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VA MENTAL HEALTH: ENSURING ACCESS TO CARE 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

OCTOBER 28, 2015 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

RICHARD BLUMENTHAL, Connecticut, Ranking 

Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

TOM BOWMAN, Staff Director 

JOHN KRUSE, Democratic Staff Director 

(III) 

C O N T E N T S 

OCTOBER 28, 2015 

SENATORS 

Page 

Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia ............................ 1 

Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from Connecticut ... 2 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 36 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 38 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 40 

Murray, Hon. Patty, Chairman, U.S. Senator from Washington ........................ 42 

Tillis, Hon. Thom, U.S. Senator from North Carolina .......................................... 43 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 46 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 65 

WITNESSES 

Karnaze, Nicholas, U.S. Marine Corps Veteran .................................................... 3 

Prepared statement .......................................................................................... 4 

Maiers, Dean S., U.S. Navy Veteran ...................................................................... 7 

Prepared statement .......................................................................................... 7 

Butler, Roscoe G., Deputy Director, National Veterans Affairs and Rehabilitation Division, The American Legion ................................................................... 8 

Prepared statement .......................................................................................... 9 

Maffucci, Jacqueline, Ph.D., Research Director, Iraq and Afghanistan Veterans of America .................................................................................................. 13 

Prepared statement .......................................................................................... 14 

Draper, Debra A., Ph.D., Director, Health Care, U.S. Government Accountability Office ......................................................................................................... 16 

Prepared statement .......................................................................................... 18 

Kudler, Harold, M.D., Chief Consultant for Mental Health Services, Veterans 

Health Administration, U.S. Department of Veterans Affairs; accompanied 

by David Carroll, Ph.D., Executive Director, Mental Health Operations; 

and Michael Davies, M.D., Executive Director, Access and Clinical Administration Program .................................................................................................... 49 

Prepared statement .......................................................................................... 51 

Response to posthearing questions submitted by: 

Hon. Richard Blumenthal ............................................................................ 67 

Hon. Bill Cassidy .......................................................................................... 72 

APPENDIX 

Murray, Hon. Patty, Chairman, U.S. Senator from Washington; prepared 

statement .............................................................................................................. 77 

(1) 

VA MENTAL HEALTH: ENSURING ACCESS 

TO CARE 

WEDNESDAY, OCTOBER 28, 2015 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2:31 p.m., in room 

418, Russell Senate Office Building, Hon. Johnny Isakson, Chairman of the Committee, presiding. 

Present: Senators Isakson, Moran, Boozman, Cassidy, Rounds, 

Tillis, Sullivan, Blumenthal, Murray, Brown, Tester, Hirono, and 

Manchin. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, 

CHAIRMAN, U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. First of all, I would like to call this meeting 

of the Senate Veterans’ Affairs Committee to order, and I appreciate everybody’s attendance today. I particularly appreciate our 

visitors who are testifying, and I will introduce them in just a 

second. 

This is a critical hearing for the VA Committee. You are all familiar with the GAO report regarding suicide prevention and suicides in the Veterans Administration. I called the first hearing on 

preventing suicide in the Veterans Administration or Veterans 

Benefit Services in August 2013 in Atlanta, Georgia, because we 

had had an inordinate number of suicides in the Atlanta area during that period of time. To Leslie Wiggins’ credit, who is the Director of the Clairmont Hospital in Atlanta, a number of things were 

done to address that subject and greatly reduce, although not totally eliminate, which is a very difficult thing to do, the number of 

suicides that took place. But, we got our arms around the problem. 

I particularly am glad that GAO has focused on the problems 

that we do have so we can focus on the solutions we must have. 

As I told a member of the media a few minutes ago outside, failure 

is not an option, as far as I am concerned. The lives of every one 

of these veterans is important. They risked that life for all of us 

and our safety and our security overseas. We have got to make 

sure they have the comfort and the care and the accessibility to 

mental health coverage so they do not take their life while they are 

here at home. That requires a VA that is responsive, a hotline that 

works, and a program to make sure that veterans can get services 

when they need them on a timely basis, not a week or two later 

on. 

2 

I am delighted that all of you chose to come and participate 

today. I appreciate your being here. 

With that said, I will introduce the Ranking Member, Senator 

Blumenthal. 

OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, 

RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thanks, Mr. Chairman, and thank you for 

having this hearing on a topic that is supremely important. There 

is no topic, in my view, that is more important than mental health 

for our veterans. 

As in the civilian world, mental health is often overlooked, given 

less attention than it should be, an invisible condition that needs 

to be treated with the same urgency and immediacy as any physical condition would be. In the case of our veterans, it is an invisible wound of war for many and has been often disregarded and neglected until recently. 

To its credit, our military now is much more focused on it, particularly when it affects our men and women in uniform engaged 

in combat, and the same sensitivity and attention have to be given 

by the VA and our civilian society, not enough that our insurance 

laws provide parity and require parity in coverage. All too often, 

incidentally, that law is neglected and overlooked—a separate 

topic. But, for our military men and women, for our veterans, mental health is as absolutely vital as an arm, a leg, any physical part 

of the body, and it deserves the same kind of world class, first class 

health care. 

The GAO report that has been issued and is involved in today’s 

hearing certainly documents failures and neglect that need to be 

remedied, and that is the topic that brings us here today, what 

more we can and should do right away, not at some distant point 

in the future, but literally right away. 

Thank you, Mr. Chairman, for having this hearing. I look forward to hearing and learning as we listen to this testimony, but 

also acting on it as soon as possible. Thank you. 

Chairman ISAKSON. Thank you, Senator Blumenthal. 

I am pleased to introduce our first panel, to which each will have 

5 minutes for their testimony and then we will do a round of questioning by the Committee members and then go to our second 

panel. We thank you for being here. 

First is Nick Karnaze, U.S. Marine Corps veteran. We appreciate 

your being here today and thanks for bringing Lauren along. 

Lauren used to work for me a long time ago and she is a great 

lady. I appreciate it. 

Dean Maiers, U.S. Navy veteran. Thank you for being here. I 

married into a Navy family, so I am kind of biased towards the 

Navy. We are glad you are here. 

Mr. MAIERS. Thank you, sir. 

Chairman ISAKSON. Roscoe Butler—and Roscoe, you are always 

with us and we appreciate your being here all the time—the Deputy Director of Health Care for The American Legion. 

Dr. Jackie Maffucci, Research Director of Iraq and Afghanistan 

Veterans of America. 

3 

Dr. Debra A. Draper, Director of Health Team, the Government 

Accountability Office. 

We are delighted that all of you are here. We will start with Nick 

for your testimony, up to about 5 minutes each. 

STATEMENT OF NICHOLAS KARNAZE, 

U.S. MARINE CORPS VETERAN 

Mr. KARNAZE. Mr. Chairman, Members of the Committee, thank 

you for inviting me here today. It is an honor to be able to share 

my story with you. 

My name is Nicholas Karnaze. I served about seven-and-a-half 

years in the Marine Corps, both as an intelligence officer and as 

a special operations officer. I have multiple combat deployments to 

Afghanistan. I am a graduate of the U.S. Naval Academy and recently completed a veteran program at the Stanford Graduate 

School of Business. 

This is an issue that is near and dear to my heart. I am testifying from the perspective of a veteran who receives all of his 

health care through the VA. 

Many men and women are suffering, as we all well know, from 

the mental wounds sustained in combat. A lot of them are fearful 

of coming forward and asking for help because of the stigma associated with it or the impact it could have on their employment. For 

those that do have the courage to step forward and ask for help, 

many are met with a lengthy administrative process to gain access 

to the care that they are asking for and desperately need. 

In my personal experience, it took me about a year to get into 

the VA system upon separation from the Marine Corps. Once I was 

actually in the VA system, the physical care received was fantastic. 

Late last year, in the fall of 2014, I was having some issues with 

concentration and just the ability to get work done, work that I 

was compassionate about. I reached out to my primary care physician to get a referral to a mental health specialist. It took me about 

a month to get that appointment. My first meeting with her was 

about an hour long, and at the end she asked if I was open to taking medication, because while I did not feel depressed, my inability 

to concentrate could be a sign of depression. 

Wanting to get my head right, getting back and wanting to get 

back in the game, I agreed. She put me on an antidepressant. We 

agreed to meet 2 months later and she let me know that it would 

probably take a few weeks to a month for the drug to start 

working. 

Several weeks into taking that medication, I actually began to 

feel depressed. I was in a very, very dark place. It was not me. It 

was not normal. I knew it was not normal. I reached back out to 

the VA to see my doctor again. She could not see me for another 

30 days or thereabouts. So, on my own, I decided to stop taking the 

medication. 

Shortly after I stopped, I was back at my baseline. I started feeling better. Things were good. I went back and I met with her and 

she said I had made the right choice by stopping the medication, 

that my body just did not metabolize it properly. 

I told her that I would like to speak to a psychologist and maybe 

get some cognitive therapy, something like that, just because, for 

4 

me, I was defining a good year by attending more weddings than 

funerals. I was losing a lot of friends in combat and I had some 

guilt associated with that. She said that was a great idea, but she 

could not provide that cognitive therapy for me. That was my last 

interaction with a mental health care professional within the VA. 

Just this week, I reached back out. I receive my care through the 

clinic at Fort Belvoir. They have one phone number listed on the 

Web site. I called that. It went to a recording and gave me another 

phone number to dial to be referred or to ask for a referral. I called 

that number, and after waiting for about 15 minutes, I decided to 

select the option of pressing one to leave a message and have the 

representative contact me when someone became available. I left 

my phone number. I left a voice message explaining that I needed 

to meet with my primary care physician, that I was in search of 

some mental health care, and to please give me a call back. 

Today, I have yet to receive a call back from my clinic. At this 

time, I am still waiting to at least get an appointment. 

I am not the only one in this position. I posted about this on 

Facebook, that I was going to be speaking before you, sir, and the 

response that I received was amazing. I received so many e-mails, 

and I forwarded them along to your staff. I included some of them 

in my written testimony, as well. 

Some of my friends have actually given up hope. My friend, Nathan Lewis, he actually went through his private health care provider with the aid of his employer to receive mental health care. 

His wife asked him to do so because his issues were putting a 

strain on their marriage. 

I and many veterans like me do not have that luxury. I am a 

small business owner, and unfortunately, at this time, I cannot afford private health care. Hopefully, that will change, but right now, 

I am still very much in that startup mode. 

A lot of people want help. They need help. As a leader of Marines, I feel it my responsibility to help with that. 

I truly believe that when we get the right access to care in a 

timely manner, we will find that we are going to see a reduction 

in veteran suicides and we are going to have healthier and happier 

families. 

I am an open book. There is no question off limits for me, I am 

open and welcome to any questions you might have that might help 

in this matter. Thank you. 

[The prepared statement of Mr. Karnaze follows:] 

PREPARED STATEMENT OF NICHOLAS KARNAZE, U.S. MARINE (RETIRED), AND

FOUNDER OF STUBBLE & ’STACHE

Mr. Chairman and Members of the Committee: Thank you for the invitation to 

be here today; it is an honor to be able to share my experiences with you. My name 

is Nicholas Karnaze, and I served 7.5 years in the United States Marine Corps both 

as an intelligence officer and as a special operations officer. I served two combat deployments in Afghanistan, and I have a disability rating with the VA. Because of 

this, I receive all of my health care through the VA. I am a graduate of the United 

States Naval Academy, and recently received a certificate from the Stanford University Graduate School of Business. 

I am testifying today from the perspective of a veteran with service-connected disabilities who has attempted to receive mental health treatment from the VA. As a 

leader of Marines, I feel it is my duty to share my personal experiences with you 

so that, together, we can ensure the men and women who honorably served our Nation receive the mental health care that they deserve. 

5 

Many men and women are suffering in silence from the mental wounds they sustained during their time in the military. Most know they need help, but some are 

fearful to ask out of concern that any mention of ‘‘mental health’’ will have an adverse effect on their government security clearance, and ultimately, their jobs. For 

those who have mustered the courage to reach out, most are confronted with a 

lengthy and discouraging administrative process in order to gain access to mental 

health care. There are extremes in mental health—for example if a person is about 

to commit suicide—but the majority of people seeking treatment have not reached 

that point. 

Often, veterans who are actively seeking help are in the stage in which they experience the feeling that something is not right. While they may know something is 

wrong, they are not on the verge of suicide, so contacting the VA’s widely publicized 

Veterans Crisis Line seems excessive. So what options do we veterans have in this 

situation? 

Upon leaving active duty, it took me over a year to gain access to the VA 

healthcare system. Once in the system, the actual physical care I received was fantastic. But, it’s the time and process necessary to ultimately receive the care is 

where the issues lie. 

In the fall of 2014 I expressed an interest to meet with a mental health care professional to discuss some issues I’d been having with concentration and memory. 

Upon referral to a psychiatrist, it took over a month before I was finally able to 

meet with the doctor. During our hour-long initial meeting, she asked if I was opposed to taking medication, mentioning that while I do not feel depressed, my inability to concentrate could be a symptom of depression. Eager to ‘‘get my head 

right,’’ I said I had no problem trying medication. She then prescribed me an 

antidepressant, and we agreed to meet several months later to assess my progress. 

She noted that it could take from several weeks to a month before I noticed a 

change in my mood. 

Two weeks into taking the medication, I began to feel depressed, beyond my initial issue with memory and concentration. Cold, lonely depression took its hold. I 

felt hopeless. At first I thought I was just having a really bad day, but these feelings 

persisted. I knew something was wrong. This was not me. I attempted to call the 

VA to talk with the psychiatrist, but she could not see me for about 30 days. I could 

not live like this for 30 days. I decided to stop taking the medication. Shortly after 

I stopped taking the drug, my mood began to improve and I was soon back to my 

original baseline. When I was able to see the doctor again, she said that I had made 

the right choice in stopping the medication. She asked if I wanted to try a different 

drug. I declined. I told her I’d like to try cognitive therapy. She said that was a 

good idea, but could not provide that for me. I was not referred to a psychologist. 

I left the clinic and that was the last interaction I’ve had with a VA mental health 

professional. 

My experience in which the VA deferred to pharmaceutical treatment instead of 

psychological treatment is not unique. On August 26, 2014, Adam Looney took his 

own life. Adam was a Marine Corps veteran and brother of my friend Kate Looney, 

also a Marine Corps veteran. Up until his death, Adam was receiving mental health 

treatment from the VA in Columbia, MO. According to Kate, the ‘‘VA’s approach 

was basically to try every psychiatric medication without really taking the time to 

counsel the root issue. He used to hate going because it was a long drive and a long 

wait. I brought him a few times, and he was never in there long. It seemed they 

were always changing his meds, losing paperwork and switching his counselor.’’ 

CURRENT SITUATION

I receive my health care through the VA Community Based Outpatient Clinic at 

the Ft. Belvoir Community Hospital. Still interested in meeting with a psychologist, 

I recently attempted to contact my clinic for a referral. The only way I’ve found to 

do this is through the one phone number listed on the clinic’s Web site. The phone 

number links to an audio recording that lists another phone number to call for referrals. After calling that number, I was on hold for about 15 minutes before I decided 

to select the option of having a representative call me back when one became available. To date, no representative has called me back nor responded to the voice message I left requesting help earlier this week. 

From a mental perspective, I feel very fortunate. No matter how bad things get, 

I always have a slight feeling that everything will be OK, that I just need to keep 

pushing forward. This feeling has been with me through my most difficult days on 

the battlefield and during my darkest times at home. Because of it, I have always 

been able to keep moving. But I know not everyone has this internal voice. When 

a person reaches out for help, especially mental health help, they are extremely vulVerDate Mar 15 2010 16:43 Jan 06, 2017 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6621 Z:\ACTIVE\102815.TXT PAULIN
6 

nerable. Not having someone pick up on the other end, someone you have been told 

will help, is crushing. When you are suffering from a mental wound, you will not 

have the emotional energy to keep asking for help if your first calls go unanswered. 

After learning I’d be testifying before you today, I posted on Facebook asking my 

friends about their experiences with mental health care from the VA. The responses 

I received were overwhelming. Alisa Beasley emailed me the following: 

I was medically retired from the Army 28 April 2014. I was just barely 

holding on mentally, that is how I felt. I saw my primary care provider by 

May and referred to Mental Health that same day! Then I saw a psychologist in July. Then nothing. I was supposed to be receiving follow up visits 

and every time I called the Mental Health number it just beeped like it was 

disconnected. I was so frustrated, and on top of that the VA had sent me 

a letter stating my benefits would be cut due to two missed appointments 

for psychiatry and neurology. I didn’t miss either of these appointments, 

they were never rescheduled like I called and asked for. I could literally feel 

my world crumbling. I had gone through a really tough divorce, he wasn’t 

letting me see my kids * * * I felt like what’s the point. I’m done. I was 

having panic attacks and nightmares and depression. I called and called 

and there was never an answer from the VA mental health building. It took 

me calling the patient advocate. By this time I was a sobbing mess and crying and shaking and felt like my world was crashing. She was kind enough 

to tell me it looks like they literally just dropped me completely off the 

mental health log. She was able to get me an appointment for February 2015, this call took place in November 2014. I didn’t see a psychiatrist to talk about possibility of meds till sometime after June 2015. 

This is not the worst-case scenario from the VA and mental health, but this 

is my story. This can not continue, others are far worse off and need the 

help they ask for RIGHT NOW not months or even days later. Why is there 

not a program set up that’s 24/7 hours where the Vet can come into the 

VA mental health building and be treated at that moment. I am going to 

school now so I hopefully can help another Vet with PTSD. I would like to 

work with in the VA, efficiently. They cannot continue on this path they 

are living up to the motto most vets live by now ‘‘The VA giving Vets a second chance to die for their country.’’ 

The saddest part is it is the truth. 

Sincerely, 

ALISA HURKMAN, 

Ret. US Army Vet. 

Like Alisa, I too have had the VA threaten to cancel my benefits for missing an 

appointment. The problem is that I knew I wasn’t able to make the appointment 

and actively reached out to the VA, but could not get through to an actual person. 

So, I left a voicemail with my appointment details and that I needed to reschedule. 

I never heard anything until I received a letter reprimanding me for missing an appointment. 

There’s a common thread here: the need to be able to efficiently gain access to 

the right care in a timely and thorough manner. Nathan Lewis, a former Marine 

Corps Officer, shared this with me: 

After my transition from the Corps my wife suggested I seek help for my 

challenges related to my two tours in Iraq. I reached out to the local VA 

hospital and asked for support. I waited months for their response. After 

three or so months I contacted them again. I was given a list of items I 

had to complete. It was an admin exercise and I decided to seek help 

through the assistance of my private sector employer. 

But what about those who cannot go outside of the VA for care? As a small business owner, I cannot afford private healthcare at this time. I am aware of several 

amazing psychologists in the DC area, but I simply cannot afford to pay for treatment out of pocket. 

In conclusion, as a veteran seeking mental health treatment from the VA, my biggest issue is gaining timely access to the right type of treatment. For me, the barrier to this is on the VA’s administrative side; gaining access to the right providers. 

I truly believe that streamlining this process and providing veterans with the appropriate mental health care will result in stronger families and dramatically reduce 

veteran unemployment and the tragic suicides that are plaguing the veteran community. 

7 

Mr. Chairman and Members of the Committee, I wish to thank you for this opportunity to present my perspective today. 

Chairman ISAKSON. Thank you, Nick. 

Mr. Maiers. 

STATEMENT OF DEAN S. MAIERS, U.S. NAVY VETERAN 

Mr. MAIERS. Good afternoon. My name is Dean Maiers. I am an 

OEF/OIF disabled veteran. I served in the Navy. I would like to 

take some time and explain to you about how my peer support specialist has been extremely helpful. 

Pretty much when I got out of the military, just like this gentleman to my right said, I had a rough time accepting that I was 

not right, and it took me numerous years in order to get to the VA 

and get help. They put me through this program at the Errera 

Center where all your doctors and peer support specialists are in 

one building. Ever since I have been going there, my life has 

changed tenfold. 

When I got out of the military. I tried to kill myself twice. I lost 

my wife, my children, my job. I was homeless for 3 years. This is 

very important to me, because our fellow veterans really need this 

help, and if it was not for the VA, I probably would be dead. I have 

all the thanks and gratitude to the VA, their staff there, and everybody here that has been so helpful. 

Every single veteran coming home deserves this program. Every 

State in this great country needs to have this program implemented. Some veterans, like myself, have too much pride to admit 

there is something wrong, after it took me 8 years to do it. 

Just the fact of knowing that someone is there for you when you 

need it, or even if you do need it, and I am—I am sorry. I am a 

little nervous. 

Chairman ISAKSON. You take all the time you need to take. 

Mr. MAIERS. Basically, I went through some trials and tribulations. I had a very, very rough time when I got out, and I am 

so grateful for this program and this country, that they are taking 

care of me now, and it just means the world to me. 

I thank you so much for this opportunity and your time. I hope 

that has been somewhat helpful. Anything I could do to help my 

brothers and sisters in arms to get the treatment they need and 

deserve. Thank you very much. 

[The prepared statement of Mr. Maiers follows:] 

HEARING TESTIMONY OF DEAN S. MAIERS, USN RETIRED

My name is Dean Maiers and I am an OIF/OEF disabled veteran. I would like 

to take some time and explain how my peer support specialist has been extremely 

helpful. 

I had a very rough time adapting when I got out of the Navy. I pretty much lost 

everything that was important to me, my wife, children, employment everything 

seemed hopeless. 

Then I found this program. It changed my life in so many ways. Ernest Johnson 

and the Comprehensive Work Therapy program at the Errera Center in West Haven 

have been a blessing to be honest. He also introduced me to several other social 

workers and other programs that have helped me tremendously, by getting me the 

right support team, and doctors to get me back on track. If it wasn’t for my peer 

support specialist, the program I am in and all the people who are there whenever 

you need them, I would never have gotten back on track. It gave me a sort of relief 

knowing that they are always there when I need them. 

8 

Every single veteran coming home deserves a peer support specialist. Every state 

in this great country needs to have this program implemented. Some veterans like 

myself not too long ago might have too much pride to admit there is something 

wrong it took me 8 years of failing at everything to give it a try - and now my life 

has improved in every way possible. 

Just the fact of knowing that someone is there for you if or when you need them 

is a great relief. I am happy to elaborate if you have any further questions for me 

today. 

Thank you so much for this opportunity and your time. I hope this has been somewhat helpful. Anything I can do to help my brothers and sisters in arms to get the 

treatment they need and deserve. 

Chairman ISAKSON. We thank you for your testimony and your 

service to the country. 

Mr. MAIERS. Thank you. 

Chairman ISAKSON. Mr. Butler. 

STATEMENT OF ROSCOE G. BUTLER, DEPUTY DIRECTOR, NATIONAL VETERANS AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN LEGION 

Mr. BUTLER. Good afternoon. Everyone in this room knows the 

highest cost of failing to provide mental health care to veterans is 

losing the life of one of our Nation’s defenders to suicide. Even the 

more mundane stakes are sobering. 

Setting aside those who take their own lives, veterans who struggle with untreated mental illness suffer daily with deep and lasting 

impact to their life, their work, and the lives of everyone that they 

hold dear. This is a crisis with deep and lasting impact to every 

facet of life and to every entire community. 

That is why ensuring veterans get the right mental health care 

is and has been a top priority of The American Legion. We are 

leading the engagement at every level, from VA and DOD officials 

to veterans and their families in every community. We hold summits. We regularly survey veterans. We are deeply committed to 

speaking to the folks who are fighting this battle in the trenches 

to make sure we are providing the voices of those fighters who it 

comes to look for solutions. 

Chairman Isakson, Ranking Member Blumenthal, and distinguished Members of the Committee, on behalf of our newly elected 

National Commander, Dale Barnett, and over two million members 

of The American Legion, we thank you for the opportunity to testify about ensuring access to mental health care for our Nation’s 

veterans. 

The American Legion has conducted detailed examinations of the 

VA Health Care System for over a decade and as part of our System Worth Saving Task Force. In 2013, we compiled ‘‘The War 

Within,’’ a detailed study of veterans and their experiences with 

treatment for PTSD and TBI. We followed that up with a survey 

of veterans’ mental health treatment in 2014 and a follow-up survey this fall that are analyzing for patterns as VA adapts their care 

and treatments. 

The survey indicated concerns from veterans about over-medications and a lack of complementary and alternative treatment options, such as art therapy, companion dogs, equine therapy, hyperbaric oxygen treatment, and many more options. 

In response to VA’s pledge to increase access to those sorts of 

treatment, by speaking to our members and traveling to VA faciliVerDate Mar 15 2010 16:43 Jan 06, 2017 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6601 Z:\ACTIVE\102815.TXT PAULIN
9 

ties as part of our System Worth Saving Task Force, has indicated 

that access to those type of treatments which could be beneficial to 

treating veterans and mental health conditions varies greatly from 

location to location. This level of inconsistency is troubling. In fact, 

one of the more serious problems plaguing the system is not a lack 

of proper ideals, but inconsistent application of VA guidance. 

When we talk to veterans across the country about how well VA 

implemented a mental health care summit initiative, the responses 

varied widely. A veteran in Chicago had an outstanding experience 

with their summit at the Jesse Brown VAMC. The veteran described positive network experiences and a strong level of interaction between VA and the veterans in the community and the applicable stakeholders. 

Conversely, a veteran from Seattle had the opposite experience. 

That veteran experienced summit meetings full of bureaucratic obstacles, mired in a lack of constructive progress, and ultimately 

was driven to abandon participation, feeling the whole mess was 

counterproductive. 

VA must improve their consistency. No matter how well intended 

their policies, if they cannot execute them evenly across the country and forge connections with the veterans they serve, they will 

drive veterans away from beneficial care for their mental health 

disorders. That must be a consistent and welcoming environment 

for veterans if VA is going to treat their disorders. 

The veterans who provide anecdotal accounts to The American 

Legion are indicative of larger patterns that even more systemic 

examinations have revealed. The independent studies of VA health 

care delivery mandated by the Choice Act found the same problems, troubling inconsistencies in terms of results across VA. 

Thank you again, Mr. Chairman, Ranking Member Blumenthal, 

for ensuring the Committee’s attentions stay focused on the critical 

issues of veterans’ mental health care. I appreciate the opportunity 

to present The American Legion’s experience on this topic and 

views and look forward to any questions you may have. 

[The prepared statement of Mr. Butler follows:] 

PREPARED STATEMENT OF ROSCOE G. BUTLER, DEPUTY DIRECTOR, NATIONAL

VETERANS AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN LEGION

Chairman Isakson, Ranking Member Blumenthal and distinguished Members of 

the Committee, on behalf of National Commander Dale Barnett and The American 

Legion; the country’s largest patriotic wartime service organization for veterans, 

comprising of over 2 million members and serving every man and woman who has 

worn the uniform for this country; we thank you for the opportunity to testify and 

for taking on one of the most serious challenges facing America’s veterans, that is 

‘‘VA Mental Health: Ensuring Access to Care.’’ 

The mental health of our Nation’s veterans is something that The American Legion takes very seriously. One of The American Legion’s legislative priorities for the 

114th Congress is to ensure Congress and the Department of Veterans Affairs (VA) 

provide help for veterans struggling with mental health issues and brain injuries 

and that they dedicate extensive resources to study the devastating effects of Post 

Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). The American 

Legion believes that additional resources and alternative treatments must be provided as options for veterans and servicemembers in need of treatment for brain injuries and mental stress. 

The American Legion has helped drive the focus on unprecedented numbers of 

veterans returning home from Operation Iraqi Freedom (OIF), Operation Enduring 

Freedom (OEF), and Operation New Dawn (OND) with PTSD and TBI which have 

been known as the signature wounds of these conflicts. To address this problem, 

10 

1The American Legion TBI and PTSD Committee Report: The War Within: Sept 2013 2 Interagency Task Force on Military and Veterans Mental Health: 2013 Annual Report 

3 American Legion Resolution No. 155: Aug. 2014 

4 American Legion System Worth Saving Report: 2014 

5 VA-OIG Report no. 14–05158–377 Mismanagement of Mental Health Consults and Other Access to Care Concerns—VA Maine Healthcare System Augusta, Maine June 17, 2015 6 VAOIG Report ‘‘OIG Determination of Veterans Health Administration Occupational Staffing 

Shortages’’: Jan 2015 

7SWS Site visit, Baltimore, MD, September 1, 2015 

The American Legion convened a TBI and PTSD committee in 2010, to investigate 

Department of Defense (DOD) and VA existing medical science and procedures, as 

well as alternative methods for treating servicemembers and veterans suffering with 

PTSD and TBI as a result of their combat service.1 In addition to the TBI and PTSD 

Committee, The American Legion’s System Worth Saving Task Force, established in 

2003, assesses the quality and timeliness of veterans health care within the VA 

healthcare system, of which mental health care is a critical component to the overall 

evaluation. 

On August 31, 2012, President Obama signed Executive Order (EO) Number 

13625: Improving Access to Mental Health Services for Veterans, Servicemembers, 

and Military Families directing the Departments of Defense (DOD), Veterans Affairs 

(VA), and Health and Human Services (HHS), in coordination with other Federal 

agencies, to take the necessary steps to ensure that veterans, servicemembers and 

their families receive the mental health and substance use services and support 

they need. 

These steps include strengthening suicide prevention efforts across the military 

services and in the veteran community; enhancing access to mental health care by 

building partnerships between VA and community providers; increasing the number 

of VA mental health providers serving our veterans; and promoting mental health 

research and development of more effective treatment methodologies.2

The American Legion applauds VA for the work the department has been engaged 

in to meet the objectives of the President’s Executive order, but much work still 

needs to be accomplished. The American Legion urges Congress to ensure VA has 

the funding needed to deliver comprehensive mental health services and to continue 

to provide the necessary oversight to ensure our Nation veterans receive timely and 

appropriate mental health services.3

VA MENTAL HEALTH HIRING INITIATIVE

Staffing shortages within VA leadership, physicians, and medical specialists within the Veterans Health Administration (VHA) remain a top concern of The American Legion. Since 2003, The American Legion’s primary healthcare evaluation tool 

‘‘System Worth Saving’’ (SWS) Program has tracked and reported staffing shortages 

at every VA medical facility visited across the country. The 2014 SWS report found 

that several VA medical centers continue to struggle with filling critical positions 

within the VA healthcare system.4

In the Spring of 2013, VA attempted to address the increasing numbers of veterans seeking mental health care by announcing the hiring of an additional 1,600 

mental health clinical providers and over 800 peer support specialists. VA reported 

they have exceeded the President’s 2012 Executive Order requirements and believe 

they are on the way to improving veterans access to mental health services. Yet 

problems with mental health scheduling clearly still exist, as VA’s Office of the Inspector General (OIG) found in a June 2015 study of mental health care in Augusta, 

Maine.5 VA’s continued struggles are indicative of how the lack of available mental 

health providers can contribute to long wait times for patients. Despite VA efforts 

in 2014 to hire an additional 1,600 mental health-care providers, time has shown 

that VA’s effort to address the lack of mental health providers still remains a serious problem. 

On January 30, 2015, the OIG released a report entitled ‘‘Veterans Health Administration’s Occupational Staffing Shortages’’ as required by Section 301 of the Veterans Choice and Accountability Act (VACAA) of 2014. The OIG report determined 

one of the occupations of critical need within VHA for Fiscal Years 2011 through 

2015 for staffing shortages were psychologists.6

When The American Legion’s System Worth Saving team travelled across the 

country, medical center staff continues to inform our team that they continue to 

struggle with recruiting mental health professionals. For example, during a September 1, 2015, SWS site visit one medical center 7 identified the following mental 

health vacancies: 

• 14 mental health psychiatrists, 

11 

8The American Legion Resolution No. 101: Department of Veterans Affairs Recruitment and 

Retention: Sept. 2015 

• 7 mental health psychologists, 

• 15 mental health social workers, 

• 1.5 mental health peer support specialists, 

• and 1 neuro-psychologist totaling 38.5 mental health vacancies in a single medical center. 

On average, a position may be vacant anywhere from 90 days to six months before 

the position is filled resulting in a significant delay in veterans receiving treatment 

for their mental health conditions. 

The VA has a systematic problem with recruiting talented people to either run 

their medical centers or to provide front line health care to veterans. The Blue Ribbon Panel, created by VACAA to examine reform of the VA healthcare system, provided a presentation to the VA Commission on Care noting: 

• 39 percent of senior leadership teams at VA medical centers had at least one 

vacancy; 

• 43 percent of network directors are in a ‘‘acting’’ status resulting in a severe 

leadership problem with VHA. 

• More than two-thirds of network directors, nurse executives are eligible for retirement, as are 47 percent of medical center directors. 

Leaders within the VA healthcare system have to be empowered and more needs 

to be done in order to grow new leadership. 

The American Legion calls on VA to establish a short and long range strategic 

plan to address their recruiting and retention problems. Whether the problem is pay 

disparity with the private sector or other disincentives to employment at VA, this 

needs to be examined and corrected. VHA needs to continue developing and implementing staffing models for critical need occupations, and work more comprehensively with community partners when struggling to fill critical shortages within 

VA’s ranks.8

VHA must find a way to fill these vacancies if they are serious about addressing 

the mental health needs of this nations veterans’. If VHA cannot fill the vacancies, 

then VHA must determine how they can better allocate the staff and resources they 

have to maximum effect. Solving the staffing problem requires both short term and 

long term solutions. In the short term, how can you treat the veterans who need 

care with the providers you have? In the long term, how can you recruit more providers, and if there are shortages of providers, how can VA help create more mental 

health professionals? 

COMMUNITY MENTAL HEALTH PROVIDER PILOT PROGRAM

On August 31, 2012, President Obama signed Executive Order (EO) 13625: Improving Access to Mental Health Services for Veterans, Servicemembers, and Military 

Families. The goal of the Executive Order was to create a vast network of support 

that had the capabilities of providing quality and timely mental health care services 

for veterans, servicemembers, and their families. Section 3(a) of the EO directed VA 

to create partnerships with community providers to decrease veterans wait times 

and increase the geographical range for veterans accessing mental care treatments 

and services. Through this action, VA implemented 24 VA/Community Mental 

Health Clinics (CMHCs) pilot programs with community-based mental health and 

substance abuse providers across nine states and seven Veterans Integrated Service 

Networks (VISNs) to enhance veteran access to mental health care programs and 

services between VA and community mental health care providers. 

In June 2013, President Obama directed all 152 VA medical centers across the 

country to hold Community Mental Health Summits with community-based programs and organizations to support veterans and their families. These summits 

were established to promote awareness of mental health services, assist veterans to 

gain access to mental health community programs and services, and to build health 

communities for veterans and their families to participate in. Annual mental health 

summits are held at every VA medical center (VAMC) across the country. The VA’s 

goal is to reach all veterans regardless of whether they are enrolled and receiving 

their health care through the VA. 

Communication within the veterans’ community is essential. As The American Legion learned from over a dozen community town halls we facilitated under our Veterans Crisis Center program last year, getting veterans in touch with VA to talk 

about their challenges is a critical tool to solving some of VA healthcare challenges. 

12 

Recognizing the importance of this initiative, The American Legion has been worked 

to track the experiences of our members with VA’s Mental Health Summits. 

One veteran told us: 

‘‘A Mental Health Summit was held on September 10th at the Jesse Brown 

VA Hospital in Chicago. It was moderated by a staff psychologist from the 

hospital and was attended by many people from various agencies and organizations. We heard from several veterans about their experiences in the 

VA mental health system and they were all positive. We also had a networking session which was, in my opinion, very positive. I made several 

good, new contacts that I will utilize in the future. Unfortunately, I understand that not all experiences veterans have with the VA mental health 

system are positive. But it was good to hear some success stories and speak 

to the veterans about what they went through.’’ 

Another veteran described their experience: 

‘‘I was asked to participate in a mental health focus group at the Seattle 

VA. The purpose of the group was to provide feedback to VA about promoting awareness, helping veterans gain access etc. I missed the first meeting, attended the 2nd and the 3rd and decided to not participate in the 

group. Our first task was to adopt bylaws for our group, select a president 

and a secretary. As I missed the first meeting the group had already selected a leader for the meeting. Staff offered a bylaws template at the previous meeting. The second meeting consisted of taking turns reading the bylaws out loud. Third meeting was even less constructive. Having served on 

the King County board to end veteran homelessness, served on several 

other boards in different capacities including President, and being well connected to service organizations such as the Legion, I felt that I had a lot 

to offer this group. However, most of the group assembled did not have experience in running organizations, access to technology to read documents 

between meetings. I decided that spending 21⁄2–3 hours driving round trip 

to attend a one hour lunch meeting progressing at a pace I deemed a snail 

would find slow a waste of my time. I was Unimpressed in Seattle.’’ 

The disparity between these two experiences is representative of perhaps the biggest challenge VA faces in delivering healthcare—inconsistency between locations. 

Where one veteran in the Midwest can have such a positive experience and another 

in the Pacific Northwest can have such a negative experience, it’s indicative of a 

system that still has a ways to go to deliver consistent care and results. VA must 

work harder to achieve that consistency if mental health efforts are going to be effective. 

The American Legion is not alone in finding these inconsistencies. The recently 

completed Independent Assessment of VA healthcare, mandated by VACAA, has 

similarly illustrated the vast range of inconsistency across VA facilities in the implementation of programs. It is not necessarily that VA is not attempting to implement 

good policy, it is often that it is executed with disparate results depending on location. That is not a recipe for success. 

CONCLUSION

Much of the problems VA faces in delivering effective mental health care revolve 

around two primary considerations—lack of staff and lack of consistency. The 

former is something VA and Congress have attempted to address with additional 

hiring, with mixed results. The latter is something that is completely within VA’s 

realm of control. If they are to change their culture to be better focused on serving 

veterans, ensuring consistency needs to be at the top of the list of priorities for 

achieving that goal. 

The country’s obligation to its Armed Forces and its veterans includes a responsibility for their care and treatment from wounds inflicted upon them while serving 

their country. The challenge raised by Traumatic Brain Injury and Post Traumatic 

Stress Disorder demands a dedicated, well coordinated, and flexible response that 

adapts care and treatment to an individual’s needs, not the other way around. 

The American Legion thanks this Committee for their diligence and commitment 

to examining this critical issue facing our servicemembers and veterans as they 

struggle to access mental health care across the country. Questions concerning this 

testimony can be directed to Warren J. Goldstein, Assistant Director in The American Legion Legislative Division (202) 861–2700. 

Chairman ISAKSON. Thank you very much, Mr. Butler. 

13 

Dr. Maffucci. 

STATEMENT OF JACQUELINE MAFFUCCI, Ph.D., RESEARCH 

DIRECTOR, IRAQ AND AFGHANISTAN VETERANS OF AMERICA 

Ms. MAFFUCCI. Chairman Isakson, Ranking Member Blumenthal, and the Committee members, on behalf of Iraq and Afghanistan Veterans of America and our more than 425,000 members, 

and as IAVA’s Research Director and resident neuroscientist, I 

thank you for the opportunity to share our views today. 

In 2014, IAVA launched the Campaign to Combat Suicide, a result of our members continually identifying mental health and suicide as their number 1 issue. This campaign was centered around 

the principle that timely access to high quality mental health care 

is critical in the fight to combat veteran suicides. 

The signing of the Clay Hunt SAV Act into law was an important 

first step to addressing this and we thank you for your support on 

this legislation. But, there is still so much work to be done. 

Every year, IAVA surveys our members, and in our most recent 

survey, half of respondents reported having a mental health injury 

and about 60 percent of those were seeking care from the VA. Of 

those, over 70 percent reported satisfaction with that care, but an 

almost equal percentage reported challenges scheduling appointments. 

Bottom line: our members have told us that access to VA mental 

health care is a challenge, but once in the system, they are 

satisfied. 

No veteran should have to wait for mental health care once they 

take that difficult step to seek help. Clay Hunt was one of these 

veterans. Clay sought help at the VA, but was repeatedly frustrated by challenges in scheduling appointments and receiving consistent care. He was a Marine, a son, a friend to many, an advocate, and humanitarian. Yet, despite his proactive and open approach to seeking care, he lost hope and took his life on March 21, 

2011. Access to care is critical. 

There is a shortage of mental health professionals in this country. The supply is waning while the demand is growing. The Secretary is working to recruit medical students into the VA and into 

mental health professions, and this is really important. However, 

there are barriers in place that make it difficult for the VA to hire 

and to retain these professionals. The Federal hiring process can 

be confusing and lengthy, and this can be a huge deterrent in attracting and identifying talent. 

A recent VA Inspector General report that looked at hiring and 

loss rates of VA psychologists and medical officers found that a significant percentage of the total gains from hiring was offset by 

losses. The VA needs to understand and address the reasons that 

these staff leave as well as how best to attract new talent. 

The VA also needs to continually assess and update its staffing 

models and hiring guidelines. There is an opportunity here for an 

innovative approach to predict local demand for mental health professionals using real time data. One of the biggest obstacles to this 

is the current scheduling system, which does not provide this type 

of data that can inform the VA of usage habits of veterans seeking 

14 

VA mental health care. This is just one of the reasons why updating this outdated system and clarifying its policies is so important. 

As part of this, we also encourage the VA to get away from 

grouping mental health professionals as one category and focus on 

defining the needs for each discipline. Each have a unique skill set. 

Defining demand and establishing targeted hiring for these professions will help in filling gaps in access, and as these hiring initiatives occur, the need for additional resources is critical. 

Outside of staffing, there are three additional areas that warrant 

focus. Telemental health is one of these areas. VA should be commended for its telemental health program, which can fill gaps in 

communities that have critical provider shortages and potentially 

encourage more veterans to seek care. This program must continue 

to be developed, assessed, and expanded to ensure veterans have 

access to care. 

Vet centers continue to be a highly praised resource among 

IAVA’s member population. We would like to see a comprehensive 

assessment of the role that Vet Centers play in supporting veteran 

mental health. It is a critical resource and fills a specific need, particularly for veterans who may be less inclined to seek services at 

VA health centers or seeking care with their family or are not eligible for VA health. We want to ensure that it is being fully utilized. 

Finally, the role of the community providers. The majority of veterans do not seek care at the VA. The care of this Nation’s veterans 

is not the sole responsibility of the VA, but rather the community, 

and yet as community mental health providers are called upon to 

serve this population, a recent RAND report suggests they may not 

be well equipped to address these needs. Pilots such as the VA 

Community and Mental Health Partnership, or existing and successful programs like the Star Behavioral Health Program, can 

help to provide a framework for addressing the skills gap. 

All veterans deserve the very best our Nation can offer. We look 

forward to working with you and the administration to address 

these very real challenges. Thank you, and I am happy to take any 

questions. 

[The prepared statement of Ms. Maffucci follows:] 

PREPARED STATEMENT OF JACQUELINE MAFFUCCI, PH.D., RESEARCH DIRECTOR, IRAQ

AND AFGHANISTAN VETERANS OF AMERICA

Chairman Isakson, Ranking Member Blumenthal and Distinguished Members of 

the Committee, on behalf of Iraq and Afghanistan Veterans of America (IAVA) and 

our more than 425,000 members and supporters, we would like to extend our gratitude for the opportunity to share our views on VA Mental Health: Ensuring Access 

to Care. 

In March 2014, IAVA launched the Campaign to Combat Suicide, a direct result 

of our members continually identifying mental health and suicide as the number 

one issue facing the newest generation of veterans. This campaign was centered 

around the principle that timely access to high quality mental health care is critical 

in the fight to combat veteran suicides. The signing of the Clay Hunt SAV Act into 

law was an important first step to addressing this. IAVA continues to work with 

Congress and the VA to fully implement this law, but there is still much work to 

be done. 

Every year IAVA surveys our members on their health experiences, among other 

issues. In our most recent survey, about half of IAVA’s survey respondents reported 

having a mental health injury, and a little less than 60 percent were seeking care 

for these injuries from a VA provider. Over 70 percent of those using VA mental 

health care reported satisfaction with that care, but an almost equal percentage of 

respondents reported having some level of challenge scheduling VA mental health 

15 

1Department of Veterans Affairs Office of the Inspector General. OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages. September 01, 2015; Report 15– 

03063–511. 

appointments. This is compared to only 31 percent of those using non-VA mental 

health care reporting scheduling challenges. Bottomline, our members have told us 

both through the survey and anecdotally that access to mental health care continues 

to be a challenge, but once in care, they are satisfied. No veteran should have to 

wait for mental health care once they take that difficult step to seek help. And this 

is where the topic of access becomes so very critical. 

Clay Hunt was one of these veterans. Clay sought help at the VA but was repeatedly frustrated by challenges in scheduling appointments and consistent care. He 

was a Marine who even after being injured signed up to deploy for a second time. 

Once he separated from the Marines, he became a veteran advocate, working with 

IAVA, and participated in humanitarian work with Team Rubicon. Despite his 

proactive and open approach to seeking mental health care, he lost hope and took 

his life on March 31, 2011. Access to care is critical. 

There is a shortage of mental health care professionals in this country. The supply is waning while the demand for mental health services is growing, as highlighted by Clay’s story. Specific to the veteran community, almost 30 percent of new 

veterans treated at the VA have been diagnosed with Post-Traumatic Stress Disorder and 57 percent have some form of a mental health injury. The demand among 

the new generation of veterans will likely continue to grow as more troops come 

home and those already home continue transition to civilian life. And we cannot discount potential growth in demand among all veterans. The nation must be prepared 

to care for these veterans for decades to come, both in and out of the VA. 

The Secretary and this Administration are working to encourage medical students 

into mental health professions, and this must continue to grow the field. However, 

there are barriers already in place that make it difficult for the VA to both hire and 

retain these professionals. The application process and the lengthy wait time to be 

hired into the Federal Government can be a huge deterrent in attracting talented 

professionals. A recent VA Office of Inspector General Report 1 looked specifically at 

hiring and loss rates of VA psychologists, determined to be a critical needs occupation. The report found that a significant percentage of the total gains from hiring 

was offset by losses. Given the amount of training and the continued demand for 

these professionals, the VA must understand and address the reasons that these 

staff leave. 

The VA also needs to continually assess and update its use of staffing models and 

guidelines surrounding the hiring of these mental health specialities at the facility 

level. IAVA believes that there is an opportunity for an innovative approach to develop more predictive models of need that can better inform these staffing models. 

There are examples of this type of data driven approach to understanding characteristics of the veteran population already in process that could drive this concept, like 

the Veteran Data Project led by the Center for New American Securities. 

As the VA continues to focus on staffing models, it must also get away from 

grouping mental health professionals as one category when focusing on hiring initiatives, and more specifically focus on the needs for each discipline. Each have a 

unique skill set and the demand and targeted hiring for these must be determined 

in their own right. 

There are additional constraints that also must be considered. Paramount to all 

of these recommendations is the need for better data within the VA to define the 

current demand. This will come as the VA replaces its extremely outdated scheduling system, an initiative in place but not yet fully implemented. Additionally, as 

demand increases and additional staff are required, there is an impact on resources, 

including facility space. 

Outside of these recommendations, there are three additional areas that warrant 

focus to address access to care: 

1) Telemental health: The VA should be commended for its work in introducing 

and developing its telemental health program. IAVA sees this initiative as one that 

is able to fill the gaps in communities that have critical shortages in mental health 

professionals. We look forward to working with the VA to continue to continue to 

develop, assess and expand this program to ensure that it is providing high quality 

mental health care to veterans particularly in areas that are geographically isolated 

and/or experiencing severe mental health staffing shortages in the community and 

the VA. 

2) Vet Centers: Since 2003, the VA has expanded the number of Vet Centers, and 

currently 300 exist. Vet Centers continue to be a highly praised resource among 

IAVA’s member population. They fill a specific need among the veteran population, 

16 

2Tanielian, Terri, Coreen Farris, Caroline Batka, Carrie M. Farmer, Eric Robinson, Charles 

C. Engel, Michael Robbins and Lisa H. Jaycox. Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families. Santa Monica, CA: RAND Corporation, 2014. 

including serving family members, hosting later hours and serving the veteran population regardless of discharge status. IAVA would like to see a comprehensive assessment of the role the Vet Centers play, the demand for these services and a determination of whether the current number of Vet Centers is addressing that demand. We feel that this is a critical resource, particularly to veterans who may not 

be inclined to seek services at the VA health centers. 

3) The Role of Community Providers: Approximately 60 percent of new veterans, 

and less than 40 percent of the entire veteran population, is seeking care at the VA. 

The care of this Nation’s veterans is not the sole responsibility of the VA, but rather 

the community at large. And yet, as community providers are called upon to serve 

this population, a recent RAND report 2 suggests that community providers might 

not be well equipped to address the needs of veterans and their families, specifically 

in understanding high quality treatments for PTSD and other mental health injuries. Pilots such as the VA/Community Mental Health Partnership can help to provide a framework for how public-private partnerships can address this skills gap. 

At IAVA, we believe our members, and all veterans, deserve the very best our Nation can offer when it comes to fulfilling the promises made to them upon entry into 

the military. There is no doubt every Member of this Committee has the best interests of our veterans at heart. We look forward to continuing to work with you and 

the Administration as partners in trying to address these very real challenges with 

innovative and scalable solutions. 

Thank you for your time and attention. IAVA is happy to answer any questions 

you may have. 

Chairman ISAKSON. Thank you very much. 

Dr. Draper. 

STATEMENT OF DEBRA A. DRAPER, PH.D., DIRECTOR, HEALTH 

CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. DRAPER. Chairman Isakson, Ranking Member Blumenthal, 

and Members of the Committee, I appreciate the opportunity to be 

here today to discuss veterans’ access to VA mental health care. 

My testimony today is based on a report released today, and my 

comments focus mainly on the timeliness of mental health care and 

VHA’s oversight. 

Of the 100 medical records for veterans new to VA mental health 

care that we reviewed, 86 percent received their initial appointment for a full mental health evaluation within 30 days of their 

preferred date. However, this does not reflect the whole story. 

We found that VHA has conflicting policies regarding how long 

it should take a veteran to receive a full mental health evaluation. 

One policy says 14 days while the other says 30 days. VHA has not 

provided guidance on which policy should be followed, which has 

caused confusion, making it difficult to ensure timely access to 

mental health care, particularly given the increasing demand for 

care. 

We also found that VHA’s wait time calculations do not always 

reflect the overall time veterans waited for care because these calculations do not account for the period of time prior to establishing 

the veteran’s preferred date, which can be quite lengthy. 

VHA disagreed with our overall wait time calculations, which 

calculated wait time from the initial request for care until the veteran was seen, stating that these calculations did not capture situations that were out of their control, such as when a veteran wants 

to delay care. While this is sometimes true, we found instances 

17 

where requests or referrals for care made prior to the establishment of the preferred date were mismanaged or lost in the system. 

Gaining a better understanding of veterans’ overall wait time experiences provides an important opportunity for VHA to identify and 

make needed improvements. 

Additionally, we found that veterans who receive a full mental 

health evaluation may experience additional delays in receiving 

treatment specific to their mental health condition. While VHA disagreed with our findings, stating that the full mental health evaluation should be considered the start of a veteran’s treatment, the 

wide variation we found in the amount of time between a veteran 

receiving this evaluation and their next appointment presents an 

additional opportunity for VHA to improve veterans’ experiences 

accessing care. 

VHA monitors access to mental health care, but the lack of clear 

policies contributes to unreliable wait time data and hinders oversight. We found that mental health wait time data may not be comparable over time because VHA has changed definitions used to 

calculate certain measures. VHA has not clearly communicated the 

definitions used or changes made, which has created confusion and 

limits the reliability and usefulness of the data. 

We also found that wait time data may not be comparable between medical centers. For example, one of the medical centers we 

visited referred about a third of veterans seeking mental health 

care to an open access clinic, which is a type of walk-in clinic, rather than scheduling an appointment. These veterans were tracked 

using a manually maintained list. Follow-up was inconsistent, and 

nearly half of those on the list never presented for care. This finding is especially troubling given VHA’s past problems with maintaining lists outside of the scheduling system. 

We recommended that VHA issue clarifying guidance on its access policies, definitions used to calculate wait times, and how open 

access appointments are to be managed. We also reiterated our 

prior recommendation, which calls for VHA to take actions to improve the reliability of its wait time measures. 

Very briefly, we also looked at VHA’s recent mental health hiring 

efforts as well as a pilot program to help expand capacity through 

the use of community providers. We found that while local improvements to mental health care access were reported due to the 

recent hiring efforts, a number of challenges were also noted, such 

as the inability to keep pace with the increasing demand for care. 

We also found that in 2013, as the result of an Executive Order, 

ten VA medical centers established partnerships with community 

providers to improve access to mental health care. A limited number of mental health care appointments resulted from these partnerships, about 2 percent of the total appointments provided by the 

participating medical centers. 

The bottom line is that work is needed to improve veterans’ experiences accessing mental health care. Given the vulnerabilities of 

veterans seeking mental health care, veterans who may be at risk 

of serious if not life-threatening events, ensuring their timely access to care is critical. 

Mr. Chairman, this concludes my opening remarks. I am happy 

to answer any questions. 

18 

[The prepared statement of Ms. Draper follows:] 

PREPARED STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, 

U.S. GOVERNMENT ACCOUNTABILITY OFFICE


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Chairman ISAKSON. We will take a round of 5-minute questions 

for each Member, and I will begin. 

Dr. Draper, the VA’s representative, Dr. Kudler, is going to testify after this panel, but in reading his testimony with regard to 

open access appointments, he says, and I quote, ‘‘The combination 

of current policy and training constitutes clear guidance on how to 

manage and schedule open access appointments.’’ 

In the report, open access is discussed quite frequently and is a 

misleading, in some cases, process in terms of the actual timeliness 

of veterans being served. Can you comment on that? 


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Ms. DRAPER. Yes. We actually found two medical centers that 

were using open access appointments. One facility—there were access audits that were done following the Phoenix issues, and one 

of those facilities, through that access audit, they were told that 

they could no longer use the open access appointments without also 

scheduling appointments. They just could not refer someone to a 

clinic without scheduling an appointment. 

The second medical center that we visited, they were not told 

that, and they would do a telephone triage. A mental health nurse 

would do a triage with the veteran seeking mental health care, and 

at that point, they were referred to an open access clinic, which is 

a type of walk-in clinic, but they have actually had a triage 

through a mental health provider, a nurse. It was not the same as 

a walk-in clinic. VHA did tell us that they provided training, but 

that is not what we observed in the field. We did not observe the 

type of walk-in clinic that they were referring to. 

Chairman ISAKSON. An open—— 

Ms. DRAPER. This was basically a list that people were put on. 

This manual list that maintained outside of the scheduling system, 

where the policy says that those veterans should have been scheduled for an appointment. 

Chairman ISAKSON. Given the problems we had at Phoenix and 

other areas on appointments and masked, m-a-s-k-e-d, use of lists 

to show appointments being made in a timely fashion when they 

really were not, this would have contributed to that. Am I not 

right? 

Ms. DRAPER. It has, and actually, the medical center that was 

doing this told us that they did this to reduce their ‘‘no show’’ 

rates, so—— 

Chairman ISAKSON. I found that to be one of the most disturbing 

parts of the report, because the last thing we need to do in the VA 

health services is continue or do anything that perpetuates the 

memory of what happened in Phoenix in terms of the manipulation 

of data. So, whatever is reported to us needs to be an accurate reflection of the timeliness of service veterans are getting. 

Ms. DRAPER. Absolutely. We found that you really cannot compare the data between medical centers because of issues like that. 

My question would be, are there other facilities that we did not 

visit that are also using the open access appointments without 

scheduling an appointment. 

Chairman ISAKSON. Well, the reason we are conducting this 

hearing today is to get the word out far and wide that we are very 

concerned about the timeliness of service to our veterans persuing 

mental health and want to make sure they get the most timely 

service they can with the very best processes they can. 

Mr. Maiers, thank you for your testimony. 

Mr. MAIERS. Thank you, sir. 

Chairman ISAKSON. In your testimony, and we appreciate your 

emotion, because I know you care much—— 

Mr. MAIERS. I apologize about that. To be honest, I did not mean 

to get that emotional about it. I am trying to stay strong here, you 

know. 

Chairman ISAKSON. I cry at weddings and funerals, too, so do not 

worry about that. 

33 

Mr. MAIERS. I hear you, sir. 

Chairman ISAKSON. Your testimony was very compelling, and 

your services that you receive from the VA, you were complimentary of those services, correct? 

Mr. MAIERS. Yes, sir. 

Chairman ISAKSON. How long did it take you between the time 

you knew you had a mental health challenge and you were able to 

get your appointment scheduled with the VA? 

Mr. MAIERS. Well, like I said before, it did take me a while to 

admit that I had a problem, but the program that was in place— 

I think I spoke to my psychiatrist and then 2 weeks later, I was 

referred to this outside place called the Errera Center. It is kind 

of like a subdivision of the VA where, basically, all your doctors— 

your primary care, your mental health, your comprehensive work 

therapist, your peer support specialist—are all in one building. So, 

instead of waiting at the VA for hours upon end for one appointment, you can knock out all your appointments in 1 day at one 

place. 

If it was not for this, I do not know, honestly, where I would be 

right now, sir. They have gone leaps and bounds with improving 

my mental health since the day I admitted I had a problem. 

Chairman ISAKSON. What facility was that? What was the name 

of that facility? 

Mr. MAIERS. The Errera Center. 

Chairman ISAKSON. The Errera Center. 

Mr. MAIERS. In West Haven, Connecticut. 

Chairman ISAKSON. Thank you. 

Mr. Karnaze, thank you very much for your testimony. I think 

in your testimony, you said it took you about a year to get into the 

VA Health Care System, is that correct? 

Mr. KARNAZE. Yes, sir, it did. 

Chairman ISAKSON. Is that a year from your severance with 

DOD going into veteran status? 

Mr. KARNAZE. Yes, thereabouts. 

Chairman ISAKSON. Why did it take you a year? 

Mr. KARNAZE. I do not know. After I started receiving health care 

here in DC—I used to live in North Carolina, which is where I 

started my paperwork, in the clinic there in Wilmington, NC. I 

moved up here and was receiving care in the DC office when I actually received a letter from North Carolina—I think it came from 

Greenville—asking if I was still interested in receiving health care 

benefits from the VA. I just ignored that letter because I already 

was. 

I am not sure, sir, why it took so long for me to get pulled into 

the system. I kind of feel like I had an unorthodox entry because 

I had some symptoms of TBI and they brought me in. I was not 

assigned a primary care physician first. I actually went to specialists and then kind of went backwards and was assigned a primary 

care physician. 

Chairman ISAKSON. Well, I am not going to abuse my Chairmanship and take extra time, but we will have a second round of questions. I want to delve a little bit further into that particular 

situation. 

Senator Blumenthal. 

34 

Senator BLUMENTHAL. Thank you, Mr. Chairman, and thank you 

for having this hearing. 

Thank you, Mr. Karnaze, Mr. Maiers, and Mr. Butler, for your 

service. 

Mr. Karnaze, I noticed in your testimony a reference to the fact— 

and I do not know whether you repeated it here—that the VA 

threatened to cutoff your benefits because you missed an appointment, is that correct? 

Mr. KARNAZE. Yes, and there was an appointment that I could 

not make, so I called that number and there was no answer at the 

other end. I left a voice mail saying I have to cancel this appointment. This is my name. This is what I am being seen for. I cannot 

make it. I need to reschedule. I did not hear anything back. 

Shortly thereafter, maybe a week or two, I received a little postcard in the mail saying that I had missed a VA appointment and 

if I continued to miss appointments, I might lose my benefits. 

Senator BLUMENTHAL. Are you familiar with that practice, Mr. 

Maiers? 

Mr. MAIERS. Yes. I have gotten several of those letters myself. I 

mean, to be completely honest with you, it is hard working a fulltime job and scheduling your time around the VA, because when 

you go in there, you do not have a choice of appointment. They say, 

Monday, 2:30, Monday, 3:30. You do not have a choice. If you physically cannot make this appointment, then there is nothing you can 

do about it. And for us to be held accountable for that, I really do 

not think it is fair. 

Senator BLUMENTHAL. All the more reason for the VA not to 

threaten you with cutting off your benefits. 

Mr. MAIERS. That is correct. 

Senator BLUMENTHAL. If you were going to a psychiatrist and 

you missed an appointment and left a message on the voice machine, the last thing in the world you would expect is for that office 

to call you back and say, we may not see you anymore, or we will 

not see you anymore. Absolutely unacceptable. 

Mr. MAIERS. I agree. 

Senator BLUMENTHAL. I want to thank you, Mr. Maiers, for making the trip here. Just so the Committee knows, you drive for a living and you spent an additional 8 hours on the road to get here—— 

Mr. MAIERS. That is correct. 

Senator BLUMENTHAL [continuing]. Overnight. 

Mr. MAIERS. Yes, sir. 

Senator BLUMENTHAL. We will forgive you if you nod off—— 

Mr. MAIERS. Yeah. I am not at 100 percent today. 

Senator BLUMENTHAL [continuing]. Which is a temptation that 

many spectators feel—— 

Mr. MAIERS. I hear you. 

Senator BLUMENTHAL [continuing]. Listening to Senators. 

[Laughter.] 

Mr. MAIERS. I will try not to fall asleep on you, sir. 

Senator BLUMENTHAL. Well, I want to thank you for being here. 

Thank you for your dad, Leroy’s, service. 

Mr. MAIERS. Thank you. I will let him know. 

Senator BLUMENTHAL. And for your strength and courage to be 

here, as well as to Mr. Karnaze. 

35 

On the Errera Center, which I have visited more times than I 

can count, as I understand it one of the programs available there 

is the peer program—— 

Mr. MAIERS. Yes. 

Senator BLUMENTHAL [continuing]. The peer-to-peer, veteran 

helping veteran, program. I have just introduced legislation, with 

support from a number of my colleagues, to expand that program—— 

Mr. MAIERS. Good. 

Senator BLUMENTHAL [continuing]. In effect, to overcome the 

stigma, alienation, sometimes shame that veterans may feel seeking mental health care. 

Mr. MAIERS. Absolutely. 

Senator BLUMENTHAL. It is against their culture, so to speak. I 

think you have been a beneficiary of the peer program. I wonder 

if you could tell the Committee a little bit about your experience. 

Mr. MAIERS. Absolutely. I would be honored to. Basically, if I can 

just elaborate on what a peer support specialist is; it is a fellow 

veteran who, basically, takes the role of a—not so much a psychiatrist, but puts things into perspective for you that only somebody 

who has been there and gone through what you have gone through 

can understand and help you with. I have been through at least a 

half-a-dozen to ten psychiatrists through the VA and I felt was that 

it was all medicine, medicine, medicine, medicine, with no regard 

for the way I was thinking. 

Ever since I have been in the Errera Center, not only do I have 

a peer support specialist, I have a primary care physician, and 

maybe three psychologists. If one does not answer the phone, the 

other one will call me back in 5 minutes. I mean, what I have going 

on for me now has turned my life upside down meaning it is 100 

percent better and it is all thanks to the Errera Center and the VA 

Health Care System and I would like to thank them for that. 

Senator BLUMENTHAL. And the peer program—— 

Mr. MAIERS. Peer support specialists, absolutely. 

Senator BLUMENTHAL [continuing]. That the Errera Center has 

helped to pioneer—— 

Mr. MAIERS. Yes. Absolutely. 

Senator BLUMENTHAL. Laurie Harkness has been a tremendous 

force for good—— 

Mr. MAIERS. Yes. 

Senator BLUMENTHAL [continuing]. In our veterans’ community. 

Dr. Draper, my reaction on reading this GAO report is I am just 

more astonished and appalled that the VA has not done better, 

even after years of records and documentation and all the rest. 

There still seem to be excessive wait times, inconsistent reporting, 

inadequate data. Do you have an explanation? Is it a failure of will 

or resources? Would you give us your sort of from-the-heart 

assessment. 

Ms. DRAPER. Sure. I have been involved with the wait time work 

for probably 4 or 5 years now. I think that what we have seen, certainly, we see a greater awareness of the need to get wait times 

under control and a greater awareness of making sure that the information is accurate. 

36 

However, we still see data reliability issues, and this goes back 

to unclear policies. A lot of schedulers enter the data correctly, but 

the issues that we saw were with the open access appointments. 

So, you cannot really compare data from across medical centers 

and the changes in the wait time calculations without providing 

sufficient definitions. 

All of that is not very comparable, and the system itself—I think 

someone mentioned that the IT system does not support good 

scheduling practices. We had one facility tell us they go in and 

check every appointment that is made that day for mental health 

to make sure that it is done correctly. That is a gross inefficiency 

of time, where you have limited resources. That is not where people 

should be focusing their time. The system should support what 

they are doing. 

The policies, ambiguous policies and inadequate oversight are the 

reasons why we put VHA on the High-Risk List this past year. We 

still see some of the same issues. 

Senator BLUMENTHAL. Thank you. Regrettably, my time has expired, but I hope to come back to this topic with you and GAO and 

a number of our witnesses and I thank you all for being here. 

Chairman ISAKSON. Senator Rounds. 

HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. 

I am just curious. It seems strange that the VA would begin their 

process by announcing an appointment without first conferring 

with the individual to find out whether or not they could make it. 

Is that consistent across all of the offices or all of the different locations in the VA? Or, did I misunderstand the statement, that in 

some cases you are missing appointments because they give you 

the time and they date. They do not ask you whether or not you 

are available in the first place. Did I misunderstand? 

Mr. MAIERS. Well, what they do is they offer you a couple of appointments, ask which can you make. If you cannot make either 

one of those appointments, then you are—I do not even know what 

word I would use—considered an unauthorized absence. You are 

not there for your appointment. I have received several letters that 

I have missed appointments, but I missed the appointments because I was in the hospital. So, how am I supposed to go to this 

appointment when I am in the emergency room? It is very stressful. 

It has gotten a lot better and I have the Errera Center to thank 

for that. I am no longer in the VA hospital. I am in the Errera Center moreso. So, it is a lot different now. 

Senator ROUNDS. Dr. Draper, did you find that in your reviews? 

Ms. DRAPER. Well, the scheduling policy calls for appointments 

to be set at what the veterans’ preferred date is. However, I think 

there is a lot of confusion about how that gets operationalized at 

the local level, because sometimes it becomes, what the next available appointment is. This is really an artificial measure, because 

a veteran does not know what that means. So, you see this sort of 

tug-of-war between the scheduler and the veteran. They are pushing the preferred date, but that really does not make any sense to 

37 

a veteran. There is still a lot of training and clarification of what 

all this means. 

Senator ROUNDS. Has implementation of the Choice Act increased access to mental health care? 

Ms. DRAPER. That was beyond the scope of our work, but we did 

look at the community pilot program for mental health and it did 

increase access somewhat. It was pretty limited, and there was a 

lot of confusion among the provider community with the many different programs that were going on, the PC–3, the Veterans 

Choice, this program, and they all pay different rates, as well. So, 

it was very confusing for people as to what the different programs 

were. 

Senator ROUNDS. I know we talked about it and there was a discussion about the ‘‘no show’’ rate. How does that play into this 

whole discussion? Is it a cascading effect where, number 1, they are 

making appointments where, in many cases, the veteran is not 

going to be able to make it in the first place? The veteran did not 

get there and now they have a no show. So, now they are going to 

try a different approach, to push the issue. What is with the noshow rates? How are the no-show rates consistent between VA 

versus non-VA? Have you looked at any of that? 

Ms. DRAPER. Not in this particular engagement, but when we 

looked at wait times back in 2012, no show was a huge problem 

for VA. At that time, they did not really have a policy. It is called 

the missed opportunity rate, which includes veterans not showing 

up for care or a clinic canceling an appointment or a veteran canceling an appointment. So, all that gets factored in. It is really lost 

productivity for the provider. 

The clinic that we talked about, the open access clinic, that was 

one way they went and tried to resolve their no show issue. They 

did it incorrectly. It is hard to really understand what each medical 

center is doing. 

The policy says that they are supposed to get the veteran’s preferred date and not supposed to schedule without the agreement of 

the veteran. 

Senator ROUNDS. What have we learned from it and is there a 

new implementation plan that is trying to achieve a better rate 

than what they have got today? Where are they at right now with 

it? 

Ms. DRAPER. Yeah, that is probably a good question for the VA 

witnesses that will come up next, but I can say they have done 

some training. Yet, the scheduler, that is a high-turnover position. 

The training is just required to be ongoing. 

Senator ROUNDS. Are there appropriate specialties available for 

the different needs? My first thought had been that a veteran 

would come in and they would be working with a specialist. What 

I am learning here is that there are multiple specialists that are 

involved with an individual. Could we talk a little bit about whether or not those specialists are available in the areas where they are 

needed, or do we have a missing link here somewhere in terms of 

the professionals, the trained professionals for the different things 

that a single veteran may need. For anyone who would like to 

answer. 

38 

Ms. MAFFUCCI. Sir, I can take a stab at that. Yes, each mental 

health professional has their own area of expertise and have their 

own relevance in providing care. I spoke a little bit to the staffing 

models, and the way the staffing models go, it is a ratio. There is 

a preferred ratio of the number of, for example, psychiatrists to Xnumber of veterans that are seeking care. 

The challenge is, at the local level, there is really not a dynamic 

system that can really qualify what the demand at the local level 

is, and often, it is left to the local medical centers to really determine that. But without the data to support it, our understanding 

is it can be really hard to get at that accurately to understand, how 

many psychiatrists do we really need? How many psychologists do 

we really need? How many social workers? And that is really where 

the data aspect comes in, in really defining a more dynamic way 

of determining the demand at the local level, but being led by the 

national VA. 

Senator ROUNDS. Thank you. My time has expired. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Senator Tester. 

HON. JON TESTER, U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman. Thank you for holding the hearing. I thank the Ranking Member, also. 

I want to thank the folks who provided the testimony. When our 

men and women go to war, go to battle, we see their courage. We 

see their sacrifices. When they come home, we never see the 

wounds that they have acquired when they were in battle, and I 

think the testimony here points that out more than ever. 

We do have a VA panel coming up. Nick, I will just tell you, I 

apologize. I mean, when you have mental health issues and you 

call somebody, the last thing you want to hear is a recording. We 

will take that up with the VA folks. We certainly do not want to 

be put off and put off, so I appreciate your testimony. 

Dean, I appreciate your service and I appreciate your passion. It 

is good to know that the Errera Center is helping you and moving 

you where you want to go. I think that is really important. 

I guess I am going to ask the first question for you, Dr. Maffucci. 

To what extent are you seeing the younger generation of veterans? 

Are they more likely to see mental health care when they need it, 

or are they like the previous generation of Vietnam veterans, or 

just tell me. 

Ms. MAFFUCCI. Certainly, among our members, we are finding 

they absolutely are seeking care. Of the folks in our survey who responded that they had a mental health injury, three out of four 

were getting care, some outside the VA, more of them within the 

VA. It is really huge that we are seeing that among the younger 

generation. There are more conversations that are happening. 

There is a support system in place, a buddy system in place; and 

in having these conversations, we are seeing a higher demand. 

Senator TESTER. OK. Roscoe, regarding The American Legion, 

you have got some veterans from previous conflicts. Is the stigma 

still there for them? Are they becoming more willing to go get mental health care, or do they still say, no, that is for somebody else? 

39 

Mr. BUTLER. For the Vietnam veterans, they continue to rely on 

the Vet Centers. They still do not trust the VA system and they 

want to be separate from the system—— 

Senator TESTER. Right. 

Mr. BUTLER [continuing]. And that the Vet Centers maintain a 

separate system, so that they believe that the information they 

share with the Vet Centers remain confidential and entrusted by 

the Vet Centers. 

Senator TESTER. Got you. Got you. 

Ms. MAFFUCCI. Sir, if I may—— 

Senator TESTER. Go ahead. 

Ms. MAFFUCCI [continuing]. Just add very quickly, stigma in the 

post-9/11 generation still does exist—— 

Senator TESTER. Yes. 

Ms. MAFFUCCI [continuing]. And I want to make sure that we are 

clear about that. But, I think it is improving through the supports 

that they have established. 

Senator TESTER. Well, we have got a long ways to go on the stigma—— 

Ms. MAFFUCCI. Absolutely. 

Senator TESTER [continuing]. Which is why when somebody like 

these two fellows are willing to step up and say, I know I have a 

problem, that is a huge step and we owe them—we owe them better—— 

Ms. MAFFUCCI. Absolutely. 

Senator TESTER [continuing]. And they ought not to have to go 

to a center to get that help, to be honest with you. 

Mr. KARNAZE. Sir, if I may, I think one of the reasons why we 

are seeing more younger veterans look for help is because within 

the military itself, we are getting better at that. 

Senator TESTER. Yes. 

Mr. KARNAZE. I know in the special operations community, we do 

something called third location decompression, where on our way 

home from the war zone we have to stop for 3 days, a small group 

of the guys—— 

Senator TESTER. Yes. 

Mr. KARNAZE [continuing]. And we have two required meetings. 

One is with a psychologist and one is with the chaplain. 

Senator TESTER. Yes. 

Mr. KARNAZE. That kind of makes it OK. So, we are leaving the 

military knowing, OK, something is not right. It is OK to ask for 

help. But, absolutely, the stigma is still there. 

Senator TESTER. Yes, and that decompression is good. That is 

something we have worked on the DOD: to make sure that there 

is an education process going on, to learn what their benefits are, 

and to know that it is a big deal if they need to ask for help, because it is curable. We can fix it, like a broken arm; we need to 

look at it that way. 

Dr. Draper, you pulled 100 medical records. I just want to get an 

idea. Is that an adequate sample? 

Ms. DRAPER. Well, they were random—we took 20 each for the 

five facilities that we visited. 

Senator TESTER. You just took them randomly out of the—— 

40 

Ms. DRAPER. We took a random sample of each facility. These 

were patients new to mental health care. 

Senator TESTER. OK. When you looked at these, did you look at 

all to see if the problem was in staffing, inadequate staffing, or facilities, or—— 

Ms. DRAPER. We tracked the date that the patient or the veteran 

initially requested care, then took it through when they first received their full mental health evaluation—— 

Senator TESTER. Right. 

Ms. DRAPER [continuing]. And the next appointment. Then, we 

also spoke with the facilities that we had these medical records. 

They confirmed that our reviews were accurate, and then we talked 

to them about their staffing needs. 

Senator TESTER. What did they say about their staffing needs? 

Were they understaffed, or did they have extra staff? 

Ms. DRAPER. The facilities that we visited, their vacancy rates 

ranged anywhere from 9 to 28 percent in mental health. 

Senator TESTER. Do you know how that compares with general 

practitioners? 

Ms. DRAPER. Yes. The vacancy rate for mental health is, I think 

it is 14 percent; and 16 percent for VA overall. 

Senator TESTER. You are saying the vacancy rate is less in the 

mental health area than it is in the—— 

Ms. DRAPER. It depends on—it ranges anywhere from 0 to 28 

percent for the facility. So, it varies by facility. 

Senator TESTER. OK. 

Ms. DRAPER. Some of the rural areas have particularly difficult 

times recruiting mental health professionals. 

Senator TESTER. OK. My time has expired. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Senator Moran. 

HON. JERRY MORAN, U.S. SENATOR FROM KANSAS 

Senator MORAN. Mr. Chairman, thank you very much. Thank 

you to those who are here to testify today. Thank you for your service to our Nation. You are once again serving our Nation by your 

testimony and I am grateful for it. 

Dr. Draper, you have been at the GAO for a while. 

Ms. DRAPER. Mm-hmm. 

Senator MORAN. Do you care to put on the record how many 

years? [Laughter.] 

Ms. DRAPER. I have had two tours of duty, so in total, 8 years. 

Senator MORAN. In those 8 years, have you been involved in reviewing the operations of the Department of Veterans Affairs? 

Ms. DRAPER. I have been involved probably for the last 5 years. 

Senator MORAN. I want to use your experience in an institutional 

way, because what strikes me today as I sit here is, once again, 

this Committee—I previously served on the Veterans Committee in 

the House. We have veterans who come tell us the circumstances 

they find themselves in. We have GAO and OIG who come and give 

us reports. We have been doing this for a long time. What strikes 

me as I listened to the testimony here of this panel, and what I, 

to some degree, can expect from the Department of Veterans Affairs, I am going to hear something very similar to what I have 

41 

heard on previous occasions about mental health or health care or 

benefits, and how the VA is or is not capable of meeting the needs 

of our veterans. 

My point of that conversation is, it seems to me, not much 

changes. As someone who has examined the Department of Veterans Affairs for the last 5 years, is that perception correct? What 

is it that we can do to get out of the cycle of inviting you to come 

and report on GAO studies? What is it that we can do to get out 

of the cycle of asking veterans how things are going and to have 

The American Legion, PVA, VFW and others in front of us telling 

us about their members and their experiences, then the Department of Veterans Affairs explaining what is going on? How do we 

get out of the cycle of hearing the same—it is a different topic each 

time, but it is the same set of circumstances that veterans find 

themselves in? 

Ms. DRAPER. I would love to report something different. I know 

that we sound like a broken record sometimes, but there are common themes. Going back to the reasons we put VHA on the HighRisk List this past year, there are five common themes and we see 

them here again in this work. (1) Inadequate policies; (2) things 

play out differently at the local level, you have got a lot of variation 

among medical centers; (3) there is poor oversight; (4) data systems 

or information technology that does not support good practices; and 

(5) lack of training and resource allocation—identifying what the 

resource needs are and appropriately allocating those. 

One of the issues with agencies that are put on the High-Risk 

List is that they are in need of major transformation, which I think 

is certainly true of VA, or VHA. VHA is what we put on the HighRisk List. 

Senator MORAN. If I could paraphrase what I think you are telling me, which is those five circumstances are common throughout 

the VA regardless of what audit report you are preparing, what the 

topic is. Those failures continue to exist systemwide—— 

Ms. DRAPER. I would say it is systemwide in VHA. 

Senator MORAN. VHA, OK. 

Ms. DRAPER. Right. 

Senator MORAN. Let me take you to my question again, which is, 

so what can we do—what can I do as a Member of Congress, what 

can this Committee of the U.S. Senate do, so that when we have 

a hearing 6 months from now, or a hearing a year from now, the 

conversation, the testimony is different than what we hear today? 

Ms. DRAPER. To get off the High-Risk List, it calls for the creation of a framework. There are specific criteria to get off the HighRisk List. I think that is a good place to start. There are five criteria which provide a good road map to help frame an action plan 

to get off the list. The independent assessment that was recently 

done, that also provides great information. The Commission on 

Care is going to be issuing a report. All that is information that 

can be funneled into a framework for transformation. 

Senator MORAN. Finally—and perhaps it is the repetition of my 

questions—there are recommendations, there is a guide plan, a 

path to reverse the themes that caused you to have placed them 

on high-risk. 

Ms. DRAPER. Right. 

42 

Senator MORAN. Is there evidence that it is being pursued, the 

path to get off the high-risk category? 

Ms. DRAPER. We have not seen a lot of progress yet. 

Senator MORAN. Mr. Chairman, thank you. 

Chairman ISAKSON. Thank you, Senator Moran. 

Senator Murray. 

HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Mr. Chairman, thank you, and thank you to all 

of our witnesses. I share the frustration that I am hearing from all 

of you and Senator Moran. When I was Chairman of this Committee, we actually held several hearings on mental health care. 

We asked for several IG and GAO investigations. We demanded 

that the VA hire more providers and listen to the providers in the 

field about the barriers they were facing. We even passed into law 

reforms. 

It is really frustrating to be sitting here again today, and I am 

having a hard time understanding what really has changed since 

2012. Why is it that the VA still does not have an accurate picture 

of wait times? We do not have a staffing model for mental health 

care at the VA that works and have an alarmingly high number 

of vacancies still? It is very frustrating, and I think something that 

we cannot just have a hearing on. We really need to work on this. 

I really appreciate having this hearing today. 

Dr. Draper, thank you to you and your team at GAO for the work 

you are doing on overseeing VA’s mental health care facilities. I am 

very concerned about the findings. You said in your testimony that 

you found a medical center with a mental health vacancy rate as 

high as 28 percent, and as Mr. Butler mentioned, the Legion found, 

in a site visit to Baltimore, they had a 38.5 mental health 

vacancies. 

What is worse, you mentioned VA projects they will need another 

12 percent increase in mental health staff on top of those current 

vacancies just to keep up the demand through 2017. There is a 

major shortage of mental health care providers around the country 

already and VA is struggling to hire. So, I am very concerned about 

how the VA is going to be able to keep up. 

What can the VA do to get enough providers into the system to 

meet the increasing needs of our veterans? 

Dr. Draper. 

Ms. DRAPER. I can talk a little bit about this. I think that what 

we found is that some of the things that they are doing, they are 

offering hiring bonuses, retention bonuses. I will say, there are real 

concerns with the hiring process itself. It is a very lengthy process. 

What we heard from the medical centers that we visited is it sometimes takes up to a year to get a mental health professional on 

board. During that period of time, they often lose people to the private sector. We repeatedly heard about all the VA medical centers 

trying to recruit at the same time, so there is a lot of competition 

between the different facilities. 

So, there are a lot of challenges related to trying to get people 

on board. I think if some of those challenges are addressed, that 

may pave the way for some smoother transition of people into VA. 

The lengthy hiring process, we heard that across the board. Some 

43 

of that depends on the sophistication of the individual facility. 

Some have more sophisticated human capital departments than 

others and it is a real struggle. 

Senator MURRAY. If a veteran cannot get into care, if they cannot 

get in for follow-up appointments, what is the chance they are 

going to stay in treatment or drop out? 

Ms. DRAPER. I will say that of the facilities we visited, there are 

some very dedicated mental health professionals. Thank goodness 

they are there, because I think the problems would be a lot worse, 

because they really work hard to try to make things work with 

what they have. 

We see things like they are spreading out appointments for 

longer periods of time. They are trying to convert space to put new 

people in. We have heard stories about converting closets into 

small offices, trying to do some sharing of space. So, there are a 

lot of things going on, but there is not a systemic or a systematic 

approach to how to counter these shortages. 

Senator MURRAY. OK. Mr. Butler, I wanted to ask you, in your 

testimony, you talked about feedback the Legion received from the 

Seattle VA community mental health summits. I was really concerned by that report. VA hospitals were actually directed to interact with patients in the community to improve communication and 

awareness of mental health services. Instead, it seems they kind of 

created pointless bureaucracy, and according to the report, managed to actually make the relationships worse. Tell me what you 

think the Puget Sound VA ought to be doing to improve communication and interaction with its veterans. 

Mr. BUTLER. Our experience varied across the country in terms 

of who responded to our questions. But in regard to the one service 

officer who shared that information, he felt that the summit was 

demeaning and it was not focused in terms of trying to draw the 

community partners together in terms of what can we do to serve 

veterans. But it was more talk down from the VA. 

I think what they need to do is to reach back out to the community and involve the community in such a way that the community 

feels that they are valued, that whatever they bring to the table 

and whatever they can offer, that the VA is being genuine and 

allow them to provide the opportunity to help the VA in that 

regard. 

Senator MURRAY. I would appreciate if you would ask your members in Washington State to get in touch with me. I would like to 

work with them and work on helping develop better relationships 

out there. So, if you could follow up with this, I would really appreciate it. 

Mr. BUTLER. Will do. 

Senator MURRAY. Thank you. 

Chairman ISAKSON. Thank you, Senator Murray. 

Senator Tillis. 

HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA 

Senator TILLIS. Thank you, Mr. Chairman. 

First off, I would like to associate myself with the comments that 

have been made by Senator Murray, Senator Moran, and others 

about the concern with this continuing dialog. I have only been 

44 

here 10 months and I am really becoming frustrated with the lack 

of progress. I cannot imagine those who have served much longer 

seeing basically the same thing. 

Some of these things speak to systemic problems that we do not 

seem to be getting at, and Chair, I have lost count. How long has 

it been since we have had a permanent IG in the VA? 

Chairman ISAKSON. A long time. How long has it been? Sixteen 

months. 

Senator TILLIS. It seems to me that when you are looking at root 

causes to these sorts of problems, the sort of resources that will 

really focus on it, like the IG’s office, like the work that Dr. Draper 

has done, we need to put every single resource that we can put on 

it as quickly as possible to get to some of the systemic problems. 

Mr. Butler, I wanted to talk to you about something. I apologize 

for being late. I had a conflict earlier. But, I happened to run into 

a veteran on a flight, sat next to a veteran and his wife on a flight 

from Charlotte up here to D.C. a couple of weeks ago, and he is 

100 percent disabled, special operator, served for 15 years, and had 

overcome his own challenges with PTSD and has really found a 

calling by helping others. He is very well known. He is down in 

Mississippi. 

He had a veteran call him who knew he was in a crisis situation. 

It was a domestic situation with his wife. He called the VA for 

help. Now, this is an immediate crisis situation, and the feedback 

that he got from the VA, it would be 4 days before they could get 

back with him. 

In these crisis intervention scenarios, did he just call the wrong 

number, or are you reporting back from your members—and anyone can respond to me—a personal experience where this is not 

just aberration, but something that we should seriously look into? 

Mr. BUTLER. I think that the person he spoke to was not trained 

in terms of the crisis intervention, the crisis hotline. Every facility 

has a crisis intervention team that should immediately put them 

in contact with the appropriate people that can—locally as well as 

at the crisis center—that can address their immediate needs and 

problems. I think that whichever facility he contacted, they need to 

provide some remedial training to their staff, because VA—— 

Senator TILLIS. There should have been an option. 

Mr. BUTLER. Right. There should have been an option. 

Senator TILLIS. OK. 

Mr. BUTLER. They have an excellent crisis—— 

Senator TILLIS. Well, I think it got worse, because then when he 

called this veteran and he realized that he needed help and he 

wanted to remove him from that situation, this man carried him 

to a hospital, drove him several hours, and they waited in an emergency room setting from about 3 in the afternoon until about midnight before he was actually able to get to a point where he was 

first able to see somebody that could help him with the intervention. Is that just another breakdown in training or a systemic 

problem? 

Mr. BUTLER. I think that that is a systemic problem with that 

particular center, because that should never have happened. 

Senator TILLIS. Now, I want to get back to Dr. Draper. Dr. Draper, on page six of your opening testimony, I want to get back to— 

45 

I have got a lot of questions I could ask you all, and you all know 

that. I have not figured out how to work in the Camp Lejeune toxic 

substances comment into this—— 

[Laughter.] 

Senator TILLIS [continuing]. I just figured I will put it out there 

randomly. I will have the next panel to talk about with that. 

This graphic is interesting. Why is it not easy to define what a 

wait time is? To me, a wait time is when the veteran is waiting 

when he or she does not want to. It sounds like a part of the questions in your testimony about an objection to your methodology, 

well, it does not count the times when the veteran really wants to 

be seen later. Great. Solve for that and then figure out what the 

real wait time problem is. What am I missing? 

Ms. DRAPER. That is really an artificial measure as I mentioned 

in my opening remarks. You know, a veteran really does not know 

what it means to have a preferred date, and we found that the time 

between initial request and getting into, you know, establishing a 

preferred date, that is done at the time that they actually talk to 

a scheduler. 

Senator TILLIS. I think with this chart you kind of set the context 

within which you should be able to define something where we can 

determine whether or not the VA is achieving acceptable wait 

times or not. 

The other question I had for you was why would the data be incompatible in your analysis between the VAMCs? 

Ms. DRAPER. The example of the two VA medical centers, or the 

one that had the open access appointments, they never really 

scheduled an appointment until the person actually showed up, 

even though they had talked to them. It may have been months before. When they actually show up, they show a zero wait time, so 

that is what gets recorded—— 

Senator TILLIS. And that happens in one and not another? 

Ms. DRAPER. It can happen for other reasons that way, but that 

was a good example of where you might see some zero wait times, 

which is not accurate. We had a case where someone on that list 

had called the VA and they were put on that list. A month later, 

they presented in the emergency room suicidal and they were admitted to an inpatient unit. It is not really a true wait time. There 

are other things, data entry errors. There are a lot of things where 

the data just are not comparable between facilities. 

The interesting thing is, we did 100 medical records, but that 

took a lot of work to do because this is a very complicated system 

to go through. What we know, one of the VISNs is currently doing 

something similar because they believe that that period of time is 

also important to identify problems. It is not consistently done 

throughout VA, and I think if the VA instituted doing audits in 

their facilities, such as what we did, they would find a lot of areas 

that potentially could be improved. 

Senator TILLIS. Which, again, points back to how I started this 

conversation. The more people we have auditing the systems and 

the outcomes, the better off we are. The VA should welcome that 

as an additional resource, not as some perceived threat. 

Thank you, Mr. Chair. 

Chairman ISAKSON. Thank you, Senator Tillis. 

46 

Senator Brown. 

HON. SHERROD BROWN, U.S. SENATOR FROM OHIO 

Senator BROWN. Thank you, Mr. Chairman. 

Mr. Karnaze, I want to understand your personal experience better. Senator Tester and I got on this Committee the same day in 

2007, and everywhere I went in my State as I did roundtable after 

roundtable with veterans, some recently returned veterans, others 

that had been in the VA system and been treated generally pretty 

well, we have a number of VA centers, VA hospitals, and we have 

in my State probably 27 or 28 CBOCs now that serve veterans very 

well. 

But, I heard repeatedly, as you all are aware, that in those days, 

that if you were home on leave from Iraq and you went to the 

CBOC in Mansfield, my home town, or you went to a hospital in 

Dayton or Cleveland, they did not have your medical records. It 

has been a long-term battle to get DOD interested enough and to 

have the right interface between DOD and the VA. We still have 

not made the progress we should yet. 

I heard repeatedly from veterans, I remember at Cleveland State 

and at Youngstown State, there were veterans that were integrating into a classroom, veterans or soldiers that were infantry 

and they returned home and they are sitting next to an 18-yearold suburban kid and the experiences were so different, all of that. 

But they also said that when they did not re-up, the DOD just said, 

see you, without talking nearly enough to the soldier or the Marine 

or the airman or woman about what VA benefits were. We see all 

those problems. I think they are improving. They are not there yet. 

I want to understand better with you, when you got out, when 

you came back, when you tried to get access to VA, you said it took 

a year before you could get in. What does that mean? They had 

none of your records? Tell me sort of your experience that way. 

Mr. KARNAZE. I consider myself quite fortunate in that when I 

was leaving the Marine Corps in Camp Lejeune, there was actually 

a nonprofit aboard Camp Lejeune that would help soon-to-be veterans get everything together and submit to the VA. I brought all 

my medical records to them. We went through it together. They 

helped me compile the second set of records for me to hold on to. 

Then, there was actually a VA center or small office aboard 

Camp Lejeune where I did my out-processing physical. I went 

through that whole out-processing physical, I guess, with them. 

They had all of my records and they set up all of the follow-on appointments for me to go through my screening process so they 

could determine what was service related and what was not. And 

then that just went off someplace. 

From that point, start the clock, I finally received a letter in the 

mail with my disability rating and saying that I now had coverage. 

During that time, I went to the local VA clinic in Wilmington, NC, 

because I was pretty sick. I had tried to get treatment and I ended 

up just leaving because they did not have anything in the system. 

Apparently at that point, I did not receive health care from the VA. 

When I moved here to D.C. is when I actually received the letter 

from the VA with everything like that. And then once I received 

that letter, I could be a bit aggressive, so I just started burning up 

47 

the phone lines, calling the D.C. office here because I wanted some 

help with some of the concentration issues, and that is when they 

connected me. 

A very wonderful nurse—I forget her name—she took me in. She 

asked who my primary care physician was. I told her, I do not 

know. I do not have one. I do not know how to get one. She was, 

like, OK. Well, let us get this taken care of first. She connected me 

with neurology. We did a bunch of cognitive exams. That is why 

earlier when I said I kind of entered in an unorthodox fashion, I 

feel like I did, because I went through all these specialists before 

I finally received my primary care physician, who is down at Fort 

Belvoir. 

I am not sure how the process is supposed to work. I just know 

that is how it was with me, and a lot of that was me being highly 

aggressive on the phone, in a tactful manner, but until they finally 

responded. 

Senator BROWN. People for a whole host of reasons are not as aggressive as you, because of the stigma, because their personality is 

not so outgoing as yours, for a whole host of reasons, if they are 

not as aggressive with you, what happens then? You said partly 

DOD. Is it all VA? What do we do to get people in the system, and 

if they want cognitive therapy, that they can make those choices 

with their provider to go in the right direction? 

Mr. KARNAZE. I think, in some cases, they die on the vine. If they 

do not reach out, I think they are lost and they will not enter the 

VA system. And for the ones that do, I feel out-processing—because 

at the time when you are leaving the military, you are pretty excited, or depending on the situation, maybe not so excited, and you 

are worried about your DD–214, right, free man, free woman. But, 

the out-processing class that you mentioned, my experience was 

very poor. It was just a few hours, a representative from the VA 

saying, hey, if you need a home loan, also, you get health care for 

5 years as a post-9/11 veteran. Here is a pamphlet, and their phone 

number is in there. I was, like, cool. Roger that. Got it. All right. 

Let us go. And then you are, like, I do not know what to do. 

Senator BROWN. That was VA or that was—— 

Mr. KARNAZE. That was a representative from the VA. We called 

it TAPS, the Transition Assistance Program. There was a group of 

us, all ranks, ages, shapes, and sizes at Camp Lejeune and we sat 

through this class. Most of the people fell asleep in the back of the 

room. The VA presented first, which I think was great, but again, 

it was a short, few hour presentation, and then we walked away 

with a cool little handbook and that was the extent of it. 

Senator BROWN. Last question, Mr. Chairman. Thank you. 

If that could have been an important discussion, meeting, briefing, how should they have done that TAPS different than that 

way? 

Mr. KARNAZE. I feel that this is such an important issue, that the 

servicemember at the time does not realize how important it is. If 

the VA or a representative took the time and fully outlined the 

process, this is what you need to do, this is where you need to submit your records, this is who you need to engage with aboard this 

base to get into the system, these are numbers that you can reach 

out to, expect this timeframe. What is going to happen now is we 

48 

are going to review your medical records and then we will get back 

to you with your disability rating. At that point, you can contact 

whoever to get assigned your primary care physician. 

The process was never outlined to me or any of the Marines that 

I served with, so we were quite confused about what was going to 

happen next. I think just explaining it, just communicating to the 

veteran the way the process works would be of great assistance. 

Senator BROWN. To your recollection, Mr. Karnaze, it is basically 

that they gave you a brochure to tell you that? 

Mr. KARNAZE. Yes, sir. 

Senator BROWN. Yes, Mr. Butler, sure. 

Mr. BUTLER. Senator Tester—— 

Senator BROWN. He is Tester, I am Brown, but that is OK. 

Mr. BUTLER. Oh, I am sorry. 

Senator BROWN. Do not ever call me that again. [Laughter.] 

Mr. BUTLER. OK. Sorry, Mr. Brown. So, prior to—— 

Chairman ISAKSON. They look a lot alike. 

Mr. BUTLER. Prior to the program changing from TAP to Transition GPS, service officers were allowed to participate in the program. Now, since the program has changed to Transition GPS, 

service officers are no longer a part of the program. If Veterans 

Service Organizations were allowed to participate in the program, 

we could bring a wealth of experience and knowledge and assistance to servicemembers prior to their transition from active military service to the VA. 

Senator BROWN. Thank you. Perfect. Thanks. 

Chairman ISAKSON. With the indulgence of the Committee, I am 

going to pass on a second round except for one question that Senator Blumenthal has—— 

Senator BLUMENTHAL. I have a—— 

Chairman ISAKSON [continuing]. Because of the importance, I 

think, that the VA testimony be heard in the context of this testimony. Thank you for being here. 

Senator Blumenthal has a question, then we are going to switch 

panels. 

I want to acknowledge for Senator Tillis that although he failed 

in his 6 minutes and 13 seconds to mention Camp Lejeune, Mr. 

Karnaze did it four times in 1 minute, so it got done. [Laughter.] 

Senator Blumenthal. 

Senator BLUMENTHAL. I have a very quick question for you, Dr. 

Draper. I am looking at your chart on page six—— 

Ms. DRAPER. Mm-hmm. 

Senator BLUMENTHAL [continuing]. Which shows that the VA, at 

least in some of its facilities, is still vastly under-calculating the 

amount of wait time, in effect, in this instance, measuring it from 

not the date of the request for health care, but from the date of the 

veteran’s preferred date, which then was unfulfilled. The veteran 

had to wait another 5 days, and that is what was measured as the 

wait time, not the full 17 days that the veteran actually had to 

wait. 

Ms. DRAPER. Yes. The policy is that it is measured using the preferred date as the basis—— 

Senator BLUMENTHAL. That is exactly the kind of, in my view, 

wrongdoing that the VA was committing in facilities around the 

49 

country that we sought to correct and the VA said it was correcting 

in the so-called reforms that it instituted after the Phoenix debacle 

and other revelations, which, in my view, cast doubt on the reliability and trustworthiness of a lot of the data we have been receiving from the VA. 

Ms. DRAPER. It is how you define wait times. It can be a wait 

time is when somebody initially requests care to when they actually receive treatment. Another part of the issue with the way that 

they are calculating it is their IT system does not support the calculations on that longer wait time. They could do what we did, do 

some audits. We have one, as I mentioned, one VISN that is doing 

that, and there is a lot to be learned by doing those types of audits 

as to what kind of systemic things you see during that period of 

time before the establishment of the preferred date. 

Senator BLUMENTHAL. Well, you know, I think a lot of us are expressing frustration with the apparent finding of your report that 

the VA may have learned nothing from what has happened in the 

past. Thank you. 

Chairman ISAKSON. For the Committee’s information as well as 

the audience, we are going to have a hearing in December on transition from DOD health care to veterans health care, to focus on 

that problem, because there is a black hole that everybody seems 

to fall into from one to the other, and the Warrior Transition Centers at active duty, which are such a good service, kind of do not 

get transferred to the VA when the veteran is getting ready to 

transfer, and we want to see if we cannot expedite that process and 

make it better. 

I want to thank our panelists for testifying and ask our second 

panel to please come forward. [Pause.] 

I am pleased to introduce our second panel for the hearing today 

for testimony, Dr. Harold Kudler, the Chief Consultant for Mental 

Health Services, Department of Veterans Affairs, who is accompanied by—I think that means they are going to back up his answers if he screws it up, but anyway, Dr. David Carroll, Executive 

Director, Mental Health Operations, Department of Veterans Affairs, and Dr. Michael Davies, Executive Director, Access and Clinical Administration Program, Department of Veterans Affairs. 

Thanks to all of you for being here today. We welcome you to 

begin your testimony, Dr. Kudler. About 5 minutes, if you will. 

STATEMENT OF HAROLD KUDLER, M.D., CHIEF CONSULTANT 

FOR MENTAL HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 

ACCOMPANIED BY DAVID CARROLL, PH.D., EXECUTIVE DIRECTOR, MENTAL HEALTH OPERATIONS; AND MICHAEL DAVIES, M.D., EXECUTIVE DIRECTOR, ACCESS AND CLINICAL 

ADMINISTRATION PROGRAM 

Dr. KUDLER. Thank you, sir. Good afternoon, Chairman Isakson, 

Ranking Member Blumenthal, and Members of the Committee. 

Thank you for the opportunity to discuss access and timeliness of 

veterans’ mental health care. I am accompanied, as we say, by Drs. 

Carroll and Davies. 

Just today, GAO reported a need for clearer guidance on access 

and wait times, and VA is committed to providing timely access 

50 

which supports veterans’ reintegration into their families and communities. We appreciate GAO’s review, concur with its recommendations, and have taken action to address them, and will 

continue to take action. 

GAO found that VA met mental health hiring initiative goals at 

the national level, but individual VAs continued to face challenges 

in hiring and in meeting the increasing demands for care. In 2012, 

VHA began its hiring initiative under Executive Order, and as of 

June 2013, approximately 5,300 new clinical and non-clinical mental health staff were hired. Almost half of these filled existing vacancies. Nationally, outpatient mental health staffing increased by 

25 percent between 2010 and 2014. By December 2013, we had also 

hired 932 peer specialists. Peer specialists, as Mr. Maiers said, can 

say, ‘‘I have been where you have been and VA can help.’’ GAO documented local improvements in the wake of these hires. 

VA has revised and tested its metrics and management process 

and is now ready to update to a 30-day timeliness standard based 

on the requirements of the Veterans Choice Act. The target completion date for this is March 2016. 

Open access ensures that any veteran can receive urgent mental 

health care at any entry point in our system within 24 hours. Each 

facility must have a defined process for warm handoffs to a professional who can conduct same day mental health evaluations and 

arrange appropriate follow-up. VHA has trained more than 23,000 

schedulers this year in support of open access. VHA has simplified 

access measure methods and definitions and publicly releases wait 

times for every facility and service every 2 weeks. 

In June 2015, we issued clarification to all network directors, 

saying VHA measures patient wait time using preferred date or 

clinically indicated date as the first reference point and the pending or completed appointment date as the second reference point. 

An updated data definition will be posted on our Quality of Care 

public site this month. 

Although excessive appointment delays do exist at specific locations, the recent MITRE-RAND assessment required by the Choice 

Act found that there were no systemwide crises in access to VHA 

care. The Altarum-RAND report of 2011 concluded timeliness for 

mental health or behavioral health care in VHA is as good or better 

than in commercial and public plans. 

VA integrates mental health services into primary care and other 

settings to minimize barriers to care. By combining effective engagement with systemwide screening, VA produced a 71 percent increase in the number of veterans receiving mental health care between 2005 and 2014, outpacing overall growth among veterans receiving any VA health care. Still more dramatic was an 87 percent 

increase in the number of mental health encounters during that 

same period. 

Last year, more than 1.5 million veterans—that is 27 percent of 

all veterans served by VA—receive mental health care in VA, and 

200,000 combat veterans, servicemembers, and family members 

were engaged and served by our 300 Vet Centers and 80 mobile 

Vet Centers. 

Access means nothing, however, without quality. The AltarumRAND study found that the quality of VA mental health care is as 

51 

good or better than that reported for patients with comparable diagnoses who receive care through private insurance, Medicare, or 

Medicaid. 

VA is an innovator in telemental health care and has provided 

335,000 telemental health encounters in 2014. Ten thousand of 

these were by video in the veteran’s own home, and new technology 

and new policy will allow us to expand that tremendously. This is 

particularly important to the one in four veterans who live in rural 

areas. Telemental health also allows VA to adjust the supply of 

providers across the country, even where those providers do not 

live. VA mobile apps and award winning online services further enhance access and engagement. 

The Veterans Crisis Line reaches an ever-growing number of veterans on an urgent basis through voice, chat, and text options. As 

the number of calls increases, so do referrals to VA. 

VA leads the world in the treatment of deployment mental 

health problems and develops gold standard tools used around the 

globe. We are developing integrated treatments for depression in 

veterans with spinal cord injury and for chemical dependents and 

those with chronic pain. 

Our Mental Health Centers of Excellence, including the National 

Center for PTSD and our MIRECC produced over 1,300 peer reviewed scientific papers per year in the last 3 years. 

Mr. Chairman, VA is committed to the care of our veterans, the 

care they have earned. We appreciate Congress’s support, and we 

are prepared to respond to any questions you may have. 

[The prepared statement of Dr. Kudler follows:] 

PREPARED STATEMENT OF HAROLD KUDLER, M.D., CHIEF CONSULTANT FOR MENTAL

HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Good morning, Chairman Isakson, Ranking Member Blumenthal, and Members of 

the Committee. Thank you for the opportunity to discuss the important topic of access to and timeliness of Veterans’ mental health care. I am accompanied by Dr. 

David Carroll, Executive Director, Mental Health Operations and Dr. Michael Davies, Executive Director, Access and Clinical Administration Program. 

VHA MENTAL HEALTH CARE

The Veterans Health Administration’s (VHA) mission is to honor America’s Veterans by providing exceptional healthcare that improves their health and well-being. 

Providing timely access to that care is a critical aspect of our mission. Access enables VHA to provide personalized, proactive, patient-driven health care; achieve 

measurable improvements in health outcomes; and align resources to deliver sustained value to Veterans. VHA is continually monitoring wait times and making adjustments as needed to ensure that Veterans have access to the best care they rightfully deserve. 

Between 2005 and 2014, the number of Veterans who received mental health care 

from VA grew by 71 percent. This rate of increase is more than 3 times that seen 

in the overall number of VA users. The increase in the number of mental health 

encounters or treatment visits, from 10.5 million in 2005 to 19.6 million in 2014, 

has been even more dramatic—an 87-percent increase. This reflects VA’s concerted 

efforts to engage Veterans that are new to our system and stimulate better access 

to MH services for Veterans within our system. These include outreach and engagement through 300 Vet Centers, 70 Mobile Vet Centers, Primary Care/MH Integration at VA medical centers, and large community-based clinics. VA Telemental 

Health innovations provided more than 335,000 encounters to over 108,000 Veterans in 2014. Telemental Health reaches Veterans where and when they are best 

served. VA is a leader across the US and internationally in these efforts. VA’s 

MaketheConnection.net, Suicide Prevention campaigns, and the PTSD mobile app 

(which has been downloaded over 208,000 times) add to the increase in MH access 

52 

and utilization. These efforts align with VA’s interagency activities including the 

Cross Agency Priority (CAP) Goals and expanding VA MH policy and practice. As 

a result of these trends, the proportion of Veterans served by VA who receive mental health care increased to more than 1.5 million Veterans. In 2005, 19 percent of 

VA users received mental health services, and in 2014, the figure was 27 percent. 

GAO REPORT

This month the Government Accountability Office (GAO) released a report regarding the need for clearer guidance on access policies and wait time data relating to 

VA mental health care. VA is committed to providing timely access to high quality, 

recovery-oriented mental health care that anticipates and responds to Veterans’ 

needs and supports their reintegration into their communities. VA appreciates the 

GAO review of timely access to mental health care issues at VA medical centers 

(VAMC) and concurs with GAO’s recommendations. We take the findings very seriously and have implemented action plans to address the recommendations. 

The GAO report found that the way in which VHA calculates mental health wait 

times may not always reflect the overall amount of time Veterans wait for care. Specifically, GAO notes that a patient who presents with Mental Health concerns receives an initial evaluation within 24 hours and may not receive a full evaluation 

until a later date. However, this initial evaluation is the start of treatment. It includes initial diagnostic evaluation and treatment of the most acute problems as appropriate. It may result in a patient being admitted to the hospital, for example, 

or medication adjustments. At the same time, these patients are often scheduled for 

a full and comprehensive evaluation at a later time. Of the 100 Veterans whose 

records GAO reviewed, 86 received full mental health evaluations within 30 days 

of their preferred date. 

The GAO report noted four findings. First, the Veterans’ preferred dates were, on 

average, 26 days after their initial requests or referrals for mental health care, and 

ranged from 0—279 days. Second, the conflicting access policies for a full mental 

health evaluation—one which mandates a 14-day deadline versus another which allows for 30 days from the Veteran’s preferred date—created confusion among VAMC 

officials about which policy they are expected to follow. Third, GAO found that data 

may not be comparable over time as the definitions or updated definitions of new 

patients have not been communicated with VISN and Medical Center leadership 

and managers. Fourth, GAO found inconsistencies in the implementation of these 

appointments; including one VAMC that manually maintained a list of Veterans 

seeking mental health outside of VHA’s scheduling system. 

GAO recommended three items for action in response to its findings. First, VA 

should issue clarifying guidance on which of VHA’s policies (14 or 30 days) should 

be used for scheduling new Veterans’ full mental health evaluations. Second, VA 

should issue guidance on how appointment scheduling for open-access appointments 

is required to be managed. Third, VA should issue guidance about the definitions 

used to calculate wait times, such as how a new patient is defined, and communicate this to VISN and Medical Center leadership and managers any changes in 

wait time data definitions. 

INCREASING ACCESS AND HIRING PRACTICES

The GAO report found that VHA met Mental Health hiring initiative goals, but 

that VAMCs reported continued challenges in ongoing hiring of mental health staff 

and in meeting the increasing demands for such care. 

In 2012, VHA began a two-part hiring initiative under Executive Order 13625 

issued in August 2012. The first part focused on recruiting 1,600 new mental health 

professionals, 300 new non-clinical support staff (such as scheduling clerks), and filling existing vacancies as of June 2012. The second part was the hiring of 800 peer 

specialist positions by December 31, 2013. As a result of this initiative, VHA hired 

approximately 5,300 new clinical and non-clinical mental health staff. As of the 

third quarter of fiscal year (FY) 2013, this included 1,667 new mental health staff, 

304 non-clinical support staff, and 2,357 staff to fill existing mental health vacancies 

and those that opened during the initiative. As of December 31, 2013, VHA had 

hired 932 peer specialists. GAO found that VAMC officials reported local improvements due to the additional hiring, such as more evidence-based therapies offered, 

mental health care provided at new locations, and a variety of benefits provided by 

the new peer specialists such as modeling effective coping, engaging Veterans who 

are resistant to discussing mental health issues, and providing peer-to-peer counseling. VAMC officials also cited several challenges to hiring mental health care providers such as pay disparity with the private sector, competition among VAMCs, the 

53 

lengthy hiring process, lack of space and support staff, and an underlying nationwide shortage of mental health professionals. 

At a national level, VHA outpatient mental health staff totals increased from 

11,138 full-time equivalents in 2010 to 13,975 in FY 2014. Over the same time period, the number of Veterans receiving outpatient mental health care increased from 

1,259,300 to 1,533,600. The increase in Veterans receiving mental health care outpaced both the related hiring and the overall growth in the number of Veterans 

using VHA services. 

The recent rapid growth in the number of Veterans seeking mental health treatment in VA has posed challenges in the area of staffing. In Figure 1 below, the solid 

line shows the growth in numbers of Veterans using mental health services, from 

897,600 in 2005 to 1,533,600 in 2014. The number of patients is expressed in terms 

of hundreds to show staff and patient numbers on the same graph. For example, 

10,000 on the vertical axis represents 1,000,000 patients and 10,000 full time 

equivalents employees (FTEs). 

Figure 1. Growth in annual numbers of patients using mental health services and 

in outpatient and inpatient FTE levels, 2005 to 2014. 

This graph also shows the growth in numbers of mental health clinical staff, 

measured in terms of the FTE providing outpatient and inpatient treatment. Consistent with a shift to outpatient care, the inpatient mental health FTEs began to 

level off after 2009. Outpatient mental health FTEs began to lag behind the growth 

in patient numbers in 2012, but as part of the President’s 2012 Executive Order 

13625, ‘‘Improving Access to Mental Health Servicemembers, and Military Families,’’ VA hired more than 1,600 new clinical providers by the June 30, 2013, target 

date. 

In the absence of any national benchmark related to mental health staffing, VA 

continues to refine a model that is intended to inform local facility decisionmaking 

about the number of staff necessary to meet local demand for mental health services. In addition, VA is addressing access through the following efforts: 

• Veteran-centered operating hours: Extended hours help increase capacity when 

space is limited and improve the match between available staff hours and the needs 

of Veterans who are employed or have other competing responsibilities during daytime hours. 

• Leveraging trainees and fellows: These professionals provide substantial 

amounts of clinical care under the direct supervision of appropriately licensed and 

privileged mental health staff. Training programs also provide ready access to wellqualified candidates for recruitment into vacant positions. 

• Support staff, adjunct professions, and peer support staff: VA has hired over 

900 peer specialists and is developing a pilot program in response to the President’s 

August 2014 Executive Actions to expand the role of peer specialists into primary 

care settings. 


1028psVA1.eps
54 

COMMUNITY PROVIDER PILOT PROGRAM

In 2013, 12 VA medical centers (VAMCs) partnered with 24 Community Mental 

Health Clinics (CMHCs) across the country to establish Community Mental Health 

(CMH) pilots. These pilots were created in response to Section 3(a) of Executive 

Order 13625 which focused on the creation of ‘‘Enhanced Partnerships between the 

Department of Veterans Affairs (VA) and Community Providers’’ designed specifically to decrease wait times and increase the geographic reach of VA mental health 

services. 

Pilot sites were able to select a model of care to best meet the needs of local Veterans. All sites used one of two broad approaches: Non-VA care or VA telemental 

health (TMH), with most sites choosing to provide Non-VA care to Veterans. NonVA care uses community providers that are paid by VA. TMH care utilizes technology to deliver mental health services via modalities such as video conferencing 

and allows for real-time (or ‘‘synchronous’’) encounters between health care providers and patients who are not in the same location. During the VA/CMHC Pilot 

partnerships, TMH services enabled Veterans to receive care at designated community clinics that were closer to their homes than the nearest VA medical facilities 

or clinics. 

VA and CMHC staff worked together in determining roles and responsibilities 

within each pilot partnership. Partnerships using telemental health required space, 

equipment, a technician, and a protocol for handling emergencies (e.g., a Veteran 

becoming distressed during a TMH session). For Non-VA care partnerships, there 

were other responsibilities that needed to be addressed: coordination of care (between VA and CMHCs), billing, and payment. While some pilot site VAMCs developed strong systems for coordinating care, monitoring patients, and billing, other 

sites, especially smaller ones, experienced challenges in these areas. 

Evaluation of the pilots included both gathering data from not only Veterans 

about their experiences, but also from key staff at each of the participating Veterans 

Integrated Service Networks (VISN) and VA Central Office (VACO) and a review 

of key documents associated with the pilots. Results from follow up surveys indicate 

that Veterans were very satisfied with the services they received via these pilots. 

When the pilots concluded, each participating VAMC was allowed to determine 

whether to continue the partnership. Since that time, VA has also moved to Patient 

Centered Community Care, a centralized contracting mechanism, and has implemented the Veteran’s Choice Program. Regardless of how such care is provided, the 

growing Veteran’s need for mental health services will increase the need for efficient 

leveraging of Non-VA community providers when access to care is not available 

within the VA system of care. VA is rising to the challenge through its Community 

Mental Health Summit program which engaged over 11,000 individuals at 144 sites 

in FY 2014 and continues annually to bring together DOD, VA, State, and Community providers and stakeholders for vital conversations at the local level. VA and 

DOD developed a joint Military Cultural Competence Training Program as part of 

the Integrated Mental Health Strategy which is now housed on the public facing 

TRAIN Web site and which, to date, has provided free training to over 2,000 providers. Whether mental health care is delivered directly by Non-VA mental health 

care providers, through TMH care at Non-VA sites, or any other means, it is critical 

for VA to continue to provide Veterans with access to high quality mental health 

care in coordination with other VA services. 

VA RESPONSE LETTER TO GAO REPORT

VA concurred with all of GAO’s recommendations in its October 7, 2015, response 

and added some additional explanation for some of VA’s policies. 

Regarding the recommendation to clarify guidance on which deadline to use, VA 

cited VHA Handbook 1160.01, which established that all new patients requesting 

or referred to mental health services must receive an initial evaluation within 24 

hours and a more comprehensive diagnostic and treatment planning evaluation 

within 14 days. The primary goal of the initial evaluation is to identify patients who 

require urgent care, such as hospitalization or immediate outpatient care. VHA’s 

policy directs that patients needing mental health care receive clinically indicated 

care as quickly as possible. 

VA explained that the 30-day policy was a result of a goal published in the Federal Register as required by the August 2014 Veterans Access, Choice and Accountability Act. VHA has since revised and tested its metrics and management process 

and is ready to update its policy to the 30-day standard consistent with the published goal, rather than a 14-day standard developed internal to VA for new mental 

health patients. Once the policy is updated, VHA will announce it on the approVerDate Mar 15 2010 16:43 Jan 06, 2017 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6621 Z:\ACTIVE\102815.TXT PAULIN
55 

priate national calls with key stakeholders. The target completion date for this recommendation is March 2016. 

For patients who already have a mental health provider who need follow up care, 

VHA’s policy of less than 30 days wait time from a Veteran’s preferred dated is consistent with The Veterans Access, Choice and Accountability Act. Therefore, this 

policy does not require revision. 

MANAGEMENT OF OPEN-ACCESS APPOINTMENTS

Open access, also known as same-day scheduling, is a method of scheduling in 

which all patients can receive an appointment on the day they call in or walk in. 

VHA’s open access is an essential component of VHA’s standard of care for conducting an initial mental health evaluation within 24 hours of a Veteran’s request 

for care. As the identification of a Veteran who may need or request mental health 

services can occur at several entry points to care, each facility must have a defined 

process that identifies a ‘‘warm hand-off’’ to a professional who can conduct the 

same-day initial mental health evaluation and arrange any appropriate follow-up. 

Open access scheduling for an initial mental health evaluation ensures that if 

during a visit to a treatment facility, a Veteran requests or is identified as needing 

a mental health assessment, it will be provided or at least offered to the Veteran 

who has the option to accept care prior to the Veteran’s departure from the facility. 

VHA Directive 2010–027, paragraph 4c(1) established the requirements for documenting same day unscheduled appointments. VHA conducted extensive scheduler 

training this year. To date, more than 23,000 schedulers have undergone training. 

VHA finds that the combination of current policy and training constitutes clear 

guidance on how to manage and schedule open access appointments. Many schedulers are still developing proficiency with the training, and therefore there are still 

occasional errors. VHA continues to aggressively monitor appointment management 

and identify areas of local inconsistency in scheduling procedures. 

VA agrees with GAO’s finding that one medical center was using inappropriate 

processes for scheduling open access appointments. VA continues to work with this 

facility to ensure their processes are aligned with VHA. 

Mr. Chairman, VA is committed to providing the highest quality care our Veterans have earned and deserve. Our work to effectively and timely treat Veterans 

who desire or need mental health care and ensure Veterans have access to the counseling and care they need continues to be a top priority. We appreciate Congress’ 

support and look forward to responding to any questions you may have. 

Chairman ISAKSON. Thank you, Dr. Kudler. 

You are the Chief Consultant at VA, is that correct? 

Dr. KUDLER. Yes. That is the policy side of mental health in VA. 

Chairman ISAKSON. OK. Are you a contractor or are you an 

employee? 

Dr. KUDLER. I am an employee and I have been for over 30 

years. 

Chairman ISAKSON. The term ‘‘consultant’’ does not really mean 

what it does in the private sector, then. 

Dr. KUDLER. It is an ancient title. I do not know where it comes 

from, sir. 

Chairman ISAKSON. Very good. You painted a glowing picture, 

quoting a lot of statistics which I did not have time to write down 

because they were coming out pretty quick, and I want to acknowledge from the outset that since 2013, when I became interested in 

this subject, the VA has made some major strides to try to address 

the problems that were there for mental health. But, I do not think 

you can totally agree, as you said, with the report done by GAO 

and then make the defense that you made without recognizing 

there still are some shortcomings in the delivery of services at the 

VA, and that is what we are here to talk about today. 

You said that the Veterans Administration this year, which is 10 

months into the year, has trained 23,000 schedulers, is that 

correct? 

56 

Dr. KUDLER. Yes, sir. 

Chairman ISAKSON. In the open access process? 

Dr. KUDLER. Yes, sir. It is part of our response to the Choice Act. 

Chairman ISAKSON. Right. Do you concur with the findings of Dr. 

Draper in the report or her comments that were made about the 

open access process? 

Dr. KUDLER. Not entirely, sir. Not entirely. I believe open access 

is a way of matching supply and demand and drilling down to answer the questions that this Committee would like answered. Do 

you have enough supply of providers in those places to meet that 

demand? Open access allows us to do that. I may defer to Dr. Davies, who has some great expertise in that. 

Dr. DAVIES. The word ‘‘open access’’ can mean different things to 

different people. 

Chairman ISAKSON. I have learned that. 

Dr. DAVIES. I think in the specific facility that the GAO visited, 

maybe two of them, they were using that term to run a clinic that 

sort of saved appointment slots and then said to veterans, go over 

there and try and get one of those. That is a prohibited practice, 

putting, you know, time slots on a list and saying, go over there. 

That is a prohibited practice. We appreciate GAO finding that. We 

contacted the facility as soon as we became aware of that. They 

have corrected the issue. We hope, and I know Dr. Carroll has done 

many site visits, that that is a rare or at least an unusual thing. 

The word ‘‘open access,’’ as a concept, is intended to mean you 

can get care without delay. It is the entry point. This is what we 

do in mental health in VA all the time. Whether you are in the 

emergency room, primary care, or in mental health, if you have a 

mental health emergency, you are evaluated within 24 hours initially. That is the intent. 

We recognize it is a big system. It does not happen every single 

time reliably. At the same time, we think that most of the time it 

does. 

Chairman ISAKSON. Well, it is a big system, and there are States 

like Montana and others that are big and where the population is 

separated by great distances where meeting those standards are 

very hard. 

Dr. DAVIES. Right. 

Chairman ISAKSON. We acknowledge that. I think the importance, at least I feel, is having dealt with mental health for a number of years and not being unfamiliar with the problem and the 

tragedy of suicide, timing of communication upon the first admission by the patient that they have got a problem is probably the 

most critical time of all. 

Dr. DAVIES. Absolutely. 

Chairman ISAKSON. The goal of the VA must be to see to it that 

somebody at risk for their own life, or indicates any tendency for 

that, gets immediate and fast help as reliably as possible wherever 

they may come from. And you think open access will accomplish 

that if it is used in the right way? 

Dr. DAVIES. The term ‘‘open access’’ means walk-in first contact, 

and the system is designed so that when there is first contact, that 

veteran is evaluated and then referred for a full evaluation later. 

I must say that there are many veterans inside the system and 

57 

people who feel passionately about this who really are working to 

make the system work. 

Chairman ISAKSON. I have no question whatsoever, and I want 

to thank Dr. Draper for making the statement she said about the 

many qualified, dedicated employees within VA are working hard. 

We are not here to castigate VA employees generically, but we are 

here to see to it that we can help the process improve dramatically 

to see to it that veterans in need get the services they need. 

In terms of open access, if I understand it correctly, most of the 

open access is with contract providers in the community where the 

VA is located, is that right? 

Dr. DAVIES. ‘‘Open access’’ means you can get care without delay. 

If we use that definition, then it exists anywhere there is an appointment available—— 

Chairman ISAKSON. Whether it is in the VA hospital itself, or in 

the CBOC, or probably not a CBOC—— 

Dr. DAVIES. Right. 

Chairman ISAKSON [continuing]. But in a hospital or a local provider who is under contract with the VA, is that right? 

Dr. DAVIES. Or not under contract and just access through 

Choice. Yes, that is correct. 

Chairman ISAKSON. But you do have a relationship with those 

local vendors so they are willing to provide that service and you 

know the quality of service they are giving. 

Dr. DAVIES. In many cases, we do, yes. 

Chairman ISAKSON. In many cases. 

Dr. DAVIES. Yeah. 

Chairman ISAKSON. OK. Senator Blumenthal. 

Senator BLUMENTHAL. Thank you. 

Dr. Kudler, why does the VA continue to measure wait times 

from the preferred date that they express rather than from the 

date of the request for health care? 

Dr. KUDLER. Almost all my years in VA have been years in the 

clinic, and in that clinic, I see a patient. We agree on a timeframe 

that is appropriate clinically and that they would like to come 

back. They go out and meet with a scheduler who sees my electronic order for when that is going to be. The patient and the 

scheduler take out their independent schedules and figure out, is 

that going to work for them or not. If it is not going to work, the 

scheduler calls me up and says, ‘‘Doc, that is not going to work. 

What is going to work best for him and from your medical point 

of view?’’ And we come up with a date. 

That date is when the patient wants. The patient may want to 

be seen next week, or the patient may say, I am going to Montana 

to visit my uncle and I cannot be seen for 3 weeks and that is when 

it is going to be, and we will work out a plan. 

In the meantime, we believe that it is appropriate to measure the 

date that the patient would like to be seen, not later, but also not 

sooner than the patient wants to be seen. 

Senator BLUMENTHAL. But the patient’s preferred date may depend on when she or he is told that there is an opportunity to see 

someone. In other words, the patient does not say, I am going to 

see somebody tomorrow. He is told, well, here are the suggested 

58 

dates, 2 weeks, 3 weeks from now. What is your preferred date, 

correct? 

Dr. KUDLER. Yeah. That is like a card trick. We do not want to 

force the card. Here is your card. Is this not what you wanted? We 

want an honest, open conversation with the veteran. What makes 

sense for you, and does that make sense clinically, as well—— 

Senator BLUMENTHAL. I am talking about data, the reliability 

and trustworthiness of data. When the VA tells us and the world 

that the wait time is 3 days, how can we trust that when that wait 

time is the number of days from some date the veteran is given as 

a possible date and then expresses as a preference. That seems to 

me inherently unreliable. 

Dr. DAVIES. Could I take a shot at that? My answer would be, 

because VA has a 30-year-old scheduling system, to your initial 

question, I do not know if you guys realize this, but the current 

VISTA scheduling system poster child for not working very well is 

in mental health, because an average psychiatrist in mental health 

does not have one schedule. They have seven schedules in mental 

health. That means you have to go to this schedule for PTSD, this 

schedule for military sexual trauma, this schedule for psychiatry, 

this schedule for alcohol treatment, and on. 

Dr. KUDLER. All with the same provider. That is—— 

Dr. DAVIES. All with the same provider. Senator Blumenthal, we 

cannot measure waiting times the same way the rest of the world 

does, which, by the way, is a very hard thing to do anyway, right? 

We have invented this time-stamped method of measuring waiting 

times, which no other health care system that I am aware of uses. 

Senator BLUMENTHAL. I apologize for interrupting you, but I 

have a limited amount of time. I think I get the thrust of your response, which is, to use Dr. Draper’s word, this problem is systemic. It is one of leadership and management. 

Dr. DAVIES. And IT. 

Senator BLUMENTHAL. I will just finish my thought, and then invite yours. We should make sure when we talk about accountability 

in this body that we are demanding accountability from the right 

people. Senator Moran and I have talked about this, and other of 

my colleagues. When we talk about blaming a VA employee, the 

temptation is to look at that person who is doing the data entry 

using a messed up system. I could think of another word for 

‘‘messed up.’’ But, the systemic issues here really have to be overcome. I think we need to focus on an accountability measure that 

puts the blame and the responses to that fact finding and blame 

exactly where they should be, not simply having the you-knowwhat roll downhill, as we used to say. 

Now, I want to ask one last question because it relates to the 

peer bill that I offered yesterday to expand the program that you 

have commented on, Dr. Kudler. I assume you would agree with 

me that the peer specialists, the veteran-to-veteran helping each 

other that Dean Maiers testified about and implemented so effectively at the Errera Center, should be expanded and should be integrated more effectively into the VA Health Care System. My understanding is that that has occurred only at about six to eight locations, and that is the reason why I have offered the legislation that 

59 

I have done. I invite you to comment briefly, and unfortunately, it 

has to be very briefly, on this issue. 

Dr. KUDLER. Very briefly, there are 932 peer counselors across 

the country because we believe in them and we agree with you. It 

is an incredibly valuable program. It is a next step forward in 

evolving the VA. 

Senator BLUMENTHAL. Thank you. 

Thanks, Mr. Chairman. 

Chairman ISAKSON. Senator Moran. 

Senator MORAN. Mr. Chairman, thank you very much. 

Doctors, thank you very much for your presence and testimony. 

Let me briefly describe what I think the reason that the Choice 

Act was passed and ask you how it now works in the delivery of 

mental health services. I think the belief and the evidence was that 

the VA was incapable of providing the services that were needed 

by veterans in a timely fashion, in part because there were a lack 

of necessary professionals. In addition to that, it was designed to 

help meet the needs of veterans who live distances from a VA facility. So, two purposes. If you look at the money, $15 billion got appropriated for the De- partment of Veterans Affairs, $5 billion of it to go to hire more professionals and $10 billion of it to pay for the services outside the 

VA in communities. I think the goal here was to alleviate the challenges that the VA has in being able to care for our veterans. It 

was fully designed to help veterans get the care they need. 

My question is, what has transpired on the mental health side 

of things as a result of the Choice Act that has improved the access 

for veterans who live distances from a facility and the ability within the VA to have the necessary professionals to meet the needs of 

those who are within the VA being treated. 

Dr. KUDLER. Well, Senator, the Choice Act has provided greater 

flexibility. It has allowed us to reach out, and with Congress’s support, now to combine a number of different programs for reaching 

out into one and create a new business structure that supports 

that, which was an essential element and, I think, was the hardest 

part about implementing Choice, is creating that business piece 

that allowed us to work with folks. 

We have a long way to go, and I want to go back to what was 

said by the IAVA representative, Dr. Maffucci, that the problem 

that we face still and that we have a lot of evolution to do, not just 

in VA but across the country, is it is not just any willing provider 

can provide this because most providers do not have the military 

cultural competence or the experience in treating deployment mental health issues that exists in VA. 

We connect now with people. We can provide more care closer to 

the veteran’s home. That is wonderful and Choice allows that. But 

now we have to raise the level of quality and the interoperability 

of our systems. If we cannot coordinate care with those folks, then 

we fragment that care instead. There are still challenges, but 

Choice has started us on a great path. 

Senator MORAN. I certainly would not disagree with the need for 

quality care, but I also know that no care, or care that is delayed, 

the quality of that care is zero. In my view, the VA ought to be utilizing Choice to meet the needs as best we can of veterans who are, 

60 

either because of time or distance, incapable of being currently 

served within the VA. 

You talked about quality care and the business model, so for 

years, before the passage of the Choice Act, I have been trying to 

convince the VA that they have an opportunity in my State of Kansas to contract with community mental health centers. These are, 

I think, 40 across the State. County commissioners levy property 

taxes to pay for these services. The State legislature and Governor 

contribute dollars. Across our very rural State, it is the only case 

in many instances that there is any access to health care. Our efforts pre-Choice and post-Choice have been pretty fruitless in accomplishing that. 

I would ask, Dr. Kudler, is there someone that you could direct 

to meet with me and with representatives of Kansas mental health 

centers to have a direct conversation about how to accomplish—assuming that you agree with my goal—to put these providers and 

the VA together in a way that after all these years and in light of 

the passage of the Choice Act, which gives, I think as you say, 

more flexibility to you to do that and to pay at Medicare rates, it 

seems to me that we are missing an opportunity. I thought it was 

an opportunity years ago. I think it is an even greater opportunity 

now. I just need you to help me put the puzzle together so that it 

happens for real. 

Dr. KUDLER. Sir, that is an opportunity it sounds like would be 

very important to develop, and I would gladly do anything I can to 

help investigate that and make that happen. 

Senator MORAN. Please have somebody, you or someone, contact 

me and let us put the people who know the details of that in front 

of you. 

Dr. KUDLER. There is a special team that has been developing 

the business rules, and I have a feeling that may be where this belongs, and I will make that happen. 

Senator MORAN. I appreciate you saying that. I have 15 seconds 

only to remind you, Dr. Kudler, we had a conversation about a year 

ago about the hiring of particular mental health professionals, 

those being licensed professional mental health counselors and 

marriage-family therapists, and you indicated in your testimony 

that you had met with those folks, you had an interest with that. 

To paraphrase you, it is not happening as fast as any of us hope. 

But to be absolutely clear, I am dedicated to doing that. Has your 

dedication resulted in the additional hiring and, therefore, access 

to these professionals by veterans? 

Dr. KUDLER. Not just in additional hiring, but we have actually, 

with the help of our Office of Academic Affiliations, created training programs internal to VA to actually produce these professionals 

in our own area so we can actually grow them ourselves and keep 

them when they have been trained. 

Senator MORAN. The statistics would show that those professionals are now available and are being utilized by veterans? 

Dr. KUDLER. They will show that, sir, and I still think it could 

be faster, and it will be faster. But, it is accelerating rapidly. 

Senator MORAN. Thank you. 

Chairman ISAKSON. Senator Tester. 

61 

Senator TESTER. Did I just hear you say that you have incorporated the marriage counselors? The veterans can already see 

them, not in the VA that you have trained yourself, but in the private sector? 

Dr. KUDLER. I am sorry, sir. We have them in the VA and they 

do exist in the private sector—— 

Senator TESTER. And have they contracted—have you contracted 

with the folks outside the VA, the marriage counselors? 

Dr. KUDLER. There has been a problem, and I may defer to Dr. 

Carroll on this. There has been a difficulty because the law stated, 

and this is not VA regulation, but the law stated that you have to 

have someone who meets Medicare standards, and my understanding is there is still some bump legislatively about licensed 

professional mental health counselors meeting Medicare standards. 

Senator TESTER. OK. 

Dr. KUDLER. This is not our wish. 

Senator TESTER. We need to follow up on this, because, quite 

frankly, if we have to change the rules, we will change the rules. 

What you have in rural America is you have no service. You have 

no standard. You have got people who need help and there is nobody there except a marriage counselor, and that is why we put 

that bill through. We need to follow up on that. 

Let me ask you, one of you said, and it might have been you, Dr. 

Kudler, or it could have been you, Dr. Davies, that mental health 

emergencies are seen within 24 hours. That is correct? 

Dr. KUDLER. Yes, sir. 

Senator TESTER. Is that off of the preferred date, or is that when 

they walk through the door, they are seen that quickly? 

Dr. KUDLER. Yes—— 

Senator TESTER. Or when they call with an emergency, that they 

are seen—— 

Dr. KUDLER. If they call in an emergency, they will be seen within 24 hours. If they are actually there physically with us, they will 

be seen immediately. 

Senator TESTER. OK. I would just say that, you know, I mean, 

I do not like to spend a lot of time, because as the Chairman said, 

you guys do a lot of things good and we need to reinforce the good, 

too, but that is not what we are talking about. We have put a lot 

of money into the VA, I have got to tell you. I mean, we have put 

a lot, and I have fought for every damn penny of it, and because 

the fact is, is that our veterans deserve it. 

Dr. KUDLER. Yes. 

Senator TESTER. To have a model, an IT model, when, by the 

way, you go down to Silicon Valley, you can go right outside of 

Bozeman, Montana, and find somebody that is still in college that 

can make you a scheduling program that will work. It is not that 

complicated, because they are doing stuff that is complicated. 

We ought to be taking care of that, because the wait time, honest 

to God, the wait time is not the preferred date, and then if that 

gets moved. The wait time is when I call into my doctor and say 

I need an appointment, if it takes 2 weeks, I waited 2 weeks. If 

they do it then, it is immediate. 

Dr. DAVIES. Right. What is published in the Federal Register is 

the method VA uses to measure wait times. 

62 

Senator TESTER. I know, and it is not accurate. I do not want to 

beat you up for it, but the fact, we can debate it, but it is not accurate, because when I call for a doctor’s appointment, when I call 

and they schedule me on the 20th, that is a 20-day wait if I call 

the first of the money. OK? See what I am saying? 

Dr. DAVIES. I do. 

Senator TESTER. I got what you have got, and I know you are 

meeting your metrics, but that is not really giving us an idea—— 

Dr. DAVIES. I—I—— 

Senator TESTER [continuing]. Because when I talk to the veteran 

and they said, you know what, I had to wait too long; then I talk 

to you guys and you say, well, no, it was only five, 5 days is it. We 

are not talking about the same standard here. 

Dr. DAVIES. You are correct, and I agree with you. 

Senator TESTER. Yes. 

Dr. DAVIES. I want to point out that we—about 5 percent of all 

of our 55 million appointments that are completed a year are new 

patients—— 

Senator TESTER. Yes. Yes. 

Dr. DAVIES [continuing]. And that is a very different experience 

than an established patient. 

Senator TESTER. You are not just kidding. 

Dr. DAVIES. We need to measure that—— 

Senator TESTER [continuing]. We hear about those new patients 

all the time, because getting through the door is the big problem. 

Dr. DAVIES. Right. 

Senator TESTER. Let me ask you about something that is what 

I want to talk about, and that is we heard in the previous panel 

about Vet Centers and how important those Vet Centers are. Do 

you guys have any input on when it comes to what the plans are 

for Vet Centers and increasing the number of Vet Centers? 

Dr. KUDLER. Sir, I am not aware of that. Uh—— 

Senator TESTER. OK. OK. OK. We should. I mean, the truth is, 

if you are talking to your vets—I talk to vets all the time—they are 

saying Vet Centers work, and those Vet Centers are not talking to 

professionals, they are talking to professional soldiers that have 

been in the field and they can share, you ought to be pushing that 

kind of stuff. That is all I am telling you. It is important, because 

in a place like rural Montana, if you can get vets together and they 

can hammer it out, you might not need some expensive psychiatrist, OK? 

Dr. KUDLER. Agreed. 

Senator TESTER. All right. I would just encourage you to push. 

And, telemental health; what is going on there? What are your 

plans to expand that, or are there no plans to expand it? 

Mr. CARROLL. Sure. We are trying to expand it. It is very important in terms of access—— 

Senator TESTER. What are you doing to try to expand it? 

Mr. CARROLL. We are working on a regulation so that there will 

be a standard credential, when a provider is in Wisconsin and providing services to a facility in Texas that there can be a national 

system for credentialing. They do not—and we are also looking at 

expanding telemental health into veterans’ homes—— 

63 

Senator TESTER. When do you anticipate the credentialing portion of this will be done? 

Mr. CARROLL. I do not know, sir. 

Senator TESTER. OK. 

Mr. CARROLL. It is being handled by our Telehealth Office. 

Senator TESTER. OK. One last thing, and then I will go, and that 

is that I live in Montana. I am in one of the rural States. I farm. 

I do not compare myself to my neighbors. If I am as good as my 

neighbor, that is not success. I have got to be better than my neighbor, OK. 

When you compare yourself to the private sector, I will just tell 

you, they have got their problems, too. We have got to be better 

than the private sector, OK. To say that, you know, our access 

times are as good and our treatments are as good, that is not good 

enough. We have got to be better, OK. 

The RAND Corporation did this survey for you. I got it. But, the 

truth is, we are losing a bunch of folks in the private sector, too, 

that are committing suicide every day. We have a little different 

standard for the folks who served this country, because if we 

screwed them up, we ought to fix them, OK? 

Dr. KUDLER. Sir, rural Americans commit suicide at the same 

rate as veterans do—— 

Senator TESTER. You are exactly right. 

Dr. KUDLER [continuing]. And I chose a career in the VA because 

I believe it is a better system. 

Senator TESTER. Got you. We need to make sure it is a better 

system. 

Dr. KUDLER. Yes, sir. 

Senator TESTER. When you say we are just as good as the private 

sector, that is not good enough, OK. 

Thanks, guys. Thanks for your work. For the record, I did not get 

into all the stuff you guys are doing well. You are doing some really good stuff, and we still need to do better. 

Dr. KUDLER. Agreed, sir. 

Chairman ISAKSON. Senator Tillis, followed by Senator Boozman. 

Senator TILLIS. That is where I was going to start, where I think 

Senator Tester left off. I always try to start by saying you all do 

a lot of great things. I have gone to all my hospitals in North Carolina and some of the health centers. There are a lot of motivated, 

dedicated people down there. It is as if we have got these incredibly 

dedicated workers in a factory that is about 30 years old and that 

we do not have the right assembly line, we do not have the right 

systems infrastructures, we do not have modern, in some cases, 

modern management structures that are needed. Have no doubt 

about it, I think that there are a lot of good people that are working hard. 

Dr. Davies, I wanted to just reinforce your comment about old 

systems and some of the problems that that creates. Senator 

Brown and I are working on a bill that over 10 years will provide 

about $6.2 million in benefits to the families of veterans who died 

in combat. We found out that in over a year, it is going to cost $5.1 

million to modify the system to allow those veterans to receive the 

benefit. Those ratios are unacceptable. We have to figure out what 

we are doing from a people process technology perspective to give 

64 

you all better tools to do the job I firmly believe you all want to 

do. 

I wanted to go back to Dr. Kudler. On page nine of the written 

testimony that has to do with the VA letter, or, actually, I guess, 

the response to the GAO report, I may just be misunderstanding 

what you are doing to clarify it. It sounds like as a result of the 

Choice bill, that we are moving from a 14-day standard to a 30-day 

standard. That seems like it is getting longer. Tell me why that is 

a good thing. 

Dr. KUDLER. Yes. Well, I am glad you asked that question because it is a key question. The 14-day standard was totally arbitrary. It was pulled out of the air some years ago. There was no 

community standard to go against to say this is a good thing or a 

bad thing. It was just, what should it be? How about 14 days. 

We have been diverting resources from more comprehensive care 

to trying to meet a standard that has no clinical basis. Instead, 

when the Choice Act came out, we looked at what the Choice Act 

said in the Federal Register. Thirty days is the standard for all appointments in VA. And, we said, this is our opportunity to take 

something that was arbitrary and actually diverting resources. 

Yes, emergencies must be seen emergency, and yes, we realize 

that that does not always happen, and with the help of the two 

gentlemen on either side of me, we are trying to fix that by drilling 

down with the data. 

But the 30 days is the standard that the Choice Act said. That 

is what we are going to get to. We are still going to be doing care 

as it is clinically appropriate. Thirty days does not mean you will 

now wait 30 days. It means, if you are not seen within 30 days, 

something is wrong and we will be there asking the questions. 

Senator TILLIS. Thank you. Another question really relates to 

long-term. What we are talking about today are the challenges we 

have with just the current inflow of potential patients. What sort 

of modeling have we done? I mean, are we going to have more 

stress on the system going forward? In other words, do we see a 

kind of leveling, or how much more stress is going to be placed on 

the problems you are already trying to address just by an increased 

patient population? 

Dr. KUDLER. Yeah. Great question, and I may ask my friends to 

help me on this. But, let me start by saying, 22.5 million American 

veterans, only about nine million of them enrolled in VA. About six 

million users per year, and that includes veterans of all eras. But, 

if you look just at the newest generation, roughly three million people have served in Iraq and Afghanistan during these conflicts. 

Half of them who are already eligible for VA have been to us, and 

more than half of them have at least one mental health diagnosis, 

and that is because we are asking about things we never asked 

previous generations about. This generation is also more vocal, has 

less stigma, wants help. 

Senator TILLIS. A mental health diagnosis related to their 

service? 

Dr. KUDLER. A mental health diagnosis, period, sir. But in most 

cases, the most common one is post-traumatic stress disorder. 

Senator TILLIS. OK. 

65 

Dr. KUDLER [continuing]. Followed with depression, substance 

abuse, problems like this. People are asking us for more. It is more 

intense. It is a younger generation. It is fresh trauma. It is not 

looking back 30 years, although that is quite complicated in itself. 

There are new demands. They are increasing. They are changing. 

Our workforce and our training has to shift to meet that balance. 

But, we are trying to model it. Women veterans are being another 

issue. Let me pause for my colleagues. Go ahead. 

Dr. DAVIES. No, I think that is right. 

Mr. CARROLL. That is a good answer. 

Senator TILLIS. OK. Thank you. 

I will yield back my 5 seconds, Chairman Isakson. 

Chairman ISAKSON. Senator Boozman. 

HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Mr. Chairman. 

Dr. Kudler, as you know, on the Committee, there is just a number of us from rural States and the huge challenge is mental health 

care in these areas, in our rural communities. In 2013, the VA established a pilot program at various VAMCs to partner with local 

community health care clinics. The pilot is now over. Some of the 

VAMCs have maintained their partnerships with the community 

health clinics while others have ended it. Can you talk a little bit 

about that? I guess, you know, in Arkansas, we have got significant 

problems. We have got community health care in all of our counties. Can you talk about why if we are using that, if not, why we 

are not using these resources through the Choice Act or whatever. 

Dr. KUDLER. Sir, to keep it short, I think we are using it, but 

we are not using it as well as we can. I think that these projects 

were wonderful, including the public-private partnerships. The 

Choice Act innovations in that, Project ARCH, very big in rural 

areas, but still a fairly small program overall. 

Now, with the chance to roll these together into one program, I 

think we can get this right, both the clinical and the business end, 

using geospatial modeling for figuring out where the demand is 

and how to best match it with the needs of the veterans and what 

capacity already exists in VA. 

Senator BOOZMAN. One of the problems that we have with the 

outside providers is that the VA does not pay in a timely way. Can 

you address that? I mean, I guess the question is, why can we not 

pay our bills on time? 

Dr. DAVIES. Well, sir—— 

Senator BOOZMAN. The problem is, is that many of these individuals do this because of the bureaucracy, because of all the other 

stuff, they do it because they want to serve veterans. We are a nation at war, and we can get them to do that. But when you have 

the bureaucracy and you simply do not get paid in a very timely 

way, it just exacerbates it. My concern is that we are losing providers simply because they get to the point they just do not want 

to fool with it any more. 

Dr. DAVIES. I would just offer that I agree with you. You are 

right. We have heard that, also. We are in a very dynamic environment with these different changing rules and processes, and I know 

the business office is working hard to improve it. That is the extent 

66 

of it that I could say at this point. It has changed so much that 

they have not been able to standardize it. 

Dr. KUDLER. Well, we will gladly join you in putting our shoulder 

to that. You are absolutely right. We reduced capacity through a 

business problem. 

Senator BOOZMAN. Right. It is a huge problem. 

Dr. Carroll, earlier, Mr. Karnaze testified about his experience at 

the VA and essentially being prescribed medicine. The medication 

did not help him. In fact, in his case, as with others, the medication actually made him worse. He quit using it and then again was 

not offered other forms of therapy that could have helped him. Can 

you tell us again what we are doing to address that problem, and 

are we just throwing pills at people in an effort to say that we are 

doing something? 

Mr. CARROLL. That certainly is not our goal or our mission at 

this point. I think we are priding ourselves in that our standard 

is to offer a comprehensive continuum of care, and in the outpatient spectrum, that may include medications. But it would include psycho-social treatments, evidence-based psychotherapies. It 

would involve group. It may involve case management. We are also 

looking at complementary and alternative medicine options. Our 

goal is to offer an entire continuum of care. 

One of the ways that we are trying to put that in place at medical centers is through creating teams within outpatient mental 

health clinics, behavioral health, interdisciplinary teams, so that 

the veteran is not just interacting with one provider who may be 

a prescriber, or it may be a psychotherapist. The veteran is working with a team and the team can work with that veteran to find 

the care that is most appropriate. 

Senator BOOZMAN. Well, as described by this patient, I mean, 

that was simply irresponsible. I think we are getting a little bit 

better at that than we used to be, but it is something that we simply cannot tolerate. Again, it is kind of like why can we not pay 

our bills on time. I understand that better than I understand this 

in the sense that it just does not seem like that is standard of care. 

Mr. CARROLL. Sir, if I may add one thing, and it goes to something that Senator Blumenthal said earlier in terms of the importance of peer support services in VA, Dr. Kudler has testified that 

we have increased the number of peer support providers. But the 

statistic that I think is very promising is that in 2013, we had just 

under 900,000 visits or encounters with the peer specialists. Last 

year, we had over 2.7 million. This is an additional resource, and 

to your question about how can we help providers look at things, 

if there is a peer support provider on that mental health team in 

a clinic, it also adds a whole another dynamic. 

Senator BOOZMAN. Good. Thank you, Mr. Chairman. Thank you 

all for being here. 

Chairman ISAKSON. Dr. Carroll, just one question. When we had 

the testimony from Dean Maiers about his experience, I believe you 

said it was the Arena Clinic, is that right? 

Mr. MAIERS. Errera, sir. 

Chairman ISAKSON. Errera. 

Mr. MAIERS. E-r-r-e-r-a. 

Chairman ISAKSON. Are you familiar with that clinic? 

67 

Mr. CARROLL. Yes, I am, sir. 

Chairman ISAKSON. Is that a quasi-VA facility, or is it a total—— 

Mr. CARROLL. No, it is a VA facility. It is a center. They have 

put together their homeless program, their community outreach 

programs for mental health, their peer support programs, supportive employment programs, all in the same center. It is a remarkable place. 

Dr. KUDLER. I just have to mention, Paul Errera was my first 

teacher when I started training at the West Haven VA, and one 

reason I took this job is he had this job. He went to take it when 

I was his student and I thought maybe I could try to follow in his 

footsteps. I am so glad to hear his name conjured with here. 

Chairman ISAKSON. I ran a company and we used a lot of peer 

challenges and peer support to motivate people to meet higher 

standards, and it would seem to me if you had something that was 

that good, based on the testimony of veterans and what you obviously both know yourselves, that ought to be the gold standard in 

the VA as to how each VA mental health center ought to operate. 

There ought to be some way we promoted that to give them a role 

model and an example within the agency of what really can be 

done. 

Mr. CARROLL. Yes, sir. 

Chairman ISAKSON. I guess you are ultimately responsible for 

mental health operations? 

Mr. CARROLL. Yes, sir. 

Chairman ISAKSON. One day, we will have a chat. I am going to 

be over there Friday morning of next week. Maybe we can get a 

chance to talk for a few minutes. I would like to see exactly how 

you all are organized and how you follow through on that. 

Mr. CARROLL. Yes, sir. 

Chairman ISAKSON. Thank you very much, Dr. Carroll. Thanks 

to all of you for your testimony. 

Unless there is any other—I guess am next to last. We are—the 

two most important ones are left, Boozman and me. [Laughter.] 

This hearing is adjourned. 

[Whereupon, at 4:33 p.m., the Committee was adjourned.] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. VA officials testified that the Department’s use of Peer Specialists has 

increased over the past several years. Please provide the Committee with data on 

the following aspects of VA’s use of Peer Specialists: 

Question 1a. The numbers of Peer Specialists staff and encounters with Peer Specialists within VA by location and by assigned unit (e.g primary care, behavioral 

health, etc.). 

Response. Please see attached. 

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Question 1b. The number of female Peer Specialists employed by VA for each of 

the past three years. 

Response. Information attached is provided for fiscal year (FY) 2013–2016. 

Data Source: VHA PAID data via VSSC ProClarity Data Cube excluding Veterans 

Canteen Service (VCS), intermittent, non-pay, medical residents, and trainees current as of 10/31/15. 

Question 1c. The number of female Veterans’ encounters with Peer Specialists by 

era of service. 

Response. Information attached is provided for FY 2015. 

Peer Specialist Encounters for Females by Era of Service 

Period of Service Encounters 

Persian Gulf War ......................................................... 13,3776 

Post-Vietnam ............................................................... 76,752 

Vietnam Era ................................................................. 28,514 

Other or None ..................................................... 1,799 

Other Non-Veterans ............................................ 1,325 

Champva—Spouse, Child .................................. 829 

Post-Korean .................................................................. 423 

Korean .......................................................................... 356 

TRICARE ....................................................................... 86 

Humanitarian (Non-Vet) .............................................. 65 

World War II ................................................................. 62 

Air Force—Active Duty ................................................ 24 

Army—Active Duty ...................................................... 14 

*Missing* .................................................................... 8 

Navy, Marine—Active Duty ......................................... 6 

Special Studies (Non-Vet) ........................................... 4 

World War I .................................................................. 4 

Coast Guard—Active Duty .......................................... 1 

Question 2. VA has undertaken a campaign for gun safety among veterans including mass media, other messaging, and dissemination of gun locks. Please provide 

the following specific information regarding VA’s gun safety campaign: 

Question 2a. General overview and any relevant web links to VA’s gun safety 

campaign. 

Response. In FY 2014, VA developed an outreach video to emphasize the importance of recommended practices for safe storage of firearms. In addition to the outVerDate Mar 15 2010 16:43 Jan 06, 2017 Jkt 000000 PO 00000 Frm 00074 Fmt 6633 Sfmt 6621 Z:\ACTIVE\102815.TXT PAULIN

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reach video, VA designed a poster to increase awareness of the importance of gun 

safety that includes information on acquiring freely-available gun safety locks. 

The outreach video is primarily used by VA staff in support of community outreach and education efforts. Simple actions can help individuals and families stay 

safe, especially during emotional or stressful times, or when someone in the home 

is in crisis. This video encourages Veterans, Servicemembers, and their families to 

make sure guns and ammunition are safely secured in their home, particularly 

when someone is experiencing a period of depression or crisis. Content and messaging for the video was developed with assistance from subject matter experts at 

the Harvard Injury Control Research Center and the National Shooting Sports 

Foundation. The video is available on the Veterans Health Administration YouTube 

page, at http://www.youtube.com/watch?v=-fGHTvTsApg&feature=youtu.be 

The poster was created using images and messaging from the gun safety video. 

The poster provides information on where to watch the video and where to obtain 

free gun safety locks, which are available at VA medical facilities or from local law 

enforcement. 

GUN LOCKS

The promotion of widely supported practices for storage and use of firearms is a 

critical public health and safety intervention that has been shown to reduce deaths 

from intentional and unintentional firearm injury. Research suggests that firearms 

are present in more than one third of all homes with children. In addition Veterans 

of military service are more likely than civilian populations to own firearms. Distribution of gun safety locks is an important component of a firearm safety program 

that seeks to reduce injury and mortality among Veterans and their families. 

Gun locks are provided to all VA facilities and VA Suicide Prevention Coordinators as tools to use in patient safety programs and in support of safe gun storage 

practices, especially for Veterans who may be at high risk for suicide. In FY 2010– 

2012, VA conducted a gun safety pilot program in partnership with the National 

Shooting Sports Foundation (NSSF). Through this program, more than 1.5 million 

gun safety locks and several thousand Project ChildSafe educational brochures were 

distributed to Veterans and their families. Response to that program was overwhelmingly positive and has led to continued collaboration with NSSF and continued distribution of gun safety locks to VA medical centers and program offices. Gun 

safety education and awareness materials are also provided in addition to gun locks 

which are available to Veterans who ask for one. 

ONGOING AND FUTURE EFFORTS (FIREARM SAFETY OUTREACH TOOLKIT & TRAINING)

VA has developed a firearm safety outreach toolkit which was disseminated to 

VA, government and community partners, and the public in June, 2015. The online 

toolkit helps support teaching of firearm safety by community members, VA clinicians and staff, and the public, and will contain the videos already described as well 

as printable brochures and materials. VA has initiated discussions with national 

leaders in the development and dissemination of educational materials promoting 

safe firearm storage and use. VA has proposed support for the development of a 

community toolkit that would include educational materials, blueprints for community organization, messages for use with local media, promotional items, implementation support from a recognized leader in firearm safety, and support for implementation in select sites through coordination with Veteran Service Organizations. The 

proposed toolkit would buildupon existing educational material for programs such 

as Project ChildSafe, a national education and gun safety lock distribution program 

designed to increase safe gun storage practices in homes with children. 

Question 2b. The number of gun locks that VA has disseminated in its gun safety 

efforts. 

Response. In 2014, VA disseminated 250,000 gun locks to Veterans who requested 

them. In 2015, 1,038,388 gun locks were disseminated from VA’s Suicide Prevention 

Program to Veterans who requested them with no questions asked. 

Question 3. VA officials have noted that they are awaiting analysis of suicide data 

by the Centers for Disease Control and Prevention before publishing updated veteran suicide data. Please provide a specific timeline for when the new data on veteran suicide rates will be available. 

Response. Data for the years 2012–2013 have been transferred to the Centers for 

Disease Control and Prevention (CDC) for linkage with cause of death information 

available from the National Death Index. CDC is processing this information and 

expected to return results from this search within the next 60–90 days. Once received from CDC, VA will process results from the search and calculate rates for 

these years. The process of data validation and analysis is expected to take an addiVerDate Mar 15 2010 16:43 Jan 06, 2017 Jkt 000000 PO 00000 Frm 00075 Fmt 6633 Sfmt 6621 Z:\ACTIVE\102815.TXT PAULIN
72 

tional 60–90 days. Barring any unforeseen delays, VA expects updated information 

on rates of suicide to be available within the next 120–180 days (approximately February-May 2016). 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BILL CASSIDY TO

U.S. DEPARTMENT OF VETERANS AFFAIRS

DATA ON MENTAL HEALTH SERVICES AT THE VA

Question 4. Please provide the following information on the mental health services 

delivered at VHA facilities from 2013–2015 and include: 

Question 4a. The number of visits and if this number of visits includes ‘‘no shows.’’ 

Response. Mental health outpatient encounters (does not include ‘‘no shows’’): 

Fiscal year (FY) 2013: 18,048,772 

FY 2014: 19,637,837 

FY 2015: 20,797,166 

Question 4b. If the number of visits includes the number of no-shows, what is the 

percent of visits that are ‘‘no shows.’’ 

Response. Does not include ‘‘no shows’’ 

Question 4c. The mean and median wait times for a vet to obtain a mental health 

appointment at VHA facilities, not including ER visits 

Response. The mean (average) waiting times for Primary Care, Specialty Care, 

and Mental Health (MH) are reported in this data (link) by facility. Veterans Health 

Administration Support Service Center (VSSC) does not calculate median waiting 

times. http://www.va.gov/HEALTH/docs/DR34_112015_Retrospective_Wait_Times_ 

Desired_Date_by_Division.pdf 

Question 4d. Does the above data vary by VHA facility? What is the range of 

number of visits per provider, number of visits minus no shows, mean and median 

wait times to obtain an initial MH visit? 

Response. VA cannot provide a meaningful range of the number of visits per mental health provider because the data vary so greatly based on factors such as type 

of provider, type of service being provided, and amount of time assigned to an outpatient clinic. 

The following information is given regarding mean wait times for an initial MH 

visit in FY 2014 and FY 2015. These data are not available for FY 2013. VSSC does 

not calculate median waiting times. 

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Question 4e. If there is significant variance, what steps are being taken to correct 

both wait times and variance among facilities? 

Response. MH wait times are regularly reviewed as part of the Mental Health 

Management System (MHMS) quarterly calls with Veterans Integgrated Service 

Network leadership and representatives from the Office of Mental Health Operations (OMHO). This call includes review of factors related to access, including staffing ratios, vacancy rates, and productivity. Additionally, MH waiting times are reviewed as part of routine OMHO site visits. Recommendations related to wait time 

improvement are included as part of strategic action plans reviewed quarterly for 

progress. 

TREATMENT PROGRAMS

According to VA MH Services Public Report (November 2014), 

‘‘The goal of VA mental health treatment is to provide effective care that 

meets the Veteran’s needs and expectations in a timely fashion. No single 

measure can capture this complex process, so VA monitors programs in 

terms of timely access to services, the types and quantity of services provided, and patients’ satisfaction with care. VA monitors these aspects of the 

experience of care using various sources of information, such as patient and 

staff reports and electronic records.’’ 

Question 5. Since treatment depends on a good diagnosis, what screening does the 

VA provide in order to properly diagnose a mental health disorder? Who receives 

these screenings? 

Response. All Veterans engaged in VHA health care are screened for a range of 

concerns, including: depression, Post Traumatic Stress Disorder (PTSD), alcohol 

misuse, tobacco use, experience of military sexual trauma (MST), and homelessness 

or being at risk for homelessness. Depression, problem drinking, and risk of homelessness screenings are completed annually. PTSD screening is completed annually 

for the first five years following separation from active duty, and every five years 

thereafter (to restart if reactivated). MST screening occurs once for every activation. 

Positive screening results trigger specific follow-up requirements, depending on 

the condition being assessed, for example: 

• Positive screens for depression or PTSD must be followed up with assessment 

for suicide risk and to determine the most appropriate disposition, which may include referral to specialty mental health services. 

• Individuals who screen positive for alcohol misuse or problem drinking must be 

provided education and counseling about safe drinking limits and health risks associated with drinking above those limits. Individuals with a diagnosis of alcohol use 

disorder must be offered additional treatment to address alcohol related problems. 

• Individuals who screen positive for tobacco use must be provided education and 

counseling about tobacco cessation, and be offered evidence-based pharmacotherapy 

to aid in tobacco cessation. 

• Veterans who screen positive for homelessness or at risk for homelessness must 

be offered assistance locating safe and decent housing through collaborative relationships with providers in the community. VA medical staff must ensure that 

homeless Veterans have a referral for emergency services and safe, adequate temporary housing. 

• Individuals who screen positive for MST must be offered MST counseling services. 

Question 6. Once a diagnosis is made, does each vet with that diagnosis receive 

the same treatment protocol including medication? Is there variation? If so, please 

explain the variation. 

Response. VA/Department of Defense (VA/DOD) Clinical Practice Guidelines 

(CPG) provide clear and comprehensive evidence based recommendations for the 

treatments that would be effective for a Veteran with a given diagnosis. These 

guidelines complement and inform the implementation of the array of services to be 

offered for a given diagnosis as defined by the VA Uniform Mental Health Services 

Handbook (UMHSH). Further, the UMHSH dictates services that are required to be 

available based on facility size and complexity. 

The initial 24 hour assessment provides an evaluation of need for emergent care 

for Veterans with a need for immediate inpatient MH hospitalization. For those not 

requiring inpatient mental health care immediately, a full evaluation occurs to determine the best clinical treatment options to meet the specific needs of the Veteran. 

If there is a need for a residential level of care, VA Residential Rehabilitation Treatment Program services would be sought. Other options for care are also available 

including specialized services for Veterans with Serious Mental Illness (SMI) such 

76 

as the Mental Health Intensive Case Management Program (MHICM) or Psychosocial Rehabilitation Recovery Center (PRRC), specialty intensive services for PTSD 

or Substance Use Disorders (SUD), and general MH outpatient services. Some Veterans may benefit from and prefer treatment within primary care and receive services from the Primary Care-Mental Health Integration team and their primary care 

providers within the Patient Aligned Care Team (PACT). 

Within each of these levels of care, there are a number of different treatment modalities available. Veterans have the opportunity to engage in individual therapies, 

group therapies, and couple or family therapy. Additionally, treatment planning is 

often informed by engaging the Veteran’s family when family involvement is approved of by the Veteran. Last, within each level and modality of care, UMHSH and 

the CPG identify a range of efficacious services to be offered for a given clinical diagnosis, these may include evidence-based psychotherapies (EBPs) and pharmacological treatment. 

Each Veteran’s specific diagnoses and needs, along with his or her preferences, 

are considered during the treatment planning process to tailor treatment to address 

the unique needs of each Veteran. As a result of this Veteran-centered approach to 

treatment planning and implementation, there is inherent variation due to a Veteran being offered the choice of efficacious treatments that would effectively meet 

his/her needs. 

Question 7. How many vets complete the treatment program recommended by the 

provider? Please include the number of visits and medication compliance. 

Response. VA monitors the types of mental health services received by Veterans 

according to specific types of services, such as PTSD or addiction treatment, inpatient admissions, or residential rehabilitation treatment. These monitors allow VA 

to understand how many Veterans are being served in these clinics or settings, and 

how much care they are getting measured in numbers of visits or days in a treatment program. However, because MH care is tailored to the clinical needs and preferences of individual Veterans, there is no ‘‘one size fits all’’ regimen that can be 

applied to all those in mental health care. In addition, even where there are treatment guidelines for particular disorders, those guidelines are not expected to be imposed without regard to individual circumstances. It is therefore not possible to 

quantify the number of Veterans ‘‘who complete a treatment program recommended 

by the provider.’’ This would require much more nuanced and detailed data about 

what the provider was recommending than is available in the administrative data. 

(77) 

A P P E N D I X 

PREPARED STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON

Thank you, Mr. Chairman, for holding this critically important hearing, and 

thank you to the witnesses for appearing here today. 

I think everyone in this room agrees that our Nation has a duty to care for its 

veterans. With so many veterans diagnosed with mental health needs, a significant 

part of that care is access to mental health treatment. 

Veterans face stress and adversity from multiple deployments, and the unique 

challenges they face during tours of duty that can make it difficult to readjust to 

life back home. Difficulties with this transition are even worse for those experiencing depression, Post Traumatic Stress Disorder, substance use disorder, or those 

suffering from military sexual trauma. These invisible wounds of war can be with 

veterans for many years—but we also have treatments that help, and can get veterans back into their lives. 

The VA has a duty to provide the services and foster a culture that actually 

serves our veterans. 

However, I am deeply concerned that despite all of our efforts over several years 

to address gaps in access to mental health care services, the VA is not making the 

changes that are needed—and that they have been required to make. As far as I’m 

concerned, that equates to failing our veterans. 

When I was Chairman of this Committee, we held several hearings on mental 

health care. I asked for several IG and GAO investigations. We demanded VA hire 

more providers, and listen to providers in the field about the barriers they face in 

trying to help veterans. We even passed into law reforms designed to improve VA’s 

ability to provide for the mental health needs of our veterans. 

But as we sit here today, I’m having a hard time understanding what has really 

changed since we covered this exact same ground in 2012, and even in 2008. 

I’m frustrated that VA: 

• still has does not have an accurate picture of wait times. 

• still does not have a staffing model for mental health care 

• still has an alarmingly high number of vacancies in mental health positions 

Now, as the Ranking Member on the HELP Committee, I understand very well 

the Nation-wide shortage of mental health providers. 

But, things need to change. So, I’ll be looking for answers on exactly how the VA 

is addressing two things that we identified as problems years ago: 

One, how the VA is making sure there are enough mental health professionals 

who can quickly and accurately diagnose and treat our veterans; and 

Two, how the VA intends to recruit and maintain this crucial workforce. Without 

proper staffing levels, the VA will never be able to satisfy the demand. 

That is a failure we cannot allow. 

Allowing veterans to seek care outside the VA is certainly part of meeting this 

need, but the sobering reality is that half of all U.S. counties do not have a single 

psychiatrist, psychologist, or social worker. Even if there were enough private-sector 

providers, it wouldn’t solve the problem. 

Because of the unique nature of the veteran experience, we need providers specifically attuned to their needs, which include evidence-based treatment and cultural 

competency. This ultimately means that for far too many veterans and their families, it is unclear where to turn for help. 

The VA Inspector General released a report this past August addressing the issue 

of VA efforts to improve veterans’ access to outpatient psychiatrists. This report concluded that the VHA has not been fully effective in its use of hiring opportunities 

or use of its existing personnel to improve veterans access to psychiatrists. 

78 

This is very alarming given that the report also found that 94 out of 140 health 

care facilities needed at least one additional psychiatrist. 

But, most concerning—these problems aren’t new. IG and GAO have reported on 

these same types of failings for years. We need to fix this. And really, it shouldn’t 

take multiple Senate hearings over the course of many years to get this done. 

Mental health is just as much of a priority as physical health. 

Veterans must have access to see these professionals, without the fear of confusion over where they can go, or lengthy wait times for initial appointments. 

The GAO report that was released today discusses some of these above concerns. 

I look forward to continuing the discussion on what we can do to address scheduling 

issues, and how to ensure we have accurate information to see where we’ve fallen 

short. 

The demand for these services is only going to increase as it has been for the last 

several years. We need to be able to devote the resources to these efforts NOW, so 

that VA has the ability to respond quickly and appropriately when someone is clearly in, or approaching a crisis. 

We also know that the fastest growing group of new veterans are women. Which 

is why it is extremely important for us to be focusing on the unique mental health 

needs of female veterans, and I’ll continue working to make sure VA is addressing 

the needs of this growing population. 

So, I am deeply appreciative of our witnesses today for their insights, and I hope 

that this hearing is a step forward in increasing accountability, improving access, 

quality, effectiveness, and efficiency of mental health services for our veterans and 

their families. 

Æ