposal last august the deputy secretaries of defense and veterans affairs signed an m o u establishing the federal recovery coordination program in january the newly identif c s completed a comprehensive training program f r c s are already developing individual recovery plans for severely injured service members and veterans as of june first this program is enrolled as in currently serving s d continue to collaborate on a number of projects related to mental health and t b i some examples include developing revisions to medical coding for t b i submission to revision nine of the international classification of diseases implementation between now and june two thousand and thirteen the veterans health administration's office of research and development has a strong portfolio of neuro trauma research which included forty three million dollars of support in fiscal program working together to address eye injuries beginning in november two thousand and seven and some ologists an optometrist began meeting to discuss approaches for improving care and coordination they initiated a consensus validation process which will identify and disseminate the most effective strategies for treatment and services in may the workgroup members began reviewing draft documents on system requirements and concept of operations for military  or vision injure injury three and always f i f a are unseen and a v a medical facility is automatically screen for t b i veterans for whom the screen is positive are referred for a full in depth evaluation which includes checks for visual impairment for veterans and active duty personnel with visual impairment v a provides comprehensive blind rehabilitation services that have demonstrated significantly greater success in increasing independent functioning than any other blind rehabilitation program anywhere the law so requires development of a v a d o d interagency program office to act as a single point of accountability for rapid development of fully  health care information between v a and d o d last month the departments form this office and appointed an acting director from d o d and acting deputy director from v a on april twenty ninth the a n d o d delivered a join september of two thousand and nine mr chairman this concludes my statement and i would be pleased to answer questions thank you most the and i'd like to make four major points first is i want to inform the congress that we in the d o d have devoted a huge portion of the energy and attention to fixing that continuum of care for when the deal uninjured and we are in plea grateful for our partnership with the department of veterans affairs in this endeavor over the last fifteen months second i want to acknowledge that while we have accomplished much much remains to be accomplished we will continue to dedicate ourselves to the mission of creating a world class continuum of care and that it is seamless between the department of defense and department of veterans affairs third i'd like to share my observation that over the last fifteen months our organizations have deeply internalized important lessons we know and this knowledge extends deeply into the career leadership of our organizations both military and civilian we know the importance of this mission and we know how important it is that what we do in d o d is to the v a s successful accomplishment of their mission and further we've learned  d to rely on the v a s expertise to help us with the challenges we face fourth point i'd like to make is that i am confident therefore that we will sustain our man i'm our energy and our leadership focus through the end of this year and that that momentum and that energy and that focus will also continue through the transition to the next administration and now last i'd like to correct what i think may be an important misunderstanding from the prior testimony that the rand study did not and cannot definitively say that there are three hundred thousand cases of clinically diagnosed p t s d the fact that there are three out of one point six million november said that or out of one point six millions they never said there were three hundred thousand clinically theater three hundred thousand people who express experience some kind of mental health stress is very consistent with our data and those people do need to be discovered they need to be this is part of the research efforts that we are now undergoing but in the data that we have garnered so far which i have to say are incomplete and not definitive it is less than one percent will actually a call p t s d that will need treatment over the you believe that you believe what you just said that there are less than one percent of these deployed soldiers who have who will have p t s d as a clinical di lights are so i mean so far this is the numbers that we are seeing that shows why you don't do anything because you think there's only a few well sir no not at all i mean we those i said that three hundred thousand need treatment and three hundred thousand need care the three hundred thousand need to be a to access mental health profession to guide them through treatment but if you look at a year after their deployment  our system now we lose there's a lot of leakers in our system we don't capture all the data yet from the v a we don't capture all the guard reserve members who don't come to our system in our system it's less than one percent now that but that's not definitive it's not authoritative that's why what's the my gratitude to the congress for the appropriations in the supplemental last year we're doing this research to really understand this problem in much greater detail or  i'm going to call mr bozeman for some questions let me i know you guys are all trained in congressional testimony and you have to be objective and nonpolitical and but i think there's been a contest to see who can suck the humanity out of this issue better and one of the other bureaucracy that is i mean we're talking about our children we're talking about life and death we're talking about suicides we're talking about homelessness we're talking about a lifetime of dealing with brain injuries and you guys sit there without anything to say this is exactly unacceptable we're going to do this and this and this get angry you know you read a few sentences that don't say anything you tell me there's one percent i mean diagnosis of p t s d where it when your doctors in the department of the fans have been told to purposely misdiagnosed p t s d as a personality disorder so we don't have to deal with them and your people are  telling their you know you're sending e mails to say don't diagnose p t s d it's too expensive for us give them an association to whatever they came up with and you're sitting here and telling me that everything is fine there's only a few mr bo but i just want to make sure we're at with that and kind of what's going on i know that right now there's a working group with optometry an ophthalmologist regarding the computer programming for the registry i guess what i'd like to know is is when that's going to be online when we're going to do some testing if we got some dates have we got a something a little bit more concrete health fairs dr because cells met yesterday with the surgeon general's and with the billy with the v a colleagues and they've agreed on the concept of operations for how the center of excellence w they've committed to the first steps of getting that registry in place they've worked out how they're going to tap into and bond with excellent technical capabilities in the v we'll get you a timeline the idea portion of building a registry thank you very much the palo alto the v a medical center there the vision screening program i seems to be really you know doing a great job and things it seems like it would be a key priority you know to to specific evaluation for those who have had severe traumatic brain injury and that is exactly what people like paul ought to have done and be on the myth of writing a directive because we would like to ensure that at all our party trauma center sites the continuing education of d o d and very medical staff on screening for vision complications from t b i should be a priority i think for the t b i centers of excellence  optometry enough to margi you know being involved seems to be key i guess i'd like to know you know kind of what we're doing in that area and you know again are we are we getting it done know we need a little less talking a lot more action regarding this and we seem to be moving for i would like a timeline again on what's going on in regard to these things  that i know that you are working hard i know that you're doing the best certainly we're not near as good as we need to do in many of these issues but i know that you've worked hard and we're doing better than we ever have before but again question because i think this is critical i think it's critical for the reason we're here on the wounded warrior side of it and i think it's critical with the disconnect on the seamless transition between v a and mr bozeman very kind on this but he asked some very specific questions and i appreciate the offer to get the timeline on this but make no mistake about it all of us are here with the same commitment to our warriors and our veterans which is uncompromised that's an absolute given this issue on t b i and peripheral damage vision damage it starts to happen because of this is absolutely critical so this center for eye care excellence on these injuries is a big part of dealing with that and this is mandated by what we came out with granted as as was stated earlier we're just a little bit ahead on this but i would have to say i've been incredibly pleased with be a detailed cost estimates all the way down the line things that have been given to us and in fact my office myself i've written secretary big urging him to sign that in the on the other hand it's vague it's not here i haven't heard anything to tell me that it's coming other than some vague reassurances on this and it gets back to the heart of the problem again where is the seamless transition where is the seeing the warrior and the veteran as one inseparable individual that their quality of care from that originating station of when they raise their hand when we honor them with a burial at one of our cemetery where is that they're in on this issue alone it's mandated it's been there i've seen what i consider to be very positive movement on the v a side and quite honestly and this is for you mr dominguez i have not seen it on the d o d side to the same level i'd like you to convince me or or tell me why what i'm seeing here is a picture of disconnect that doesn't reflect many of the problems we've had in the past on disconnect and why are we why should i as as mr bozeman ask how do i know this is actually come going to come forward or it'll come forward because it's mandated in the law and we're going to prepare a report and deliver that report as i mentioned earlier doctor because cells has met with the surgeons general and they have agreed on the concept of to costing the detailed specifics of ok how do we put it in place now that we understand what it's going to look like how it's going to work where it's going to be how do we build all that stuff so that work  you know is now away in partnership with the v a because as i said over the last fifteen months we've learned were that we have to be together on these things absolutely and this will look different than if i went back and eighteen years ago the seamless transition on electronic medical records where you're working together and eighteen years later we're asking the same questions mike my concern is you're telling me that it takes more you have to have a plan first  that's never the question what we're questioning is how we actually deliver this on the large scale and i think it's our responsibility as the overseers of this to make sure that we're continuing to ask and bushels question is never a question of motive it's always a question of how we get it in and especially this this seamless transition but i am pleased there is movement forward i'm optimistic on this one and i think it's going to be a big first step in helping that seamless transition part get there my last question to you on this and this goes back mr chairman has as the question in the interchange i guess w the chairman on this says i just want to be clear on this you have problems with the methodology in the rand study no matter at all i think they found the same thing that we're experiencing it it's just nonbinding on know that thirty three hundred thousand people out there with combat stress symptoms that need attention is consistent with our findings internally my objection was   first of all start by qualifying i statements in saying that that i was extremely pleased to see secretary peake get appointed because he had been with the department of defense prior and i was hoping and i'm still hoping that arriving here for the longest time we've been talking not a new one and i don't want because the people that are here before me are not necessarily the ones responsible it's a system that the odi and v a that need to get it together it's not only in terms of bringing down the cost when you work cooperatively but also from a humane perspective in terms of what needs to happen for those soldiers and the sooner we recognize that this is going to help our soldiers and that it's the right thing to do we're going to do it and i hear the words we got to prepare the report the importance of the mission my god we've been waiting for this for some time it's not it's not something that all of a sudden came about and we've been talking about to please make every effort to start coming together and bring forth an effort to sincerely respond when the soldiers serves our country that folder to follow him to the v a as quickly as possible so that we can be be able to prepare the best type of services for him and it's just a simple as that and it seemed so that we've got we got to show you know some sense of you know as the chairman talks about you know we've got these are individuals that are hurting and we have to start from scratch when they come to the a and start the process all over again when in some of those cases that's not needed and we could be saving resources not to mention in terms of what it means in terms of the approach the humane approach in terms of treating  some of these individuals now post traumatic stress in this area we got to be able to pick it up as quickly as possible we know we're doing some research now in and we had not provided the resources  there and we also have a responsibility there that we have not been providing those those resources in order to make that happen because and i and i agree that and i hope that the results is that as soon as we engage them and provide that treatment that hopefully it will not be a long duration that there will be suffering from that and hopefully within six months or a year they will be ok and i'm hoping that that will be the diagnosis that will come about but unless we engage him because right now my understanding was that it was taken almost over a year before we get to pick them up and and so the sooner we pick them up the better and so it shouldn't take a year in order for that to happen so i would hope that and i do at least at least mr chairman i want to thank you because i don't recall the time that i've been in this committee that we've been able to even get a the person to come before us you know and very few times i do want to thank you for being here that is a big plus the fact that both of you are here and we hadn't been able to even accomplish that with the a you mention one of the that concerns me the national guard and reserve us forty percent how do we you know and i'll throw this out how do we go after that forty percent that are you know that are up there the state guard and all the other national guard to be able to do the same  thing as secretary peake is equally concerned about the rural health care and all facets and not just p t s d and in fact we do have a advisory committee which is in place now to take a take a look and give him specific recommendations and advice in addition to his own staff working on it so that we can improve our capabilities but things like tele medicine which we talked about  earlier those are key things that we're taking advantage of now and we'll continue to take advantage of any innovations that become available so that we can take care of veterans and i do want to thank you have a lot of rule area but let me go to that question work together with the national guard and reserve to create advocates in each of the guard units who in each state work together with very closely to make sure that we're aware of events where we could conduct outreach and get information out to members of the guard so that they know where we are and how to get in touch with his income get care or compensation as appropriate we are in the process of developing a similar memorandum of understanding with the reserve throughout the country and we'll continue to provide those same services to the members of the issue with specter the folder that you brought up i wanted to speak to a little bit the electronic xchange of clinical information is problematic and a challenge and of course we have a lot of stuff we could say about that later if you want to get into it but when you add in the distributed nature of the guard and reserve it makes that further complex and it makes it complex for a variety of reasons one we're talking about of substantial amount of healthcare delivery that is takes place in the private sector where the penetration of information technology is very low so in order for there to be an electronic actually change when that guard reserve is goes back home and maybe seeking care from neither of our institutions is itself a whole nother set of challenges anybody looking at that right now well our our secretary has asked us to begin to make some serious let's say inroads into that there are several levels and i'll yield back in a minute here the several levels one is is with the guard reserve itself and the equipment they have number two what it is we both department do for purchase care when we when we deliver when we purchase health care from the private sector not delivered inside of our to sions and thirdly is the relationship that we need to develop or are developing with the national health information network initiative of the department of health and human services to facilitate the connection between us and all those private sector doctors who ultimately are going to be linking themselves electronically to that national health information network so it's a care is unique challenges socially with providing that care and support to the members of the guard and reserve so we intend to do that there is a similar provision for gender issues by the way which we intend to do that  together to reach out to guard reserve team people who are coming back with a full spectrum of care which will include some health care and mental health counselors and those kind of people that either will provide  r and we've also actually seen our tri care network providers step up and particular deal with the rural challenges by getting deployed teams of health care providers in particular mental health  people out to these events where we're really were there you know shipping people out or bringing them back so there's a lot going on a lot to be done a lot going on i'm just doing this you said earlier  that you don't a problem with the three hundred thousand figure of people who showed some symptoms of mental illness would you consider those casualties of war i don't i don't know that i'd call you made fun of the three hundred thousand about the three twenty thousand where brain injury well again i think you don't have three hundred twenty thousand brain injuries you have three hundred twenty thousand people who have been in or around a you create a tone you're the leader you're one of the leaders in the leadership creates a tone and your tone is only if you get him back into battle they're not casualties they have some symptoms and so what that leads i mean leads to a lot of things that leads to people not willing first of all to admit anything and commanders saying don't admit anything because your promotion will be held up but it leads to things like in your department as i understand some of the reports at least twenty thousand people who asked for who had a p t s d diagnosis or thought they had p t s d were rediagnosed or deliberately diagnosed with personality disorders and now not only does that beg the question of why we let these people in with personality disorders but it means that the v a doesn't have to treat them because that was a  a preexisting condition that's what your kind of testimony leads to i mean it leads to people saying hey we're not going to even we're not going to take this serious sir we apologize if i conveyed that tone i want to emphasize all of these people who experience combat stress need help they need to get to people therapist counselors who can help them process that stress what they've been are they doing not know they getting their help we are trying our best are i mean you know now one of the things i do want to point out is the line the leadership of the department secretary gates himself attacked this problem of question twenty one on the security clearance form and this year we made some major revisions of that in terms of what people need to be able to answer to get to deal with that's an important step forward i agree  the lying leadership if you look at for example the army secretary garron and general casey the chief of staff ensure that every soldier in the army including every leader and the army was trained about combat  symptoms combat stress the importance of watching your peers your body there's no question you're doing all these good things that let her do it but there is there are thousands and thousands of young men and women who aren't getting the help who aren't allowed in the sense to to admit that they have a problem when they get home don't get the help or deny that they need help and so yeah you're doing all these things but you've got all of these this evidence that we're not doing not only enough but anywhere you've just come to my district next it could come home with me tomorrow i have camp pendleton in my you know right near my district we have the biggest navy base in the world and i'll show you more than a few of p t s d both active duty and veterans i mean i see him every day and they don't know what to do so i don't commit suicide you've got the highest rates of suicide since the vietnam war in the army right of our combat troops does that say it's just the problem of a few third of those who have been diagnosed with p t s d that is who actually got the diagnosis with all the problems of getting that have committed felonies when they come home is that a big problem two hundred homicides amongst those felonies of family members i mean that's real and that's significant and that needs to be taken seriously by everybody from you on up to the present i don't see anybody saying can't keep denying these figures they say and they're vastly overblown it's only a few so we don't have to make care we are taking teary asli you have combat stress of finding people who need help and getting them help how do you count out a hundred homicides  of guys coming right out of iraq who killed two hundred people most in their own family how to explain it thing that we committed then you're not going to ever solve the problem we have not done i take care of our children the evidence is there you just don't want to admit it or look at it what i'm saying  mounting any aggressive effort it is continuing to deal with this combat stress i noticed you didn't have run to my possible way didn't do it you didn't respond to my statement about the personality disorders i  i haven't read the report but i'm positive it's going to be those only for those those who have been had that discharge the majority been in less than two years and majority were not deployed in combat however this discussion of and your focus on that did cause us to tighten our policy and where so the use of that discharge now requires certification by a psychiatrist that p t s d is not present and  if the person being discharged with this just charge has been to combat the surgeon general of the service must sign off on ok well i read the report but i can to i can guess what's in it and i can tell you that doctors have come to me i wish they would testify in public and i'm trying to get them to that that they have been ordered to misdiagnose p t s d as a personality disorder i wish i could do it in public i will try to do that but i will tell you people have told me that that's a concern and in the v a i mean you had you know this e mail that went out that became public and the head of the post combat trauma unit at a v a hospital said rights to all of her team given that we are having more and more compensation seeking veterans i'd like to suggest that you refrain from giving a diagnosis of p t s d straight out consider a diagnosis of adjustment disorder additionally we really don't have we don't really don't have time to do the extensive testing that should be done to determine p t s d also there have been some incidents when the veteran has his compensation and pension exam is not given a diagnosis of p t s d then the veteran comes here and we give the diagnosis in the veteran appeals his case based on our assessment oh wow now we have a problem we're going to have to compensate them how does that happen i think it happens because of the kind of testimony you give today that the leadership is given these signals that we're spending too much money we don't take it seriously we only have a few so somebody some middle level ministr has the nerve to send that kind of message out to her people how does that happen and well done there your people sir that e mail was poorly worded worded it's very well worded it says cut out the diagnosis of p t s d where where is she getting that kind of instruction where is she getting that kind of sense where is she getting that kind of sort of right to say that  coming from you in the top it's not come from me sir it will have to come from anybody it does not come from anybody in the leadership of the or i came from somewhere nobody sends out a memo like that it's based on the signals that you guys are given at hearings like this that's where it comes from but now it can you explain to me everybody who comes testify here says we give mandatory anybody comes in a v a from from  a get screened for p t s d and t b i can you tell me i mean first you're saying only those who come in right you're not going out and finding people but second what is that screening what exactly what happens in that screening let me address two things the first question is what are we doing about those who are not coming to us for care secretary peak has an initiative of a call center which got started a few weeks ago where we are reaching out to all  servicemembers all reference who have been discharged they have to call in to the call center you know they are making the outreach call and what are they saying and then and they are offering them services that v a offers including the sights and if any of them need an appointment or look at what our greatest and i will tell you by the way because i've seen your suicide brochures and stuff the very peak all you need to reach are those who are don't want to talk to the government don't want to talk to  bureaucrats they want something else and what you're telling them we're going to give you come see the government we're all here to help you it is being done by a contracted service and the but the second point most likely what can you give me the script for the what they're saying  we can have it thank you i'm sure ok what happens when they come in and they get their screening actually all we have reference there's a clinical reminder in the computerized patient records system which is based on boolean logic so anyone who has been discharged from the service since two thousand and one there's a series of reminders that they have to undergo and which the clinicians especially the primary care physicians in our clinics both in the community based outpatient clinics as well as a medical centers have been trained to complete which includes a series of questions they don't look at yesterday the secretary said when he was here and you said today everybody comes as we give there's a mandatory screening for p t s d yes tell me what that screening is what exactly is that is that eight appointment for an hour with a psychiatry is that a questionnaire given out by a clerk what is the let me explain that sir is actually a series of questions which are asked by the clinician a clinician who is seeing how many questions in that series so it's been a while since i've given it myself i'm a practicing clinic it's to i've seen the questionnaire i've talked to the guys who've gone into there's two questions that are asked one that says have you ever been subject to a blast or something and maybe i forget the other one do you have nightmares there's two questions my wrong there i would need to get you th you know you would seem i want to know the exact screening what happens who does it what's the questions asked and for what time period i am told by dozens and dozens of soldiers who have gone through this that it's two questions it's done by going into a clerk and if they don't want to admit that they have it they know what to say no on both and then there's no follow up on it they just say no and that's it no sir it's actually a more detailed question than two questions and clinical questions are not asked by clerics they are asked by a point where you have to show me because everybody i talk to says here's my so here's what i said to these questions so i can get you the screen and again to do that does the the army and the marines give mandatory evaluations for p t s d and brain injury when they leave the combat areas or leave the service so we do these they say yes to any of the questions that's correct and all night if a marine knows that his promotion is threatened or he's going to not get a job in law enforcement he leaves most of your marines are smart enough men answer no to those questions  and especially if somebody checks us as and i will give you i can give you the names and dates of this stuff and their commander says you better look at this again because if you press if that stays yes you're going to stay here a few more days for some further evaluation and that marine wants to go home he doesn't want to be saddled as we can go to see the wizard as they call him in the pink house that they say i mean everything is set up to make sure that they fear going to so you don't have to go someplace else there's no you know so you can mask that you're getting mental health treatment second is this training that's going on in the in the leadership about combat stress taking care of your body be observant help your body and then communicate that part of the warrior ethos is you know being strong to get strong enough to get help taking the stigma out of it by you know attacking that question twenty one secretary gates but you know what as i told several of your surgeon generals the best thing they can do is take a colonel or something at that level who has had p t s d is had to deal with it publicly talk about his his that's what you need to do sir would try and a lot of different things i want to point out there's a brigade commander at fort lewis who's who have taken his entire brigade through mental health counseling as they redeploy starting with him ok so there are things like that that are going on it's good today in the army to try and in the department fence try and understand how to do this better and how to make sure that people who do need care because combat stress is real and combat is not a normal and you think i think you need to do that a lot faster and a lot more comprehensively and get mad that it's not being done mr bill you're i mean to the point that you were making if you remember when we did our when you held a hearing on personality to fort stewart before they went over the v a did that that's operating outside the lines in the jurisdiction of the v a now why why was that a pretty important because i think that was the v a being responsive to the concerns that to defend liberty and this country and we want to strong but we also recognize that there are times it can be very challenging for them and when they come back you're absolutely right mr chairman they're eager to get back to their families  get back to their lives and that's why the v a being responsive to opening the door to be there it's telling that the first line of diagnosis it's really the husband or wife that was left at home they're watching the transition of their loved one in how they talk on the telephone what they're writing what are they saying on e mail and then when they come home are their sleepless  how are they reacting to the to the children how it what they see that's different and they're the ones now that they're building a relationship with the v a that has been established during during the family support centers i think this is a good thing that's going on it addresses the point that you were making so i want to give you sort of an up and thank you i would i would invite both secretaries to you know to meet with some of the people that are giving us this other kind of sense of what's going on warrior provisions now i've got the the the defense authorization act and the reason all of this is in the defense authorization act is is that the chairman waive jurisdiction of this committee and we gave them to the our house armed services committee in cooperation though when when the chairman did that he worked with chairman ike skelton so the house then adopted our recommendations of the committee and so that's why i'm referring now to this now one of the things we did i you have done or not so let me let me ask you about these sections sixteen sixteen was the establishment of a wounded warrior resource center and it was to be  to among other things the center was to provide a multi method of access including at a minimum internet web site and toll free phone number and i believe this is supposed to  ensuring that and we made a decision it's a military one source will be the number but ensuring that the capacity to answer all the questions that are going to be there so that you can win when somebody calls you can make sure that they get that assistance that they need we're building that structure right now i want to say that we're doing that in partnership again with the military services who do also have their eight hundred numbers out there and our and working when can we anticipate that you're in compliance with section sixteen sixteen of the wounded warrior act get you that for the or i think it is it's best for me to provide that to you for the record so that we can be accurate in our communications to you about when that whole capability will be avail your you have the you have the opportunity to provide the leadership we've given you what we've wanted you've had a lot of time so please provide here to the committee and an expectation of when this will be implemented you already bust busted through our expectations to when we thought it could be done so what are we talking about each other since it within fifteen days or within thirty days within sixty days within ninety days i mean you're now not in compliance with the law i'd feel uncomfortable if i was a secretary and i were in compliance with the law yes here we are late and standing up that capability it is of concern to me and i have people working it saved us we so what is the expectation what is our what is your expectation i can't provide you that right now sir within a year within the year oh yes you're absolutely within six months i would say so yes there we go within six months all right let's talk about other provision the committee on armed services and the house of representatives a report describing the changes undertaken within the department of defense and the department of veterans affairs to ensure that traumatic brain injury victims receive a medical designation that is concomitant with their injury rather than medical designation that assigns a generic classification now to the d o d and the v a do you have the report no sir i think we're probably late on that one to now i know that we are working this issue of the most you have some better information provide some information yes there is a a group that has been currently working on the coding proposal this proposal is going to be submitted to the national center of health statistics and following that period there's a comment period before it's accepted by the i c d nine   right one of the challenges that the chairman and i and other members of the committee have had is working with the medical communities with regard to designations because we've been exporting confortable with this mild traumatic brain injury and coming up with the right terminology because it's like what's there's been a concussion and a mild from at t b i and we're moving into into this mental health and and and exploring this in greater detail so we wanted to make sure when we put this together that with regard to the v a and d o d if we're going to be seamless that we want to make sure that everyone is using the right terminology and everything is coded in cooperation because if the v a in fact is the leader as rand testified that we wanted make sure that then as as we then work in concert through tri care and with and with other providers that everybody begins to take off of our lead and doesn't designations and encoding this is pretty important you can you tell me where you are and why you have not met this deadline a revision will be submitted to the committee by the september of this year expectation is that it takes about a year for that to go through the peer review and get actually assigned to that does not nor because i'm not a subject matter expert but what i do know that it happened does have to go the proposal is pretty ready but it has to go to external agencies like the national center of health statistics before it can be submitted for the actual coding does i c d nine code currently has you know does not have a code for mine t b i so there's a process that it has to go through and it is fairly in the final process of being submitted so you anticipate the compliance then with section six sixty four by september it will be submitted to the i think nine committee by september accomplish and not accomplish so we have a mike and i chair dva committee which is tracking knees we have a spreadsheet that we've created that breaks those down based on the reports we would be happy to provide you a copy of the spreadsheet gives you an indication of our progress in each of those requirements all right to the two secretaries being transparent with us is a good thing letting us know what you can achieve what's realistic and reason to set that backdrop so difficult to see decisions are not procrastinated i don't question your heart and neither neither of you no one on this panel that's why i'm asking you are these deadlines that we set are they realistic to  i think i'll be able to have a better sense of that for you later this month i do want to express some disappointment that i thought we were tracking every one of those and had sent interim reports on the deadlines that we specified that told you what we were doing and that we were going to be late in those cases or we have if we missed some of those in appears we did i'll go back and make sure that we  you got an early start you began the joint pilot program on the disability valuation system last november combining examinations and evaluations into one process and having a single rating system for the use by both apartments i cumbersome task but it is something that should have been accomplished long ago would have saved wounded warriors a lot of frustration and worry that they shouldn't have to endure after sacrificing prices so much already i see this pilot as a great opportunity for both apartments to start from scratch and put in place a streamlined efficient system that avoids many of the complications that mire the current system as you know i am a longstanding advocate for increased use of information technology and electronic medical records  my questions is the pilot program establishing electronic file systems for its claims  inner agency program office which we stood up for health records for everyone yes or no i'll just add to that that that that of course is an accurate statement of affairs today as that pilot moves forward and we india to get smarter on how we want to conduct that we well could come to realize that some additional requirements are necessary those will be formulated in more solutions we brought to bear but right now the answer is nothing unique to that but that we intend to learn from it it is it is an interest of the chairman and myself to you know we look out there in the private sector on how well they do the electronics claims processing and we don't do it as well and so it is of interest to us i want you want you to know from entry into the disability system to the time when you have a notice in your hands of here's the benefits you will get from the department of veterans affairs we compress that quite significantly is about one hundred  sixty days where normally it's in excess of five hundred that hundred sixty days actually involves about seventy or so days of convenience time to the member so that there's actually you know about ninety days of administrative processing time for us in our two departments so we have compressed the time the second is there's a lot more customer care a lot more customer care we so it's a higher touch higher trained people around the system to make it work and to make sure that the people going through it understand what's going on so we anticipate  higher satisfaction which we're now serving with that those are qualities of any problems we see so far challenges so there's lots of challenges in conducting a process like that where there's we're working between not all not only just v a and duty but between each of the services because they all do it slightly differently in accordance with their instructions so we've had problems similar to getting the right type of computer  coordinators desk getting the right amount of bandwidth to that person's computer so that they could provide the service that was needed in some cases we would us we would have someone assigned an appointment and we might find that their commanding officer for good reasons had sent them on leave to be with their family and they were unavailable we had to reschedule the appointment so there are lot of those sort of in iraq those are those are antidotal you don't have showstopper challenges this can be done it can be accomplished i believe that yes i'm confident it can be accomplished sir and as we look towards the expansion we're going to look at more challenges of having the capabilities close at hand so to date admiral are you aware of how many claims have been processed through the pilot to up to today there is one individual who has been completely through the process and been discharged through that process or there are approximately four hundred individual service members who have been enrolled in this pilot program in there and various say when did you open the door for the pilot november twenty sixth and you've only processed one person through since november under the pilot one person has been discharged as a result of that sir and many are in the pilot right now the last those kind of things which runs on our clock but yeah we go we set was to cut this time in half from the time you enter its billing system to the time you have the v a benefits so  sort of the the saddest rate of satisfaction among people who are involved in the program that's my last question you know we are serving that now so we don't have anything definitive other than you know the anecdotes and the fact that we're not getting complaints and many many people are not appealing you know their ratings but again it's so early and such  it's hard to tell i mean we're very concerned that this be a process that people view as more user friendly and more and more open in concern to them as opposed type of pilot error findings a year so we instituted a pilot for a one year period of time an expected to gather data over that period of time so i would say after with the what's going on i think we would both say and you're talking about timelines and evaluations in the years of reporting going to this committee and that committee i mean if your child received a brain injury or concussion in iraq would you want to wait this amount of time before we make sure that these whether he has a brain injury what the treatment for it think of that because i've said it several times but these are our children we're not taking care of them properly and you know sit here and talk about your timelines in that year i mean you're going to have thousands and thousands and thousands of our bravest young men and women who are injured who don't get the proper help who may commit suicide they may commit a felony they may kill a family member we know that's happening get mad and do something about