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[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

    HEARING ON VA MENTAL HEALTH CARE STAFFING: ENSURING QUALITY AND 
                                QUANTITY

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                          TUESDAY, MAY 8, 2012

                               __________

                           Serial No. 112-59

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                                _____

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

            Helen W. Tolar, Staff Director and Chief Counsel

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                              May 8, 2012

                                                                   Page

Hearing on VA Mental Health Care Staffing: Ensuring Quality and 
  Quantity.......................................................     1

                           OPENING STATEMENTS

Chairman Jeff Miller.............................................     1
    Prepared Statement of Chairman Miller........................    77
Hon. Corrine Brown, Acting Ranking Democratic Member.............     3

                               WITNESSES

The Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans 
  Affairs........................................................     4
    Accompanied by:

      Hon. Robert A. Petzel, M.D., Under Secretary for Health, 
          Veterans Health Administration, U.S. Department of 
          Veterans Affairs
      Robert L. Jesse, M.D., Ph.D., Principal Deputy Under 
          Secretary for Health, Veterans Health Administration, 
          U.S. Department of Veterans Affairs                        78
      Mary Schohn, Ph.D., Director, Office of Mental Health 
          Operations, Veterans Health Administration, U.S. 
          Department of Veterans Affairs
      Antonette Zeiss, Ph.D., Chief Consultant, Office of Mental 
          Health Services, Veterans Health Administration, U.S. 
          Department of Veterans Affairs
      Annie Spiczak, Assistant Deputy Under Secretary for Health 
          for Workforce Service, Veterans Health Administration, 
          U.S. Department of Veterans Affairs
John D. Daigh, Jr., M.D., Assistant Inspector General for 
  Healthcare Inspections, Office of the Inspector General, U.S. 
  Department of Veterans Affairs.................................    34
    Prepared Statement of Dr. John D. Daigh, Jr., M.D............    83
Linda A. Halliday, Assistant Inspector General for Audits and 
  Evaluations, Office of the Inspector General, U.S. Department 
  of Veterans Affairs............................................    35
Nicole L. Sawyer, PsyD, Licensed Clinical Psychologist...........    44
    Prepared Statement of Nicole L. Sawyer.......................    87
Diana Birkett Rakow, Executive Director of Public Policy, Group 
  Health Cooperative.............................................    46
    Prepared Statement of Ms. Rakow..............................    92
James Schuster, MD, MBA, Chief Medical Officer, Community Care 
  Behavioral Health Organization of University of Pittsburgh 
  Medical Center.................................................    48
    Prepared Statement of Dr. Schuster, MD.......................    95
RADM Thomas Carrato, USPHS (Ret.), President, Health Net Federal 
  Services.......................................................    50
    Prepared Statement of Mr. Carrato............................   100
Joy Ilem, Deputy National Legislative Director, Disabled American 
  Veterans.......................................................    64
    Prepared Statement of Ms. Ilem...............................   107
Alethea Predeoux, Associate Director of Health Legislation, 
  Paralyzed Veterans of America..................................    65
    Prepared Statement of Ms. Predeoux...........................   113
Ralph Ibson, National Policy Director, Wounded Warrior Project...    67
    Prepared Statement of Mr. Ibson..............................   116

                        STATEMENT FOR THE RECORD

Hon. Tim S. McClain, President, Humana Government................   120
Thomas J. Berger, Ph.D., Executive Director, Veterans Health 
  Council, Vietnam Veterans of America...........................   123

 
                    HEARING ON VA MENTAL HEALTH CARE
                       STAFFING: ENSURING QUALITY
                              AND QUANTITY

                              ----------                              

                          Tuesday, May 8, 2012

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:38 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Stearns, Lamborn, 
Bilirakis, Roe, Stutzman, Johnson, Runyan, Buerkle, Huelskamp, 
Turner, Brown, Reyes, Michaud, Braley, McNerney, Walz, Barrow, 
and Carnahan.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. What I would like to do before we actually 
start is I think the IG folks have stood down at this time. Mr. 
Secretary, we are glad to have you, and go ahead and call this 
hearing to order.
    I want to welcome everybody to today's hearing. I apologize 
for being tardy, but we are going to be talking about VA Mental 
Health Care Staffing: Ensuring Quality and Quantity.
    As I think most of the Committee knows, two weeks ago the 
VA inspector general released a report reviewing veterans' 
access to mental health care, something that we are all very 
interested in as are all veterans and Americans across this 
country.
    And I have got to say that the findings in the report are 
more than troubling. It is an understatement to call them 
troubling.
    One of the most disturbing things that the IG discovered is 
that more than half of the veterans who seek mental health care 
through the VA wait an average of 50 days, to receive a full 
mental health evaluation.
    Let me be real clear from the outset--A veteran who comes 
to the VA for help should never, never under any circumstance 
have to wait almost two months to receive the evaluation they 
have asked for and begin the treatment they need.
    And I do not believe anyone in this room thinks that there 
is any excuse for that type of delay.
    Given the gravity of the issues we will discuss this 
morning, I invited Secretary Shinseki to participate in today's 
hearing.
    I was a little concerned, Mr. Secretary, based on a letter 
from you last week that you may not be joining us this morning, 
but I am very glad that you are here with us because I know 
that this is important to you and the people who work at VA.
    As you know, leadership and accountability begin at the 
top, not with an under secretary, not with a deputy under 
secretary, but with the secretary.
    And these hearings are much more than opportunities for 
this Committee to hear from the department. I think that it is 
important for the department to hear from Members of this 
Committee as well because we hear from our constituents on a 
daily basis.
    There is no one better positioned to represent the VA than 
you. So, again, let me reiterate my thanks to you for being 
here this morning.
    Two days before the IG report was released, interestingly 
enough, VA made a surprise announcement that VA was going to be 
increasing their mental health staff by 1,900 people, adding 
approximately 600 clinicians and 300 support staff to their 
current roster of just over 20,000 mental health professionals.
    Ensuring the VA is staffed adequately to fulfill the care 
needs of our veterans and their families is a priority of mine 
and each Member of this Committee.
    So on its face, this is an encouraging step. However, I am 
concerned by the timing and the implication of the 
announcement.
    The IG's report clearly illustrates that the VA does not 
have meaningful or reliable data, to accurately measure a 
veteran's access to care or facilities' mental health staffing 
needs.
    In fact, the IG states, and I quote, ``The complexity of 
the computations and inaccuracies in some of the data limits 
the usability of productivity information to fully assess 
current capacity, determine optimal resource distribution, 
evaluate productivity across the system, and establish mental 
health staffing and productivity standards,'' end quote. Which 
begs the question, if the VA does not even have a complete 
picture of the problem, how confident can we be that access, in 
fact, will be increased and care enhanced by really what could 
be termed a knee-jerk reaction to what has been going on?
    This is not the first time we have been here. There is a 
long history of IG, government accountability office, and 
stakeholder reports that have found serious deficiencies within 
the VA mental health system of care including appointment 
waiting times, scheduling processes and procedures, provider 
performance measures, and data collection efforts.
    There is an equally long history of congressional 
oversight. Strides have been taken, but they are far, far from 
enough.
    I would like to give the department the benefit of the 
doubt. I believe that we all have the best interest of our 
veterans at heart, but I am afraid that VA's response in this 
instance is yet another example of a Federal bureaucracy 
providing a quick fix, cookie cutter solution to a very serious 
multifaceted problem.
    A true definition of access to care can be found in 1993 
Institute of Medicine report which reads in part, ``The most 
important consideration is whether patients have an opportunity 
for a good outcome, especially in those instances in which 
medical care can make a difference.''
    The 1.3 million veterans who sought mental health care 
through VA last year deserve better. The very least we owe our 
veterans is a chance. VA can make a difference. VA must make a 
difference.
    And, again, Mr. Secretary, thank you for being here today.
    And I yield to our Ranking Member, Ms. Brown, for an 
opening statement.

    [The prepared statement of Chairman Miller appears in the 
Appendix)

           OPENING STATEMENT OF HON. CORRINE BROWN, 
                ACTING RANKING DEMOCRATIC MEMBER

    Ms. Brown. Thank you, Mr. Chairman, for holding this 
hearing today on such an important issue.
    I would like to thank all of you that are here today in 
support of the veterans.
    Since 2007, VA has seen a 35 percent increase in the number 
of veterans receiving mental health services and a 41 percent 
increase in mental health staff. While only one percent of 
Americans have served in the war in Iraq and Afghanistan, 
servicemembers represent 20 percent of suicides in the United 
States.
    The VA report that 52 percent of the returning veterans 
from Operation Enduring Freedom, Iraqi Freedom, and New Dawn 
who access VA health care do so for a mental health issue.
    Oversight of VA mental health programs have long been a 
focus for this Committee. Numerous hearings have been held, 
funding has been increased, and legislation has been passed to 
ensure that veterans of all era active duty servicemembers and 
guards and reservists all have access to timely and quality 
mental health care service wherever they choose to live.
    While I agree that much has been done, I am discouraged 
that we still hear stories of the struggles many veterans face 
when trying to access VA mental health care services. Whether 
it is a delay in care, denial of care, or that the care is not 
available, frustration with the system may lead the veterans to 
forego needed care altogether.
    The inspector general's report was blunt and to the point. 
The report found that the Veterans Health Administration does 
not have a reliable and accurate method to determine whether 
they are providing patients timely access to mental health 
care.
    I would like to hear how VA plans to move forward with the 
recommendations obtained in the IG's report on the heel of this 
report before the announcement from the department that 1,600 
new mental health providers would be hired along with the 
addition of 300 support staff.
    Given that there have been some inaccuracies in the 
information of the report over the last year, I am interested 
in hearing from the VA today what methods and modeling VA has 
used to arrive at the number and what and how long it is going 
to take for the hiring timeline.
    Finally, because there have been many improvements and 
expansions in mental health services, I would like to recognize 
the hard work and dedication of the VA employees who go to work 
every day with the goal of making a positive difference in the 
veterans' lives.
    And, Mr. Secretary, I want to thank you for coming here 
today. I want to thank you for your 38 years as a military 
person, and as the Secretary for the Department of Veterans 
Affairs.
    I have been on this Committee for 20 years and I met with 
many, many secretaries. And I can tell you many of them, they 
come to this Committee, they talk a great talk, but they do not 
walk the walk or, as the veterans say, roll the roll. You do.
    We have a big task. And we are a very bipartisan Committee 
and I am interested in working with you to make sure that we 
improve the lives for all of the veterans.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.
    The Chairman. Thank you very much, Ms. Brown.
    I want to welcome again the panel to the table. We have 
already recognized the secretary of VA, the honorable Eric 
Shinseki.
    Also, he is accompanied by Dr. Mary Schohn, the Director of 
the Office of Mental Health Operations; Dr. Antonette Zeiss, 
the chief consultant for Office of Mental Health Services; 
Annie Spiczak, the assistant deputy under secretary for Health 
Workforce Service; and also Dr. Jessee and Dr. Petzel.
    Thank you for being here with us today.
    Mr. Secretary, you are recognized. Thank you.

 STATEMENT OF ERIC K. SHINSEKI, SECRETARY, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS ACCOMPANIED BY MARY SCHOHN, DIRECTOR, OFFICE 
 OF MENTAL HEALTH OPERATIONS, VETERANS HEALTH ADMINISTRATION, 
U.S. DEPARTMENT OF VETERANS AFFAIRS; ANTONETTE M. ZEISS, OFFICE 
  OF MENTAL HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, 
 CHIEF CONSULTANT, U.S. DEPARTMENT OF VETERANS AFFAIRS; ANNIE 
   SPICZAK, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR 
    WORKFORCE SERVICE, VETERANS HEALTH ADMINISTRATION, U.S. 
  DEPARTMENT OF VETERANS AFFAIRS; ROBERT A. PETZEL; ROBERT L. 
                             JESSEE

                 STATEMENT OF ERIC K. SHINSEKI

    Secretary Shinseki. Thank you.
    Mr. Chairman, Ranking Member Brown, distinguished Members 
of the Committee, thank you for this opportunity to speak on 
behalf both of veterans and their families but also the 
employees of VA about this important issue of mental health.
    Mr. Chairman, I ask the department's prepared written 
statement that was previously submitted by Dr. Jessee be 
included in the record.
    The Chairman. Without objection.

    [The prepared statement of Dr. Robert L. Jessee appears in 
the Appendix]

    Secretary Shinseki. Okay. Thank you.
    Well, joining me today, as you have introduced them, are 
the leaders and senior clinicians of the Veterans Health 
Administration, who are the appropriate experts to provide 
clinical staffing and policy information that you had requested 
in your letter.
    I want to be clear. Mental health and well-being of our 
brave men and women who have served the Nation is the highest 
priority for me, for this department, and for our Nation. We 
are here to care for veterans' mental as well as physical 
health and well-being.
    Today's testimony takes me back a few decades, Mr. 
Chairman, of my own experience coming back out of combat 
situation. And I think you will appreciate why this has 
priority for me and remembering some of the transitions I went 
through.
    I am here to speak to America's veterans and their families 
as well and represent the dedicated employees of this 
department and especially today to the 20,590 mental health 
providers that are part of this discussion.
    History shows that VA's requirements will continue to grow 
for a decade or more after the operational missions as they 
have in Iraq and next in Afghanistan come to an end.
    And as veterans depart the military, we must ensure that 
all of them have access to quality mental health care. I 
believe we are all united in that pursuit. I believe the strong 
actions taken under the President's leadership have illustrated 
that clearly for the past four budgets.
    And the last three years, VA has devoted more people, 
programs, and resources towards mental health services to serve 
the growing number of veterans seeking mental health care from 
VA. Last year, VA provided specialty mental health services, 
Mr. Chairman, as you pointed out, to 1.3 million veterans.
    With the President's 2013 budget request, VA has increased 
the mental health care budget by 39 percent since 2009 and if 
we add to that the 2014 advanced appropriations request that is 
currently being considered, that increases that factor to 45 
percent.
    Since 2007, VA has seen a 35 percent increase in the number 
of veterans receiving mental health services, as the Ranking 
Member pointed out, but at the same time 41 percent increase in 
mental health staff to adjust to that.
    And I think this describes a little bit of what we are 
dealing with and that is in our process here, Mr. Chairman, you 
resource us to a requirement and at best, those requirements, 
because of the advanced appropriations request that gives us a 
two-year budget, those requests are based on a prior year 
number of folks who walk in the door. We try to extrapolate 
that into some estimate of the future, but we are really 
covering about four years as we look forward.
    And what this really means is we are essentially in a react 
cycle, that what walks in the door becomes the basis for 
understanding what the requirements could be in the future 
years.
    And so if the trend line is smooth and uniform over time, 
there is an opportunity in this system to react because it is 
primarily reaction process.
    Where we have spikes in that requirement, then we have 
these occasional needs to address the staffing issue as we have 
in this case.
    Additionally, in 2010, I think we will all recall that the 
department simplified its rules for veterans submitting PTSD 
related disability claims which has greatly simplified access 
to care and benefits and contributed to growth in the PTSD 
mental health requirements.
    So that was done in 2010. The claims have been submitted 
and we are beginning to see a growth in PTSD mental health 
requirements and, therefore, not unexpectedly, a requirement to 
adjust our staffing.
    VA's announcement on 19 April that we would add 
approximately 1,600 mental health clinicians to include 
psychiatrists, psychologists, mental health nurses, social 
workers, as well as 300 support staff to our existing workforce 
of 20,590 reflects both our commitment to mental health and 
acknowledgment that changes in policy are having an impact.
    And our efforts will likely not cease with the announcement 
of 1,900 additional personnel being added to our workforce. 
Future adjustments may be likely.
    VA has a long history of being on the cutting edge of 
mental health care whether through the use of vet centers, our 
National Center for PTSD, our veterans' crisis line, or 
integrating mental health into the primary care environment of 
our health care facilities.
    We will continue to review and monitor our facilities and 
veterans' feedback so we can make other adjustments that are 
needed and we will not hesitate to take action again. And I 
appreciate the support of this Committee and the Congress over 
the past years as you continue to provide us the resources we 
need and the authorities we need to make this care available to 
our veterans.
    My invitation is let's continue to work together along with 
our partners in the veteran service organizations focusing on 
what is important, providing timely access to care and benefits 
our veterans have earned.
    And I look forward to working these issues with the 
Committee and look forward as well to your questions. Thank 
you, Mr. Chairman.
    The Chairman. I apologize for the clock being on you, Mr. 
Secretary. I ordinarily would not have done that. I just 
noticed that it was on.
    Did you have anything else you wanted to add? You kind of 
sped up at the end and I do not want to take time away from you 
in your testimony. Anything else you wanted to add?
    Secretary Shinseki. No. I will let all the statements 
stand. You have accepted our written statement and I am happy 
to take questions.
    The Chairman. Thank you. Thank you very much.
    We will start a round of questions if we can. You talked 
about the press release on April 19th. You have acknowledged 
also that there are about, 1,500 mental health staffing 
vacancies. It could be a bit more or less. And your testimony 
today talks about maybe hiring more than 1,900.
    So what I would like an answer to is, I know you are going 
to try to fill the 1,500 vacancies that exist and you are going 
to add an additional 1,900 plus staff. Is that correct? Then a 
couple other things.
    How quickly do you think VA can hire the additional staff? 
Where are you going to put the additional staff? And how will 
you be able to measure the impact that they will have on 
improving care?
    Secretary Shinseki. Mr. Chairman, let me just make an 
opening statement here and then I am going to call on Ms. Annie 
Spiczak who does the recruiting and retention personnel work 
for us because you are asking to see what tools we have and 
what our expectation here is.
    We think that we will get most of that done in the next six 
months, but some of these specialties are difficult to recruit 
and I would, you know, be honest with you. I am not sure I can 
pin a date when all of them will be in. But the vast majority 
of the work will be done in the next six months. Some of this 
may carry over into the second quarter of fiscal year 2013.
    Let me call on Ms. Spiczak to talk about the process here.
    Ms. Spiczak. Thank you, Secretary.
    Sir, I would say that we have a four-fold strategy to 
recruit and hire the mental health professionals that we need 
in VHA.
    The first part of that strategy is to have a very robust 
marketing and advertising campaign to do that outreach to 
mental health providers and professionals. That is by the use 
of USA Jobs, using social media, getting all of those vacancy 
announcements posted to specialty sites and job boards.
    The second part of that is using our national recruiters. 
We have 21 dedicated health care recruiters and they are very 
involved with the VISNs and the medical center directors to 
recruit those hard to fill positions, especially our 
psychiatrists and our psychologists.
    Thirdly, we are going to recruit from our active pipeline 
of trainees and residents. VHA has a very robust training 
program and they are an integral part to filling that pipeline 
of our workforce.
    And, fourthly, we are going to ensure that we have complete 
involvement and support of VA leadership.
    Secretary Shinseki. Mr. Chairman, I am going to call on Dr. 
Petzel to just add some concluding points here.
    But I would also point out that the national recruitment 
program, the 21 high-quality recruiters that Ms. Spiczak 
referred to all are veterans. Eighteen of them have extensive 
experience in recruiting.
    And for any new individual who joins the team, they go 
through a training program and oversight, mentoring by some of 
the old-timers. And so this is a pretty robust tool we are 
talking about.
    Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Mr. Chairman, I just wanted to add briefly the VA trains, 
has 1,000 psychiatric residency positions. We have over 730 
internship positions for clinical psychologists just to mention 
a couple of the professions.
    We are the largest trainer of mental health professionals 
in the country. And this group of trainees is the primary place 
that we are probably going to be recruiting those individuals 
to fill those 1,900 jobs.
    And the last thing I would like to add is that the most 
difficult to recruit group is psychiatrists, particularly in 
rural or remote areas.
    And we have recently sent a memo to the secretary which I 
believe he has signed or is about to sign to change the pay 
table for psychiatrists and to make available other incentives 
so that we can compete more equitably with the private sector 
and DoD in terms of recruiting psychiatrists.
    The Chairman. Ms. Spiczak, how long does it take for VA to 
fill a vacancy like the 1,500 that are open now for mental 
health professionals? What is the average time that those 
positions have remained vacant?
    Ms. Spiczak. Sir, it takes anywhere from four to six. But 
for some of our hard to fill positions, it can take up to a 
year to fill those positions.
    The Chairman. Have you ever been even close to a hundred 
percent staffed at the full level with the 1,500 that you 
currently have?
    Ms. Spiczak. Sir, we will always have a turnover rate, a 
vacancy rate, that we are always trying to close that gap, but 
you have my commitment that we are going to work very hard to 
close that.
    The Chairman. At what level is the vacancy rate? Is it more 
at the upper level or the lower tier? I hate to say lower tier, 
but obviously the psychiatrist level downward, which is the 
higher rate?
    Ms. Spiczak. No, sir. Our turnover rate in fiscal year 2011 
for our mental health professionals was 7.23 percent. And the 
Bureau of Labor Statistics for the health care industry shows a 
28 percent turnover rate.
    The Chairman. The last question that I would like to ask in 
this round is, how are we going to pay for the extra 1,900 
mental health professionals?
    Secretary Shinseki. For that question, I am going to call 
on Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Mr. Chairman, we have estimated that the cost in fiscal 
year 2012 will be relatively small because it is going to take 
some time to get these people on board. And we will use money 
that we have available in 2012. We expect that this will not 
exceed $29 million and maybe a bit less than $29 million.
    In fiscal year 2013, we are going to separately identify 
the funding for this particular initiative as part of each one 
of the VISN's allocations and then the VISNs will receive a 
hiring target based on this allocation. And we are going to 
keep very close track of that hiring target.
    Ms. Spiczak can give more detail about how we are going to 
do that, but we are basically going to be daily looking at how 
they are meeting that hiring target.
    We will identify each one of these positions electronically 
on USA Jobs by a special number so that we can track all of the 
1,900 new people as well as all of the vacancies that exist 
right now.
    Secretary Shinseki. Mr. Chairman, just a data point. 
Psychiatrists are the toughest to recruit. And I think under 
this new model, we say it is about 57 that we are going to go 
after in this group of 1,900. Of 57, 37 have already been 
recruited. Seven are already serving. Thirty are being on-
boarded.
    And so we are beginning to hone in on this most difficult 
recruiting challenge and working it down. So there is some 
evidence that we can recruit what we need here.
    The Chairman. Before I turn it over to Ms. Brown, I also 
want to say that I had the pleasure and the honor of 
accompanying Ms. Buerkle to Syracuse, to visit the medical 
center there. And I want to tell you that what I saw from their 
mental health professionals was exactly what I think you want 
to see around the country, the care and compassion they have 
not only for the veteran but for the veteran's family as well, 
and helping them to be able to assimilate and understand the 
issues that they are confronted with.
    And, you know, those ghosts, if you will, that the veteran 
fights sometimes the family fights too. They have done what I 
think is an outstanding job at that facility.
    With that, Ms. Brown, you are recognized.
    Ms. Brown. Mr. Chairman, I want to be the last on my side 
because I have a real in-depth knowledge of this issue since I 
have an educational specialist in counseling. And so I am 
thinking about a different approach.
    The Chairman. Very well. Mr. Reyes.
    Mr. Reyes. Thank you, Mr. Chairman, and thank you, Madam 
Ranking Member, for yielding.
    And welcome, Mr. Secretary. We are looking forward to your 
visit later on this month in El Paso.
    And I guess my first question, does the VA do an ongoing 
assessment? And the reason I am asking this question is because 
since the 2005 BRAC, I will use my district as an example, we 
gained the First Armored Division.
    And as the downsizing of the army occurs down to 490,000, 
we anticipate, and we are seeing already, a rapidly increasing 
number of soldiers coming out of the army staying in the El 
Paso region and, therefore, impacting our VA facility.
    So my question is, is there an ongoing assessment to be 
able to take care of areas like our district?
    Secretary Shinseki. Congressman, this is a good point. And 
this is a little bit of that resourcing to requirement that I 
referred to. And the example I used was a decision to grant 
PTSD, combat verified PTSD to anyone who had served in combat. 
So for every generation from World War II to the current, 
suddenly a new opportunity for them to receive care and the 
numbers are beginning to reflect that.
    Same issue here with the First Armored going to El Paso. We 
are not part of that decision process.
    Mr. Reyes. Right.
    Secretary Shinseki. But we have worked very closely with 
Department of Defense for the last three and a half years to 
try to get better synchronization for us with understanding 
where they are headed. And in many cases, they have shared with 
us whatever they knew. Some of this First Armored going to El 
Paso was probably a later breaking issue than we would have 
been able to anticipate.
    But, nonetheless, these are part of the changes that occur 
in the requirements that then drive us to go back and review 
our resourcing format. So, yes, I would expect that First 
Armored soldiers would remain in El Paso and requirement for 
veteran health care including mental health will go up and, 
hence, a discussion about a future VA medical facility becomes 
pertinent over time.
    Mr. Reyes. Well, the assessment itself, is it ongoing or 
how is that done by VA?
    Secretary Shinseki. Well, heretofore it has been a sort of 
acknowledge the requirement when people walk in the door 
seeking help and that becomes a registration point of a 
requirement for health care.
    We have worked with the Defense Department to create the 
single electronic health record so we would have a better 
handoff, a warm handoff of individuals departing the military 
who are coming to VA.
    And we have worked at this with the attitude that everyone 
who leaves the military ought to be enrolled in VA. And part of 
the VOW Act was to create a transition assistance program and 
we have been in discussions with DoD about how to structure 
this.
    For our purposes, during the transition period, we would 
like to see individuals still in uniform have access to my 
healthy vet, to e-benefit so that they are in our database 
before the uniform comes off.
    And as you know, we are working towards this integrated 
electronic health record that will transfer automatically all 
the information that they have built up in their military 
service coming over to us.
    And we are shooting to have integrated health record 
probably initially, initial form of it ready in about two 
years.
    Mr. Reyes. And at what point or at what stage will 
facilities like the one in my district get an idea of how many 
additional personnel will be coming out of the new hirees?
    Secretary Shinseki. Let me ask Dr. Petzel to provide that.
    Dr. Petzel. Thank you, Mr. Secretary.
    Congressman Reyes, we are right now discussing the 
allocations with the VISNs. Dr. Schohn and her group actually 
are doing that. And we expect that we will know within a couple 
of weeks at probably the latest what it is going to specific.
    Let me just go back to the question that you asked the 
secretary and add one more thing. You talked about being able 
to anticipate a surge or an increase in the number of people.
    The foundation for how we determined the 1,900 people that 
we felt we needed to distribute across the country is a 
prototype of a staffing model. No one in this country has a 
staffing model for mental health. We have developed what I want 
to call a prototype because it has not been fully vetted.
    But that model then can be applied to any population of 
patients requiring mental health services to predict the kind 
of both support personnel and mental health professionals that 
are needed. This is going to be an ongoing assessment across 
the Nation of our needs.
    And we would hope to be more anticipatory now with this 
model and less reactive than we have been in the past so that 
in terms of returning veterans, we will be able to predict the 
need and have the resources in place to be able to manage that.
    Mr. Reyes. Great.
    Thank you, Mr. Chairman.
    The Chairman. Dr. Petzel, you are talking about the 
allocation of resources and it begs the question--what type of 
a workload analysis did you do prior to the announcement that 
1,900 was the number? Could it be considerably more than 1,900, 
could it be less, or was that just kind of a middle figure that 
you worked with just to roll it out?
    Dr. Petzel. Chairman Miller, that is an excellent question.
    And Dr. Schohn can talk more detail about how this 
prototypic model was developed, but it basically looks at the 
population of patients requiring mental health services. And it 
is able to say, as an example, across the country, we feel as 
if we need about 5.3 mental health professionals for every 
thousand patients that are presenting.
    We began doing this, sir, back in November. This was not a 
reaction to the IG. We began looking at what kind of staffing 
increases we needed back in November. Dr. Schohn and her group 
developed a prototype of this model, applied it, as well as 
other information that we had and arrived at the number of 
1,900.
    It is being in a very detailed fashion tested in three 
networks to see how predictive it actually is, but we think it 
is going to allow us to do a better job of anticipating need in 
the future and we think it appears to be quite reliable.
    The Chairman. If, in fact, you did start back in November, 
why wasn't this proposal in the President's budget submission 
this year?
    Dr. Petzel. We had not developed the model and we did not 
know for sure until at least into January how this might work 
and exactly the number of people that we would want to apply.
    The Chairman. But I think even in January it would have 
been able to have been included. I mean, two weeks after the IG 
report comes out, it looks like a knee-jerk reaction. And I can 
appreciate the fact that you may, in fact, have been working on 
it.
    But if you knew it was going to be an issue, I think it 
would have been wise to have included it, especially a number 
as large as 1,900, in the President's budget submission.
    With that, Dr. Roe, you are recognized.
    Mr. Roe. I thank the Chairman and I thank the secretary for 
being here.
    And I would like to introduce a guest before I start with 
any questions. I would like to introduce a constituent of mine 
from east Tennessee, Staff Sergeant Derrik Plank. Derrik is a 
combat-wounded veteran who entered the army in 1995 right out 
of high school and went on to serve three tours of duty in the 
former Yugoslav Republic under General Shinseki, Bosnia, and 
Iraq.
    Derrik served with the Fourth Infantry Division in 
Operation Iraqi Freedom. On May 5th, 2003, he suffered a 
traumatic brain injury caused by shrapnel wounds when his tank 
was attacked by an RPG. Derrik retired later that year.
    As a reward for his bravery, Derrik was awarded the Bronze 
Star for valor, the Purple Heart, four army commendation 
medals, and a combat action badge.
    He holds a master's degree in arts and education from East 
Tennessee State University as well as a doctorate in education 
from the University of Maryland.
    He continues to be very active in the veterans community 
and is a strong advocate on their behalf. As a part of this 
support, Derrik recently wrote a lengthy dissertation on 
suicide prevention and the proper treatment of mental health 
injuries among veterans and servicemembers. And I would 
certainly recommend that you read it.
    As a veteran and doctor and co-founder of the invisible 
wounds caucus, I recognize firsthand the need to address these 
issues.
    And I want to thank Derrik for his service to our country 
and his efforts to continue supporting our veterans.
    [Applause.]
    Mr. Roe. I thank the Chairman.
    And, Derrik, thank you for being here today.
    And I do strongly encourage you to read this not from the 
bureaucratic point of view but from the eyes of a veteran who 
has been through the various treatments and sees the positives 
and the minuses.
    I think one of the things he brought up in his dissertation 
that I read is, and it is a tough issue, Mr. Secretary, when a 
soldier goes in, we have been very sensitive in this country 
about culture, and it has been an issue as you have seen 
recently and the photos that have been made. Our leadership 
from someone like yourself has been very culturally sensitive.
    The question is, is the VA being culturally sensitive when 
it treats veterans?
    Derrik's concern is when he goes in to see someone who is a 
mental health provider who may be from a different culture, for 
instance, Major Hassan is a perfect example of that, it is very 
hard for these veterans to go and display these issues that 
they have with someone that a few weeks or months or years ago, 
even when these issues pop, that were the enemy. And it is a 
real issue.
    Is there any sensitivity on the VA's part--maybe Dr. Petzel 
can answer this--in hiring individuals to treat these veterans 
because it has been an issue for Vietnam era veterans and 
certainly is an issue today for our Iraq and Afghanistan 
veterans?
    Secretary Shinseki. Congressman, I am going to call on Dr. 
Petzel here to try to address the specifics of your question 
which is a good one.
    But I am also reminded that this is why this model we are 
talking about is imperfect. I mean, it is the best we have 
right now. It will get better as we finish the piloting. And 
this is to get to the staffing issue.
    What you are talking about is the special trust that 
develops between a patient in the mental health arena and the 
provider. And this is unlike the relationship in other 
disciplines of medical delivery. Without that trust, not much 
positive will come out of it.
    And so I think here in the mental health side of medicine, 
we are into the art of understanding what the right staffing 
levels and capabilities are, whereas maybe in the other 
disciplines in medicine, it is more the science where you can 
measure and metric and get pretty accurate outcomes.
    So when Dr. Petzel says he started with his staffing model 
and began to adjust it in ways that would be helpful to mental 
health, we are still learning how to do this because we have to 
get to this answering what is the right number and what is the 
right relationship we are trying to develop here.
    And I would expect that there would be some concern like 
you are describing that we would have to take on and deal with. 
But we will do that as we see patients. And let me ask----
    Mr. Roe. I think these issues make it almost impossible for 
that veteran to get the quality care. It is not the quantity so 
much but the quality.
    Secretary Shinseki. Yeah.
    Mr. Roe. In his case, it was very difficult.
    Secretary Shinseki. Yeah.
    Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    And, Dr. Roe, thank you.
    You bring up an incredibly important issue and that is the 
ability of not just in mental health but in medical care in 
general the provider being able to empathize culturally with 
the person that they are talking to. Do they understand where 
they are coming from? Do they understand what the nature of the 
experience is that they have had previously that have led them 
to seek medical care?
    And I am proud to say the VA has pioneered a program to 
teach in medical schools and in other clinical education 
settings about the military culture, about the issues 
associated with combat, about the problems that may be faced by 
somebody who has recently been discharged.
    And I would venture to say that in almost every medical 
school now in the country there is a section of education both 
for medical students and for residents about dealing with 
veterans and dealing with the issues of the military culture.
    Mr. Roe. Dr. Petzel, I know Congressman Reyes and 
Congressman Walz, myself, others have served. And how many of 
these mental health individuals are veterans, because I think 
it is--you know, when you put your pants on every day with 
these guys and you go out in the tents and you go out with 
them, you have a different view? I can tell you you just see 
through a different set of lenses.
    Dr. Petzel. The only figure I know, Congressman Roe, is at 
our vet centers, the 300 vet centers that we have around the 
country, 70 percent of those people working in those vet 
centers are veterans.
    Mr. Roe. What about the 37 psychiatrists that General 
Shinseki has spoken of and dealing with those?
    Dr. Petzel. I do not know, but we can certainly find out 
and get back to you about that.
    Mr. Roe. And it does not mean that you cannot provide good 
care. I do not mean that at all. You certainly can. You do not 
have to have had a heart attack to treat one. I understand 
that. But certainly if you are treating combat stress, boy, an 
ideal person is somebody like Derrik or someone who has been 
there as General Shinseki has on many occasions. It is again a 
different set of lenses that you look through.
    Dr. Petzel. Just one more thing, Congressman, I would like 
to add that I neglected to mention earlier. We have started 
because of legislation that Congress passed, we have started 
developing a peer counseling program and are in the process of 
training 400 peer counselors that will work in our medical 
centers. And these, of course, will all be veterans.
    Mr. Roe. Okay. I yield back.
    The Chairman. Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Thank you, Mr. Secretary, and the panel for coming here 
this morning on this very important topic, especially after the 
IG came out with their report last month.
    And I am very pleased to see the VA's response. In the 
report and that I would like to quote, it says, and I quote, 
``Unequivocally committed to providing veterans the best 
possible care, the VHA would act rapidly on all findings that 
may improve veterans' access to mental health care,'' end of 
quote.
    As the VA knows, the timeliness in providing that care is 
extremely important when you are dealing with PTSD patients and 
I really appreciate that.
    My question is, do you believe that contracting to non-VA 
facilities that have a proven track record in this regard would 
be extremely important?
    And the reason why I ask that question is looking at the 
1,500 current positions that are vacant, looking at the 1,900 
new staff that you are looking to be bringing on board, it is 
going to take some time to get those on board. And, 
unfortunately, some of our veterans I do not believe can wait 
that long. So you have to look at other areas where contracting 
has proven to be successful.
    And I mention that because actually earlier this year, 
Congressman Mike Thompson invited me out to California to visit 
a program that they are currently offering out there in 
California, pathway homes. And I had a great opportunity to 
talk to a lot of the veterans that actually have gone through 
that particular program and they had nothing but high praises 
for the program.
    And I also asked why did you not go to the VA and some of 
them mentioned they just felt like they were a number in the VA 
system. They did not feel that they were getting the 
appropriate health care needs that they thought they might get. 
So they went to this particular program which seems to be very 
successful.
    So I know contracting out has always been a concern among 
some of the VSOs and the VA, but this program seemed to be a 
proven program.
    So is the VA going to be looking towards contracting out to 
help relieve some of the burdens that is currently there in 
this area?
    Secretary Shinseki. I am going to call on Dr. Petzel for 
that, Congressman.
    Dr. Petzel. Thank you, Mr. Secretary and Congressman 
Michaud.
    We have several mechanisms for reaching out beyond the VA 
to provide care and we do use them. One of them is fee basis as 
I think you are familiar, non-VA care where we actually allow 
people to be seen by private practitioners. And they then bill 
us and we pay for the service.
    And the other is contracting. And we do have in mental 
health as well as in other parts of our health care system, we 
do have contracts on the outside, often in places that are 
quite remote or rural where we do not have a provider.
    If you look at our system of community-based outpatient 
clinics, we have over 800 of them and we provide mental health 
services in virtually all of them. And many of them, that is 
done by contract. We have a contract with mental health 
providers in the community and that is the way we deliver 
services in that clinic.
    So it is an excellent idea. It is an excellent suggestion. 
We do do it. And in some remote areas, I think we are going to 
have to be doing it more than we do now.
    Mr. Michaud. In the interim, until you get all the new 
employees that you plan on hiring, I would assume that you 
probably would need to take care to do more of it at least 
initially for programs that have worked. And that is a concern 
that I have is the lag between when you get these new employees 
on.
    You mentioned the CBOCs and the VA system. Are there 
current plans now to upgrade, you know, the business plan for 
these different areas to look at the increase of new employees? 
How far along is that process?
    Dr. Petzel. I am not sure I understand, Congressman 
Michaud, the question. In terms of the facilities, yes, we are 
updating their business plans to reflect the new people----
    Mr. Michaud. New model.
    Dr. Petzel. --that are coming on board. Exactly. And you 
make an excellent suggestion about fee and contract. And we do 
have other things that they can do in the interim, locum 
tenens, and shifting some resources within the medical center. 
But fee and the possibility of contracting should also be a 
part of that. Absolutely agree with you.
    Mr. Michaud. And my last question is, looking at the 
additional 1,900 new staffing, is that to take care of the 
current needs that are currently out there today and have you 
taken into consideration over the next five years that there is 
going to be about a million soldiers back in--will be into the 
VA system, a huge increase? So does that 1,900 address the one 
million that will be coming into the VA?
    Secretary Shinseki. Congressman, the 1,900 addresses what 
we know are today's needs. And we have said, as I said in my 
opening statement, we are comfortable with this, but this 
requirement could likely grow and, hence, the importance of our 
relationship with DoD and being able to see what the future 
brings.
    The one million figure I have used and others have used, as 
we talk to DoD, they indicate that that is not going to be as 
big a spike as at one time was predicted. That reality is it is 
going to be a much smoother transition out. It will still be an 
increase, but this will be something that we think with this 
model that they have created and we are piloting, we will begin 
to anticipate a little better than we have which has been 
primarily reaction.
    Mr. Michaud. Thank you.
    The Chairman. Mr. Stutzman.
    Mr. Stutzman. Thank you, Mr. Chairman, and thank you for 
having this hearing today.
    I want to thank Secretary Shinseki for being here. It is 
good to see you and thank you for your service and all that you 
work to accomplish at the VA. This is obviously a very 
important issue.
    And I represent northeast Indiana where we are going to be 
having a new outpatient mental health care facility that is 
being built there. And with the IG's report that has just come 
out, you know, this is obviously concerning.
    And I am curious why these issues which have been raised 
numerously have not been resolved. I know the VA has convened a 
working group to attempt to address these problems in the IG 
report.
    My question is is, what is going to be different about this 
particular group? What is going to be different about your 
approach this time in tackling these problems so that, you 
know, I can make sure that the veterans back home are confident 
of the services that they receive?
    Secretary Shinseki. Let me call on Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary, Congressman Stutzman.
    I will do just a little bit of history about measuring wait 
times which is, I think, what this is about. There are three 
different ways to do this. One of them is to look for the third 
next available appointment. That is called a capacity measure 
because it measures your capacity. It does not give us 
information about how long any individual would have waited. 
And we at one time used that to predict our capacity for seeing 
patients in the clinic setting.
    But the two other ways of measuring this are desired date 
which is you ask someone, a provider or a patient when do you 
want to be seen. They say a date and then that becomes the mark 
and you see how close to that date you can actually get the 
appointment. It is called desired date.
    The other is creating date. It means that there is no 
interest in what the desire of the patient or the clinician is. 
It is the day that that appointment is asked for. It becomes 
the create date, relatively inflexible, but very easy to 
measure and very easy to do.
    We have used desired date since about 2007, 2008 and 
trained everybody about how to do desired date, et cetera. It 
is clear both from our look and from the IG's look that there 
are difficulties for new patients with desired date.
    So the first change we are making is that new patients are 
going to be tracked based on create date so we can be 
absolutely certain of that particular date. It requires no 
judgment on a scheduling clerk's part. It is the date that that 
appointment is asked for. And I am quite certain that is the 
conclusion the work group is going to come to.
    The second thing that we have to address then, and that is 
only 17 percent of our appointments, our new patients, 
relatively small amount. You have to remember that people 
access our system in a lot of different ways. They come into 
the emergency room. They call the crisis hotline. They are in a 
primary care clinic and they are treated for mental health 
there or they are referred out.
    Very few people actually walk in or call in and say I want 
an appointment in mental health, so we have to address how we 
are going to measure appointment times with that other 83 
percent of the patients and that is the primary job with this 
work group.
    We need to. Absolutely agree with the IG. We need to be 
able to tell our veteran patients, our employees, and you how 
long people are waiting to get times. And we are not able to 
provide the data to be accurately doing that right now.
    We will work with the IG after we come to a decision about 
what we want to do to be sure they understand and agree about 
the way we want to do this so when someone comes to audit this, 
we will not have the confusion and the issues that we had with 
this audit.
    Mr. Stutzman. Okay. I know my time is short here. But in 
the next panel, we will hear from a private sector provider who 
states that they are able to increase patient access and 
satisfaction by trying to fill open appointment slots with 
patients waiting for appointments.
    Does the VA have a similar system in place? If not, or yes, 
no?
    Dr. Petzel. I would ask Dr. Schohn to respond to that.
    Ms. Schohn. Yes. Actually, at local sites, certainly people 
keep lists to get people in sooner. That is part of the sort of 
routine standard of practice.
    Mr. Stutzman. Okay. All right. Thank you, Mr. Chairman. I 
will yield back.
    The Chairman. Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for coming today and your 
testimony.
    There is no doubt in my mind about your commitment to this 
issue. There is no doubt in my mind about it and the dedication 
of your staff. I am sure that psychiatrists could make more 
money in the private sector, so working for the VA shows a 
certain amount of dedication. I appreciate that.
    My first question is really following up on an earlier 
question. Dr. Petzel, I just want to be really clear in your 
answer about this. Do you believe that the VA should assume 
responsibility for treatments when the patient is referred to 
outside agencies by the VA for PTSD or TBI treatments?
    Dr. Petzel. Well, Congressman McNerney, yes, we are 
responsible. When we refer somebody out, the patient is still 
our responsibility. We have a responsibility to see that that 
is high-quality care, that it is done in a timely fashion, yes.
    Mr. McNerney. So the VA is assuming responsibility for 
payments to these outside agencies?
    Dr. Petzel. If we refer somebody to an outside 
organization, yes, we are responsible for the payments.
    Mr. McNerney. Okay. Thank you.
    Secretary Shinseki, Chairman Miller, and this is a follow-
up on Mr. Stutzman's question actually, mentioned that the IG 
report gives a two-month waiting period for some veterans 
seeking mental health assistance.
    What was your reaction to that? It sounds like from Dr. 
Petzel's testimony that the standard for judging that two 
months is a little bit mushy, but I would just like to hear 
what your response is to that.
    Secretary Shinseki. Congressman, I am not sure I would have 
concurred in the IG's report exactly the way the department 
did. And the reason I say that is like all of you, I am trying 
to figure out what the issues are and how to apply our 
resources and energy.
    And so we have this large health care system in which if 
you enter a vet center, you are into mental readjustment 
counseling and if required, you get referred into the mental 
health system.
    As Dr. Petzel has indicated, there are 300 of these vet 
centers out there. There are 800 plus community-based 
outpatient clinics in which you can enter the mental health 
system through contact with a primary care provider.
    And that grows when you add our telehealth links, that 
people in remote or even not so remote community-based 
outpatient clinics can be linked in to psychiatrists, 
psychologists that is at a distant station. So there is a level 
of robustness here that I understand exists.
    There are 152 medical centers and you can enter the system 
by going to the mental health clinic and the medical center or 
you can go enter the system through the primary care arena in 
that same hospital because we have integrated mental health 
care in with primary care providers or you can enter it through 
the emergency room after hours if you need care. There is an 
opportunity to get connected to a mental health provider and 
then referral.
    So a fairly complex system and we have added to that with 
the homeless initiative that we have put in place. It is a 
robust system in which entry into mental health care is 
numerous.
    I welcome the insights from the IG. I also welcome their 
help in helping us create a model that will solve this 
scheduling issue that occurs in a variety of ways. And it is 
not just at the scheduling desk in a mental health clinic. It 
is one entry point.
    And I do not know that we fully understand and can measure 
right now the robust aspects of what we do in mental health. 
And my guess is we are doing good work here. We are just not 
able to document it.
    Mr. McNerney. Thank you.
    Dr. Petzel, could you give me a little insight into the 
nature of the model that has been developing, the staffing 
model? Is it an Excel spreadsheet or how does it work? What are 
some of the details?
    Dr. Petzel. Congressman, I would like to turn that over to 
Dr. Schohn whose group actually developed that model.
    Mary, could you help.
    Ms. Schohn. Sure.
    We developed the staffing model using the same kind of 
methodology that VHA previously used in developing a method to 
look for our staffing model for primary care. And that included 
looking in the literature to look and see what is out there, 
what has been published.
    There is very limited literature on outpatient mental 
health staffing models, a little bit more literature on 
inpatient, but we were really focused on outpatient.
    We also connected with other health care systems, so we are 
aware that DoD is actually piloting a staffing methodology and 
we got details from them and ran it by our subject matter 
experts.
    It was promising, but we have a variety of different kinds 
of services than DoD offers to its constituents, so we were 
unable to effectively adopt that system.
    We also talked to Kaiser Permanente to see, in fact, what 
kind of model they had and they currently do not have a model 
of the kind that we are looking for.
    We were unable to get any information from other systems, 
so we looked to our own data and we looked at the utilization 
standards, staffing models and so on to look at the numbers.
    We also had looked at what are the predictors of staffing 
within VA. So we ran a model that looked at, you know, what 
predicts. It includes things like, not surprisingly, the number 
of patients served, the kinds of services, so including 
residential services, inpatient services, as well as some 
characteristics of facilities where patients are at, so things 
like, is it a teaching hospital, are all predictors.
    We put that together and we looked at our data and 
identified that as kind of a starting point for us, 5.3 
independent clinicians per 1,000 veterans looked like the place 
to start in terms of looking at does this effectively do what 
we want to do in terms of improving access as well as providing 
veteran and provider satisfaction.
    Mr. McNerney. Thank you, Mr. Chairman. I yield back.
    The Chairman. Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman.
    And, again, Mr. Secretary, it is good to see you here 
today.
    I am going to start off with a little bit of a difficult 
question. You know, year after year in annual budget 
submissions and annual performance reports, quarterly reports, 
congressional testimony, and in countless press releases and 
statements, the VA has consistently touted the 14-day standard 
as the number one measure of mental health care access.
    In a five-month investigation, however, the IG found that 
measure to have no real value and to be essentially 
meaningless.
    Mr. Secretary, how is it possible that that is not bubbling 
up to your level? How is it possible that you do not know that 
and who is responsible for misleading Congress and the public 
on this metric and how will they be held accountable?
    Secretary Shinseki. Congressman, I do not think anyone has 
misled Congress here. Dr. Petzel described three methods of 
identifying in the scheduling arena capacity, desired date, 
create date.
    They have in the mental health arena been using desired 
date now since 2007 and my understanding was this goes back to 
when we had a previous discussion like this.
    I am not sure how the results were achieved, but it just 
seems to me that desired date and create date in the report are 
brought together in a way. It is hard for me to determine 
whether there was a pure assessment of whether desired date was 
being executed properly, whether staff were properly trained 
and following the instructions. That would allow us to focus on 
corrective actions.
    Right now part of my discussion with Dr. Petzel is that we 
have got to sit down with the IG and make sure we come up with 
a clear standard here so that when we audit in the future, 
there is not this confusion about which date we are using and 
that we get a cleaner outcome and understanding.
    I am not able to address the specifics here, but I would 
assure the congressman there is no misleading of Congress.
    Mr. Johnson. I can certainly agree that there is no 
intention to do so, but I think we all agree here that the 
objective here is to make sure that those veterans that request 
mental health counseling get it as soon as absolutely possible.
    Secretary Shinseki. I would just like to assure you so we 
do not confuse the two terms, access is being able to get 
treatment. Scheduling is the timeliness of this. Both are 
important. But I want to assure you that veterans who and even 
active component individuals who come to us for mental health 
care do have access.
    We are going to go to work on the scheduling issue to make 
sure that timeliness standards are clear and that we can 
measure whether we are achieving them.
    Mr. Johnson. Okay. Thank you.
    Dr. Sawyer who we will hear from on the next panel 
mentioned in her written testimony an issue of space for 
clinicians at some VA mental health facilities.
    What is your plan to make sure that the 1,900 new 
clinicians and support staff will have adequate space to do 
their jobs?
    Secretary Shinseki. Let me call on Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Congressman Johnson, the two relatively rapid ways we have 
for dealing with space issues are the nonrecurring maintenance 
and repair money and the minor construction money.
    We do have already in the pipeline projects in both those 
areas dealing with ambulatory mental health as well as other 
ambulatory space.
    In addition to that, we can give priority right now because 
they fall into one of the five special categories, we can give 
priority to move nonrecurring maintenance and repair money 
projects that deal with mental health up. And we are going to 
do everything that we possibly can to see that the projects 
that need to be done to create this space is done.
    I cannot argue with the statement that there is going to be 
or there are going to be space issues at some places. We are 
going to address those as quickly as we possibly can.
    Mr. Johnson. Okay. One final question. Do your performance 
measures only apply to OIF and OEF veterans or any veterans?
    Secretary Shinseki. Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary and Congressman 
Johnson.
    No, they do not. We have a long list, and I want to just 
briefly mention them, of performance measures that look at all 
categories of veterans.
    Now, the timeliness is just one performance measure. There 
are many other things that we look at. Are patients timely 
referred if they are at risk for suicide? And we track that. 
Are patients getting the eight sessions of individual 
psychotherapy within eight weeks if it is prescribed and if it 
is needed? Are high-risk patients being referred to the high-
risk patient case management in a timely fashion? Are we 
following up post discharge? Everybody is supposed to be 
contacted after discharge from a mental health facility within 
seven days of the discharge. Are all new patients being 
screened for depression, alcohol misuse, and in the case of 
OEF/OIF particularly PTSD?
    So, no. The performance measures apply to every single one 
of our mental health patients.
    Mr. Johnson. Okay. Thank you.
    Mr. Chairman, I yield back.
    The Chairman. Ms. Brown is going to go ahead and ask her 
questions, Mr. Walz, if that is okay with you.
    Ms. Brown.
    Ms. Brown. Thank you, Mr. Chairman.
    Recently I participated in a workshop with Secretary 
Donovan and the Mayor of Jacksonville and the issue was 
veterans, just veterans and veterans' mental health.
    And we were discussing how we can combat this working with 
our partners, not just the VA, but how can we work with other 
stakeholders.
    And recently I visited the VA facility in Los Angeles. And 
the reason why I mention that I had an educational specialist 
in counseling is because I think everything should be group and 
counseling and working in that group setting.
    I was surprised the number of veterans talked about how 
they prefer or in addition like the online and accessing the 
system.
    Can you tell us how you plan on expanding the system to 
include that aspect of, you know, video conferences and other 
aspects?
    Secretary Shinseki. Let me call on Dr. Petzel. We are doing 
many of these things now, Congresswoman.
    Ms. Brown. You are, but I was surprised that they liked it.
    Secretary Shinseki. That is a new generation.
    Ms. Brown. Yes, it is.
    Secretary Shinseki. They are folks that are very 
comfortable with the technology and they do not mind that 
little gap distance----
    Ms. Brown. That is right.
    Secretary Shinseki. --between themselves and the provider.
    Dr. Petzel. Thank you, Mr. Secretary.
    Congresswoman Brown, you put your finger on what I think is 
probably the most important future development in not just 
mental health services delivery but in medical care delivery in 
general and that is tele-mental health and telehealth.
    The VA is a pioneer in tele-mental health. We had over 
150,000 people using tele-mental health facility services this 
last year. It is particularly important in rural and remote 
areas.
    Just as an example, we have a telehealth PTSD treatment 
program on the Rosebud Indian reservation in South Dakota. It 
has been in existence for almost ten years now. And it provides 
PTSD treatment for Native American veterans living in Rosebud 
and Pine Ridge reservations being followed by a psychiatrist in 
Denver at the University of Colorado.
    So we absolutely agree with you. This is a fundamentally 
important thing. We are pushing the development of tele-mental 
health particularly as rapidly as we possibly can.
    One more example of that. I dedicated or helped dedicate a 
new mental health building at the Pittsburgh VA Medical Center, 
a state-of-the-art inpatient and outpatient facility. They have 
19 cubicles for mental health providers to be providing tele-
mental health at remote areas in Pennsylvania.
    Ms. Brown. Thank you, and that is very helpful.
    But one of the reasons why I mentioned the meeting with 
Secretary Donovan was that we talked about the array of things 
that needs to go to help veterans like the housing, like the 
casework, making sure we have a caseworker there in the homes 
that we are working with. And we have many stakeholders and 
partners that is already doing it and want to partner with us.
    Seems like we in Congress in many areas, we always talk 
about--I do not like the word even--outsourcing or, you know, 
that is a negative to me, but in this area, it seemed like it 
makes some sense to partner with people that have the same 
level of expertise as long as we have the oversight and making 
sure because the problem is so deep.
    Secretary Shinseki. Congresswoman, good points. We do not 
rely on just our internal capabilities. I think Dr. Petzel has 
referred to fee basis contracting. Telehealth, telemedicine, 
you know, I think we are doing the right things in investing in 
the technology for the years ahead. I personally do not think 
we are investing enough. If this is the breakthrough in medical 
delivery in the future years that is going to create, reduce 
the tyranny of distance and get veterans, patients in need of 
help in contact with health care providers I think this is it. 
If it is, I think we could be doing more here in investments. 
But we are moving quite smartly. $360-some-odd-million this 
year investing in telehealth connectivity.
    Let me call on Dr. Petzel for anything else he adds here. 
But especially in the area of mental health we talk about it as 
though it was all one kind of issue.
    Ms. Brown. Yes.
    Secretary Shinseki. And it is all individual. And we also 
find out that you almost have to tune to the individual patient 
the care that is going to make a difference. And so we want to 
have as many options as are available and that we can afford to 
be sure that we have something that will work.
    As you know we have five polytrauma centers. The most 
recent one opened in San Antonio. I happened to visit the one 
in Richmond and while they were giving me a tour I 
encountered--with a veteran briefing at each station. At one 
station I encountered a female person who in this polytrauma 
center was, spoke to me and there was no speech problems that I 
could see. Had all appendages. And I said, ``This is a 
polytrauma center. Are you a member of the staff?'' She says, 
``No, I am a patient here. I am one of those comatose patients 
who came in here some time ago and this place brought me back 
to consciousness and brought me back to the ability to speak, 
and walk, and do all the things I did before.''
    We are doing some terrific things here. And when I ask 
people, ``What is opening the door?'' You know, there is really 
no good answer. Because when you push the envelope you do not 
necessarily know how to seal the lid on things. You just keep 
going. So this young lady is a promotable master sergeant in 
the United States Air Force. She is going to leave Richmond 
here sometime this summer, according to plan, and she will go 
back and be promoted on active duty.
    So we need as many tools as we can get, and that is what 
you are talking about here.
    Ms. Brown. Yes, sir.
    Secretary Shinseki. And we will look to incorporate as many 
as we can and balance that in a way that is both efficient and 
cost effective.
    Ms. Brown. Thank you again for your service, sir.
    The Chairman. Ms. Buerkle?
    Ms. Buerkle. Thank you, Mr. Chairman. And thank you, 
Secretary, for being here, and to all of you for your service 
to this Nation and to our veterans. I think that is the place 
we all start at, how can we make sure we are doing the right 
thing for our veterans?
    I am chair of the Subcommittee on Health and many of you 
have been here and testified before the Committee. In December, 
on December 2nd, we had a hearing in the Subcommittee regarding 
suicide and the grave concern that we have at the rate of 
suicide. And of course, that plays into what we are talking 
about here today. There is not really the luxury of time, and 
that was part of that conversation, and it is again the part of 
this day's conversation. We do not have the luxury of time. We 
do not have the luxury of sitting down and trying to come up 
with plans and think tanks. We really need to act 
expeditiously.
    In that hearing Dr. Jan Kemp spoke and she testified on 
behalf of the National Mental Health Suicide Prevention at the 
Veterans Health Administration. And she talked to us about the 
VA has significantly expanded its suicide prevention program 
since 2005, when it initiated the Mental Health Strategic Plan 
and Mental Health Initiative funding. So that has been in 
place. There is an awareness of Post Traumatic Stress. There 
has been an awareness. Why now is, it, I get the impression 
this morning that now the IG's report came out so now there is 
increased awareness. This is nothing new. This is, she assured 
us in that hearing that the proper steps were being taken. And 
my concern is that there is a lack of coordination. That many 
good things are happening within the VA, and as the Chairman 
pointed out in Syracuse we have an excellent facility, always 
ready to meet the needs of the VA. But I am concerned about a 
lack of coordination. We have heard that in other hearings, 
that one hand does not know what the other hand is doing. And 
ultimately those who get hurt are the veterans. So if you could 
comment on that?
    Secretary Shinseki. Congresswoman, I could not agree with 
you more. Better coordination is needed. We think we are doing 
good work but there is more to be done. And I think the issue 
here is trying to come up with a good scheduling tool that will 
allow us to incorporate all of the opportunity that is 
available in the VA system and do what you are suggesting. And 
better coordination will enable us to have faster access to the 
right quality of care that veterans need.
    We need a tool to do this. Right now we are operating one 
that is 20 years old?
    Dr. Petzel. Oh at least, yes.
    Secretary Shinseki. And it has been useful but it has I 
think, you know, it has outlived its usefulness. We need to 
move on and we have taken steps to do that, come up with a new 
tool. Let me call on Dr. Petzel here.
    Dr. Petzel. Thank you, Mr. Secretary. Congresswoman 
Buerkle, you bring up, as the Secretary pointed out, an 
excellent point. A couple of things I would like to mention. 
First of all, the assessment of staffing goes back a long time. 
This was not a reaction to an IG report. We began looking at 
this long before the IG was even out in the field. We 
appreciate the fact that they substantiated what we feel is the 
case, and that is that we needed to have more staffing and 
particularly in certain parts of the country.
    In terms of the integration and coordination, let me tell 
you how we try to accomplish this. We have set up within the 
last two years a unit in our operating organization. There is a 
group of people that operate the medical care systems. And up 
until two years ago when I got here there was no clinical 
presence there. It was basically an administrative operation. 
What we have done is taken clinical people from other parts of 
the central office organization and put them into operations. 
Dr. Schohn is the person who that is responsible centrally for 
the operation of the mental health system out in the field. She 
has a lead in each network. She has a council in each network 
composed of the leads from each one of the medical centers. And 
this is the way we intend to create a uniformity of 
distribution of care to assure that the evaluation of care is 
being done in a comprehensive, thorough way. So I think that we 
are going to have a much better grip on the integration of our 
health care deliver system.
    But I do want to point out that this system is without 
question the best integrated mental health care delivery system 
in this country. Nobody has the breadth and the depth of 
services available that we do.
    Ms. Buerkle. Thank you, Dr. Petzel. I just, if I could, I 
would like to make comment of my colleague from Florida about 
the concern that, I do not believe that the VA can do it alone. 
We need to partner. We recently had a symposium in Syracuse 
about communities partnering. And I would please ask the VA and 
the way you think it is going to take the VSOs, it is going to 
take the private sector, it is going to take communities, it is 
going to take the clergy and churches to work together to make 
sure that the veterans have what they need and what they 
deserve. And we have got to stop thinking in terms of silos. We 
as communities, we as a country must reach out and provide what 
it is our veterans need. I thank you all very much.
    Secretary Shinseki. Congresswoman, I could not agree with 
you more. And then if you were to look at what we have tried to 
do in the homeless effort, the thing I think I am proudest of 
is we have connected from our level, the national level, down 
through the network directors, down through our medical 
centers, and out into the communities, touching all of the 
providers and nonprofit organizations that work with the 
homeless to create this collaboration that you are talking 
about. And it has begun to show results. So I could not agree 
with you more.
    Mr. Bilirakis. The gentleman from Minnesota, my good friend 
Mr. Walz. You are recognized.
    Mr. Walz. Well thank you, Mr. Chairman. And Mr. Secretary, 
thank you and your staff for being here today. This room with 
you being at the point of it understands care of our warriors 
is our top priority, whatever it takes. And I have said it many 
times, I will continue to say it. I am your staunchest 
supporter and I can be your harshest critic as we ask. And so 
when the IG reports come out we value their input to this. But 
I want to, I want to make several things clear. I want to thank 
the Chairman for holding this. I would like to ask him, and 
hopefully right now let us schedule the follow-up for this 
because you will want us to see what happens in six months and 
things down the line. But the Chairman is not here, but I would 
make mention. I was going to ask him. I think his comments in 
his opening statement that this is an example of government 
bureaucracy gone wrong, if only it were that simple. We could 
handle that, I think, even though a tough one there.
    This issue is far broader than that. This issue of mental 
health parity and mental health care is absolutely fundamental, 
one of the issues this country needs to face. And less than two 
weeks ago Senator Domenici, former Senator Domenici had an op 
ed in the Washington Post where he stated, ``mental health 
insurance plans still refuse to cover lifesaving mental health 
treatment. Others create discriminatory barriers to care, such 
as imposing stricter prior authorization requirements for 
mental health care. And sadly, underscored in a recent report 
by Assistant Secretary for Planning and Evaluation at Health 
and Human Services levels of care for evidence based behavioral 
treatment such as residential psychiatric services are being 
eliminated because of uncertainty of what is required.''
    This is an issue of mental health parity and much broader. 
Senator Domenici spent a career on this, Senator Wellstone did 
so also. So I take this, that we do have to come together. It 
was echoed by Ms. Buerkle. It was echoed here. And I think you 
have talked about leading this, that this is a collaborative 
effort. This is our opportunity to create the model. There is 
no private sector model to go grab to fix the problem on this. 
Mayo Clinic's CEO met with me last week about trying to see if 
I can help foster collaboration on telehealth with the VA 
because we know that that is Mayo's model that they are moving 
to with the lessons that were learned.
    So this is a much broader issue. This is an issue where we 
are going to have to, as Ms. Buerkle said, work together to 
find solutions because volume numbers do not matter, good 
intentions do not matter, outcomes matter. And we as a Nation 
are going to have to address this. So I am certainly not going 
to be an apologist for if there is care not being delivered 
appropriate, timely, and effective to our veterans. That is 
where I will be that harsh critic. But I think we need to look 
at this in the macro sense of what you are saying, how we are 
going to get there. How we talk about those use of resources.
    And I want to be clear, the past is prologue on these. When 
these conflicts started, we were told it would be weeks not 
months. And if I recall there were a couple of voices at least 
telling us to look longer, that there would be issues here. So 
we as a Congress have a responsibility to get this. It is not 
as easy as just saying that the entire system failed and if you 
just farmed it out it would work its way right. I would lay in 
front of this Committee if the IG did a mental health care 
inspection of any major health care facility or institution in 
this country you would come up with results that would not get 
to this. So we have to figure this out.
    So I guess my question is, of listening to you and hearing 
you lay this out and where things are going, how do we 
accelerate the ability to move this forward? How do we recreate 
this model that you have heard all of my colleagues talk about 
to try and get to that place? Are we moving in the right 
direction? I know Dr. Petzel talked about it, talked about 
those measures. The public is going to pick up on when care was 
not delivered immediately, when the scheduling was an issue, 
when anything else came. But how do we build that together? And 
I will, the Chairman is back so he can defend himself as I was 
going after that. But please, Secretary?
    Secretary Shinseki. Congressman, I would tell you as I said 
in my opening statement, based on what I know of what we have 
put our youngsters through for the last ten years, and based on 
my own recollection of what coming home from combat is like, 
this has my highest priority. And I am going to drive this 
hard. You know, we set a priority on homelessness and we got 
that ball moving. And we will bring this one along as well.
    Mr. Walz. Do you think we are getting there? And I think, I 
hear what Ms. Buerkle is saying because my constituents are 
telling me that too. They want more options. They want more 
choices. We are probably providing more than anything. This is 
going to come down to a question that is a fair question for us 
as both the watchdogs of the care of our veterans as well as 
the tax dollars, I too wonder if you have the resources. I do 
not know where you are going to put all these people, those 
1,500. I am concerned. Do you have what you need to do the job? 
Is this a matter of now implementation and follow through?
    Secretary Shinseki. Right now that is the assessment that 
is underway, Congressman. And as soon as I have an answer if I 
am in need of assistance we will come and talk.
    Mr. Walz. Well, I thank you. I yield back, Mr. Chairman.
    The Chairman. Thank you. Mr. Bilirakis, you are now 
recognized.
    Mr. Bilirakis. Thank you, Mr. Chairman. Thank you, General. 
I appreciate your service and I think you are doing a great job 
as our Secretary. I really appreciate it very much on behalf of 
our veterans. How will the 1,900 new VA mental health employees 
be allocated amongst facilities?
    Secretary Shinseki. Let me call on Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary. Congressman 
Bilirakis, we have a tentative distribution to the networks. We 
are now negotiating with discussing with the networks the 
actual distribution to each one of the facilities. And I had 
mentioned earlier in testimony that we hope to know the 
allocations to individual medical centers within about a couple 
of weeks.
    Mr. Bilirakis. Okay, thank you very much. I want to follow 
up on Ms. Brown's testimony and questions with regard to 
telemedicine. I have spoken to many in my district, both health 
care providers and veterans, and have learned that stigma and 
individual will are significant barriers for servicemembers and 
veterans to seek out mental health services. Can you elaborate? 
You mentioned briefly on the telehealth services in your 
testimony and you answered Ms. Brown's questions. The 
availability is very important. How are veterans informed that 
such services are available to them? How can they gain the 
access? In your opinion, will this reduce the stigma associated 
with mental health services, because that is important. And 
also, how effective are these services?
    Secretary Shinseki. Dr. Petzel?
    Dr. Petzel. Congressman Bilirakis, you make an excellent 
point about stigma. And the VA is involved in a nationwide 
campaign to help reduce the stigma that is associated with 
seeking care for mental health. Two of the things that we are 
doing I think are significant. One is that we are providing 
mental health services now in the primary care clinics. So that 
a patient does not have to go into a special clinic that has 
got a sign saying ``Mental Health'' on the top of the door and 
be identified as somebody going into a mental health clinic. 
They get this care as a part of their primary care. Which I 
think is very reassuring, if you will, to those patients. 
Number two----
    Mr. Bilirakis. Do they choose these types of services?
    Dr. Petzel. We provide it, we offer it----
    Mr. Bilirakis. --voluntarily to do the telemedicine as 
opposed to the face to face appointments?
    Dr. Petzel. There is some choice associated. I just want to 
mention, telemedicine is the same way.
    Mr. Bilirakis. Yes.
    Dr. Petzel. It is done in the clinic and it is not 
associated with walking into a particular mental health clinic. 
In some cases there is a choice. When it is available, it is 
offered. I can tell you that. Most people pick up on it, but 
not everybody.
    Mr. Bilirakis. Thank you very much. Again, you know, we do 
not really want this to be utilized in lieu of face to face. 
But if we can have the telehealth appointments I think that is 
very, very important that they get the care they need 
immediately rather than waiting. Do you want to comment on 
that?
    Dr. Petzel. Oh, I absolutely agree with you. I will just 
give you, my personal opinion is that in terms of mental health 
ten years from now 40 percent or 50 percent of the encounters 
that you see in mental health are going to be done by a 
telemental health, I think. Not, I do not mean just in this 
system, but I mean across the country. And I think when you, 
when you talk about general consultations here is what I think 
is going to happen. You are going to have a primary care doctor 
who is going to see a patient, and he is going to say, ``You 
need a cardiology consult.'' They are going to dial up on their 
webcams the cardiologist and that consultation is going to 
begin right then, whether it is 200 miles away or two floors 
away. It is definitely the wave of the future.
    Mr. Bilirakis. Have VA looked into partnering with private 
telemedicine mental health providers? You are doing that 
currently. I believe there is a pilot program. But do you plan 
to expand that?
    Dr. Petzel. Well Congressman I am not aware that we are 
piloting, we have a pilot going or any interactions going with 
other telemental health providers.
    Mr. Bilirakis. Maybe the Department of Defense?
    Dr. Petzel. With Defense, yes.
    Mr. Bilirakis. Okay.
    Dr. Petzel. And the PTSD telemental health program I 
mentioned with you before is actually with the University of 
Colorado, a non-VA provider. So there are some examples of 
that. And we would certainly encourage doing that where we can.
    Mr. Bilirakis. Okay, very good. Thank you very much. I 
yield back, Mr. Chairman.
    The Chairman. Mr. Carnahan?
    Mr. Carnahan. Thank you, Mr. Chairman. And to our Ranking 
Member for holding this today. And for Mr. Secretary and your 
team for being here, and thank you for the work you do that 
oftentimes is difficult and sometimes may seem thankless. So I 
want to start with a thank you. And I want to really talk 
about, we have covered a lot of the issues that came out in the 
report today. But I really wanted to talk about two particular 
veterans and their stories and what, how that fits with the 
reforms that you are trying to make.
    I saw a young new generation veteran in the last few weeks 
when I was back home in St. Louis. He knew he had mental 
issues. He had gone to the VA. He wanted to get well. And 
doctors there prescribed him medicine, but he could not get 
into see counselors. He was not getting that follow up, human 
interaction that he needed. And so he had to go elsewhere, out 
of his own pocket. Again, just out of his own willingness to 
get what he needed. But whether it was capacity, or delays, or 
whatever he was not, you know, the VA was not serving that 
veteran. And so my first question about this veteran is how is 
this additional capacity that you have planned you think going 
to help with those kind of delays for that veteran and veterans 
like him?
    Secretary Shinseki. Let me call on Dr. Petzel and then I 
will close.
    Dr. Petzel. Thank you, Mr. Secretary and Congressman 
Carnahan. First of all, we would like to find out about that 
particular individual veteran so we can contact him and get him 
or her into the right kind of care with the VA. The issue that 
the increased staffing primarily is directed at addressing is 
this next level. As you pointed out, this patient came in, was 
seen, and began some treatment. And I am assuming from what you 
say that his treating physician felt he needed individual 
therapy and that was not available, at least in a timely 
fashion. And these people are intended to address that specific 
issue. So that we do have those services available in a timely 
fashion. So there is not an excessive wait. So that patients 
when they need to be seen can and will be seen.
    Mr. Carnahan. Mr. Secretary?
    Secretary Shinseki. I would just add part of this is also 
this scheduling issue that we are wrestling with. And so we 
have increased the staffing to shore up what we think are 
requirements. We also need to see where the capacity is that is 
not being used and make sure that we are maximizing all of what 
is out there, even as we bring on the 1,900.
    I just mention I think that mental health is a large issue 
for us and this country. CDC, and it is, you know, one of those 
issues that is difficult to talk about. CDC has released ten-
year studies that show suicide amongst Americans, the top ten 
causes of death in this country, suicide figures very 
prominently in it. So it is an issue out there. And then when 
you subject youngsters to the stress of combat repeatedly, we 
have work to do here. Between ages 15 and 24 suicides, 15 and 
25 suicides are number three cause of death amongst Americans.
    Mr. Carnahan. Thank you, Mr. Secretary. That really is an 
important segue into the other issue I wanted to raise. Another 
issue, time is so important in how we address these issues. On 
the front end when treatment is going on, but the other time 
factor that we encountered, we had a Vietnam veteran that 
served on my local veterans advisory Committee. Had been a 
great advocate for veterans mental health for years, took his 
own life. And, you know, he is somebody that again just was not 
getting what he needed. And some veterans I think we are 
missing because of this time factor of having to get into the 
system within five years from discharge or release. And that we 
also need to look at that because, again, for the doctors here 
we do not always catch that in that initial five-year period. 
And I would like to ask your comment about that. And I have 
also worked with several other members on legislation that 
would remove that five-year limit so again we are not missing 
those kind of veterans. I would like your comment about that?
    Secretary Shinseki. Well obviously we are having a 
discussion here. I think I agree with, you know, the idea here 
that sometimes PTSD shows up later than this five-year policy. 
I do not have enough data here to be able to say that it is a, 
how broadly this happens. But I do know that PTSD and perhaps 
other mental health issues do not follow the usual clock. That 
they may show up later, but I just do not know how broad a, you 
know, an issue that is. And I am happy to try to do some 
research, and provide you a better answer.
    Mr. Carnahan. Yeah, if you all have additional information. 
Any others that want to, can address that issue in particular?
    Secretary Shinseki. Dr. Jessee?
    Dr. Jessee. So we have mentioned outreach a few times here. 
And I just would like to take a second to talk to the extent 
that we are doing that. We, you know, public campaigns are all 
well and good but sometimes people who need help do not know 
they need help, and they have to be brought along. We are 
working very closely with our chaplains, for instance, with the 
Guard chaplains. But most, even more so they are working with 
lay chaplains to teach them about the very subtle signs that 
their returned hero is struggling. And in many rural areas that 
is the only mental health provider really, are the churches.
    We do that in order that they know how to get people 
referred into our system. The Vet Center was a brilliant 
program established several years ago just to bridge a trust 
gap but to provide readjustment counseling. Because in many 
cases that is what people really need. But they are very well 
trained to identify the higher risk people and get them into 
the system.
    And the one other thing I just want to be very plain about 
is mental health issues, like heart attacks, so I am a 
cardiologist, I can always refer it back to that, you know the 
first thing you have got to do is make sure people are safe. 
And I think we do that very well. We see people very quickly. 
We have staffed up our emergency departments with very strict 
criteria about the mental health capabilities in the EDs 
because that is where people, that is the door to the hospital 
that is open 24/7. And we have to make safe and secure. And the 
one thing in the IG report is this first 24--hour evaluation 
and we do that well. So the safety piece I think is front and 
foremost. But outreach also means bringing people in. And as 
you say often it may take a lot longer time for them to come to 
grips with the fact that they have got a problem. The more we 
can work with them coming home the better we will be at that.
    Mr. Carnahan. Well again, thank you. And thank you, Mr. 
Chairman. And I look forward to working with you all on that 
issue of that five-year limiting period to see really what the 
magnitude of that issue is in terms of who we are missing. 
Thank you.
    The Chairman. Mr. Turner?
    Mr. Turner. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary. Many mental health problems are accelerated and 
exacerbated through drug and alcohol abuse. Are you making use 
of any of the NGOs, particularly AA and NA, incorporated into 
these programs to kind of address the problem of drug and 
alcohol abuse?
    Secretary Shinseki. There is certainly some tangentiation 
here between some of the mental health issues and also, you 
know, self-medication if you will. Let me call on the experts 
to be able to address this.
    Ms. Schohn. In our drug and alcohol programs referral and 
use of AA and NA or other self-help groups for issues is often 
a critical component of it. So the VA recognizes that it is not 
just the VA itself that really has to be working to address 
these issues but that we do need to partner with community 
resources, particularly for times when a veteran is not in 
treatment and when he goes home and needs resources in the 
community. So it is a critical component of the care. And I 
will turn to Dr. Zeiss to add more.
    Ms. Zeiss. Or one additional thought. We do work very 
closely with the Office of the National Drug Control Policy. 
And they have actually stressed that VA's substance use care is 
a model in terms of how it is integrated with mental health 
care and how we partner with nongovernment agencies, but also 
provide that integration with care in VA. And we certainly work 
with them, the ONDCP, on their yearly national policies and 
strategic goals. So we definitely are trying to partner on this 
issue as on others.
    Secretary Shinseki. Congressman, if I would. I am the non-
clinician at this table. My other concern is do we overmedicate 
and create some of the problems? I do not know the answer to 
that, but I get paid to ask the questions and get assured that 
we have good controls and good balance so we are not creating 
on our own the kinds of issues that you are referring to here.
    Mr. Turner. All right. Thank you, Mr. Secretary. I yield 
back.
    The Chairman. One quick comment. I would hope that 
organizations that have a faith-based component are not 
squeezed out of the process. The fear that I have, and not just 
at VA but also within DoD and other Federal agencies, is that 
we do not allow these organizations to participate because they 
do have that component. I do not think at all that is anybody's 
intent at that table, but just to comment.
    Secretary Shinseki. Fair enough. I will go take a look at 
it, Mr. Chairman.
    The Chairman. Mr. Stearns?
    Mr. Stearns. Mr. Chairman, thank you very much. And Mr. 
Secretary, thank you very much for serving and for all you are 
doing under some difficult situations, obviously. I have got 
before me some audits of the VA Health Administration 
outpatient waiting times. And I have got another one dealing 
with outpatient scheduling procedures. And when you look at 
those I guess you wonder, you announced on April 19 of this 
year that you are going to hire 1,900 new mental health staff, 
is that correct?
    Secretary Shinseki. That is correct.
    Mr. Stearns. And I guess the question is based upon these 
audits of the VA Health Administration how can you assure, I 
guess, to the Committee that these new employees, the 1,900 new 
employees, and perhaps even the current employees, are going to 
receive the proper training considering I guess these audits 
have indicated otherwise? And this goes back to 2003. So from 
2003, 2004, 2005, 2006, 2007, on up they are saying that they 
have not got the training. So I guess the question is the 
Committee just wants to have an understanding that the new 
1,900 are going to get the proper training? Is that legitimate, 
Dr. Petzel?
    Dr. Petzel. I will make an opening comment and then I think 
I will turn to the two mental health experts. There will be a 
period of orientation for anybody that is new to the VA, 
whether it is a licensed counselor, a pastoral counselor, a 
psychologist, a psychiatric social worker, a nurse mental 
health clinician, or a psychiatrist, they will all have an 
orientation to VA. An orientation to our approach to the 
treatment of the various kinds of disorders that we might see 
in our patients. So with that I would ask briefly just describe 
what happen?
    Mr. Stearns. Maybe the question is for your experts, are 
they aware of these audits, and what the audits have said about 
outpatient waiting times and outpatient scheduling procedures? 
How----
    Dr. Petzel. Let me ask Congressman Stearns, are you, is 
that the audit that addresses the scheduling clerks?
    Mr. Stearns. Yes, that is one of them. Yeah.
    Dr. Petzel. The scheduling clerks, sir, do undergo annual 
training and annual certification to demonstrate that they 
understand the scheduling procedures. But as we have said 
earlier we have a task force that is looking at the way we do 
scheduling in mental health as well as in every other area to 
try and simplify and clarify the scheduling task so that we can 
do a better job of saying how long someone is waiting to get an 
appointment, how long it takes for them to get an appointment. 
We agree with the IG in a general sense in terms of the 
recommendation, and that is that we have to find a better way 
of measuring the scheduling time. So yes.
    Mr. Stearns. Okay. You know, when I looked at some of the 
definitions here I think the VA has claimed about a 95 percent 
success rate in seeing veterans within 14 days. However, I 
guess a IG report this year indicated that the VA has been 
measuring when they see the veteran to conclusion not when and 
how long from their request, which averages about a 50 days 
wait. Does that seem logical? Is that a fair explanation? That 
the IG report does not agree with your 95 percent success rate 
in seeing veterans within 14 days?
    Dr. Petzel. That----
    Mr. Stearns. Do you disagree with the IG?
    Dr. Petzel. That, Congressman, is an appropriate 
conclusion, that they did not agree with our 95 percent. That 
is correct.
    Mr. Stearns. So do you agree with what they said, that it 
is an average of 50 days wait? Do you agree with what they say?
    Dr. Petzel. There is some discussion with the IG, 
Congressman, about the way they measured versus the way that we 
measured. And while we----
    Mr. Stearns. Do you think they are wrong?
    Dr. Petzel. Sir, while we agree with their recommendation 
that we need to have a better system of scheduling so that we 
can measure the wait times, do not necessarily agree with the 
fact that only 49 percent of the people were seen in a 
particular period of time.
    Mr. Stearns. Okay. You mentioned earlier that the model 
used to measure wait times came from the previous model from 
the VA. What in the previous model has kept and what was 
changed or improved? I guess maybe a better understand of what, 
have you changed the model? Or have you used the model complete 
from the previous ways you have done this for the wait time?
    Dr. Petzel. Congressman Stearns, in----
    Mr. Stearns. It seems that the IG and you are having a 
little trouble understanding these procedures. So I am just 
trying to understand what model you are using.
    Dr. Petzel. The, Congressman we changed our method of 
measuring wait times to desired date. I explained this earlier 
in the hearing.
    Mr. Stearns. Okay.
    Dr. Petzel. Desired date back in 2007.
    Mr. Stearns. Yeah.
    Dr. Petzel. And there is another way to do this called 
create date.
    Mr. Stearns. Yes.
    Dr. Petzel. And the discussion with the IG is around the 
appropriateness of using desired date or create date. And our 
intention is after our task force comes to an agreement about 
what we need to do in the future to work with the IG so that we 
agree about the way to measure waiting times.
    Mr. Stearns. Okay. Mr. Chairman, it looks like we have got 
the difference between desire date and a create date. Is that 
not what you are saying? That there is a difference between you 
and the IG in those areas? Is that----
    Secretary Shinseki. There is a third measure called 
capacity, I believe.
    Mr. Stearns. Okay. So between those, the capacity date, the 
create date, and the desired date, that is differentiation, the 
IG is not completely in agreement with you? Is that a fair 
statement or am I missing something?
    Dr. Petzel. I think that is a fair statement, correct.
    Mr. Stearns. Okay. Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Stearns. Ms. Brown, closing 
comments?
    Ms. Brown. Thank you. Thank you, Mr. Chairman, and thank 
you for holding this meeting. And thank you Mr. Secretary for 
coming and bringing all of your people that is involved in the 
area of mental health. There are just a couple of points that I 
want to make. I want to first of all thank the President and 
the First Lady for their initiative including the entire 
family. And I hope as we develop mental health programs that we 
realize that it is not just the person in the military but it 
is the entire family that is involved, and making sure that we 
include it and make it inclusive of the entire family, the 
sessions, the programs, as we move forward. Because that 
person, that spouse, or that mother, whoever is with that 
person, knows that that person needs assistance even if that 
person that needs the assistance do not know it. So let us make 
sure we have some way to evaluate and include the family.
    Secondly, we need to make sure we are evaluating that 
provider. Because the person that had a complete breakdown at 
Fort Hood was someone that was working for the government and 
was working in the area of mental health. So we need to have 
some checks and balances working with that person, obviously 
under stress, you know, doing the counseling, doing the 
advising. And so we need to make sure we include that.
    And I want to once again thank all of the professional 
people that we have working with us. And just mention that the 
Chairman asked me to have a round table kind of hearing next 
Monday, May 14 and 15 down in Orlando about the Orlando 
facilities and meeting with the contractors and the VA to 
discuss how we can be online and changing the subject, but 
making sure that my hospital is one that will come in for our 
veterans that we have been waiting on for 25 years efficient, 
cost effective, and ready to operate as soon as it opens up, 
Mr. Secretary.
    Secretary Shinseki. I hear you, Congresswoman.
    Ms. Brown. Thank you, Mr. Secretary. And with that I will 
yield back the balance of my time.
    The Chairman. I think the lingering question in today's 
hearing from the department's perspective is if you have a 
vacancy rate of 1,500 individuals, and you are talking about 
hiring an additional 1,900, 3,400 new hires, how in the world 
are you going to accomplish that in a timely fashion in order 
to provide mental health care to the veterans who need it 
today? I do not know if you want to take that for the record, 
or if you want to respond. I do not think anybody at this 
Committee believes that you can quickly hire 3,400 plus people.
    Secretary Shinseki. Fair enough. And I would like to take 
that for the record. But Mr. Chairman, if you think that we can 
achieve a zero turbulence turnover rate, you know, it is not 
going to happen. We will always have a working set of numbers 
because we do not require people to give us warning two years 
out that they are going to make a change decision, you know, in 
their lives. Sometimes we get it in about 30 days.
    The Chairman. But even if you use the rate, though, that 
Ms. Spiczak quoted earlier of 7.5 percent, or even double it. 
Say 15 percent, even if you have a 15 percent vacancy rate you 
are talking about a tremendous lift. Not that the veterans do 
not need those people out there, but the department has been 
unable to fill 1,500 slots. Now you are putting 1,900 plus on 
top. And if you would I look forward to your----
    Secretary Shinseki. Fair enough. Let me provide that for 
the record. But I would say most large organizations, 7 percent 
turnover is not unexpected.
    The Chairman. But I would say that you have got higher than 
7 percent at this point. If I would, also, before you leave, 
Mr. Secretary, I want to ask that you work to provide the 
Committee with a couple of things that we have requested. And I 
would go ahead and outline them for you. On 29 November of 2011 
we requested information on VA's SES bonus review. And after 
repeated follow ups with the Congressional Affairs Office I 
still await an answer for that.
    On the 19th of April of this year we asked for information 
regarding VA facility activations. To date after again repeated 
inquiries there have been no information provided to us.
    And then VA provided the Committee a delivery date of today 
for the Committee's post-hearing questions in connection with 
the February, the February budget hearing. And just a reminder, 
we continue to await those responses. I have got a couple other 
outstanding requests that the Committee staff will get to 
yours. But I ask a renewed effort from VA and a timely response 
to our Committee requests. I know that you are responding to 
our requests, as well as the Senate as well. But I would ask 
that you look into these and the others that we provide. And I 
thank you for providing the Committee your personal testimony 
today, Mr. Secretary. I appreciate you being here. And with 
that the first panel is excused. Thank you.
    Secretary Shinseki. Thank you, Mr. Chairman, and the 
Committee for your courtesies and generosity. Thanks.
    The Chairman. I will go ahead and call the second panel 
forward if we could. I apologize for the confusion. But joining 
us as the new second panel, because we did separate them from 
Secretary Shinseki's panel, Dr. John Daigh, the Assistant 
Inspector General for Healthcare Inspections; and Linda 
Halliday, the Assistant Inspector General for Audits and 
Evaluations. Thank you both for agreeing to speak with the 
Committee this morning. And you are recognized for your opening 
comments.

  STATEMENTS OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR 
    GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR 
  GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND LINDA A. 
     HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR AUDITS AND 
 EVALUATIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT 
                      OF VETERANS AFFAIRS

                STATEMENT OF JOHN D. DAIGH, JR.

    Dr. Daigh. Thank you, Mr. Chairman, Ranking Member, members 
of the Committee. It is an honor to be able to testify before 
you here today. I and my staff from the Office of Healthcare 
Inspections address current clinical issues in VA on a daily 
basis and I do believe that the leadership and employees at VA 
strive hard to provide the highest quality medical care 
possible. I also do believe that VA provides veterans with high 
quality medical care, to include mental health care.
    The report that we published focused on access to care 
standards, which I think need a great deal of work as our 
report outlined. VA, though, however, is a leader in quality of 
care standards and has done a great deal of work in that area.
    Listening to the comments made earlier, I would like to 
make a couple of comments. The first would be I think that the 
IG has worked for a long time, over five or six years at least, 
to get VA to develop what I would call staffing standards in 
order to be able to answer the question of how many people do 
you need to do any one particular job? Be it nurse staffing 
standards, or medical specialist staffing standards. So I think 
that VA needs to focus on its business practices in order to 
have the relevant data available to address the need and timing 
of hiring 1,900 people as they have indicated that they plan to 
do.
    I would also be remiss if I did not indicate that there 
have been several software projects which have not been 
successfully concluded over the last period of years. One would 
be the scheduling effort, which was not successful several 
years ago and which I think VA does need a better scheduling 
platform. And the other two would be the Core FLS platform and 
Flight, both of which were financial systems which would allow 
the gentlemen in the first panel to have I think more accurate 
data on productivity and related issues that would allow them 
to make a better business case for the changes they think are 
required.
    With that I will end my testimony and invite Ms. Halliday 
to comment.

    [The prepared statement of John D. Daigh, Jr. appears in 
the Appendix]

                 STATEMENT OF LINDA A. HALLIDAY

    Ms. Halliday. Chairman Miller and members of the Committee, 
thank you for the opportunity to discuss the results of our 
recent report on veterans access to mental health services at 
VA facilities. We conducted the review at the request of the 
Senate and House Veterans' Affairs Committee and the VA 
Secretary. Today I will discuss our efforts to determine how 
accurately the VHA records wait times for mental health 
services for both new and established patient appointments. I 
am accompanied by Mr. Larry Reinkemeyer, our Director of our 
Kansas City Office of Audits.
    Our review found that inaccuracies in some of the data 
sources and inconsistent scheduling practices clearly 
diminishes the usability of information needed to fully assess 
current capacity, resource distribution, and productivity 
across the system. In VA's fiscal year 2011 performance and 
accountability report VHA reported 95 percent of first time 
patients received a full mental health evaluation within 14 
days. However, we concluded that the 14-day reported measure 
has no real value as an access to care measure because VHA 
measured how long it took to conduct the mental health 
evaluation, not how long the patient waited for the evaluation. 
Using the same data that VHA used to calculate 95 percent 
success rate shown in the PAR report, we calculated the number 
of days between the first time patient's initial contact in 
mental health and completion of their evaluation. We projected 
VHA provided only 49 percent, or approximately 184,000 of the 
evaluations, within 14 days of either the veteran's request or 
a referral from mental health care. On average it took VHA 
about 50 days to provide the remaining patients their full 
evaluation.
    Once VHA provides the patient with their evaluation VHA 
then schedules the patient for an appointment to begin 
treatment. In fiscal year 2011 we determined that VHA completed 
approximately 168,000, or 64 percent, new patient appointments 
for treatment within 14 days of their desired date. Thus, 
approximately 94,000 or 36 percent appointments nationwide 
exceeded 14 days. In comparison VHA's data showed that 95 
percent received timely care.
    We also projected that VHA completed approximately 8.8 
million, or 88 percent, of the follow up appointments for 
treatment within 14 days of the desired date. Thus, 
approximately 1.2 million, or 12 percent appointments, exceeded 
14 days nationwide. In comparison, VHA reported 98 percent 
received timely care for treatment. We based our analysis on 
dates documented in VHA's own medical records. However, we have 
concerns regarding the integrity of the date information 
because providers told us they use the desired date of care 
based on their schedule availability. This is in direct 
conflict with the VHA directive. VHA should not use that, the 
date the patient requests.
    I want to point out that we reported concerns with VHA's 
calculated wait time data in earlier audits of outpatient 
scheduling procedures in 2005, again outpatient wait times in 
2007. During both audits we found schedulers were entering 
incorrect desired dates. And our current review shows these 
practices continue. For new patients the schedulers frequently 
stated they used the next available appointment slot as their 
desired appointment date for new patients. This practice 
greatly distorts the actual waiting time for patients. To 
illustrate, VHA's data showed 81 percent, or approximately 
211,000 new patients, received their appointments on the 
desired date of care. We found veterans could have still waited 
two to three months for an appointment and VHA's data would 
show a zero wait time.
    Based on discussions with medical center staff and our 
review of the data, we contend it is not plausible to have that 
many appointments scheduled on that exact day the patient 
desired. In conclusion, VHA needs a reliable set of performance 
measures and consistent scheduling practices to accurately 
determine whether they are providing patients timely access to 
mental health services. And they need to ensure the desired 
date of care is defined by the patient without regard to 
schedule capacity. That would be true as to whether they use 
the create date or the desired date of care.

    Mr. Chairman, I would be happy to answer any questions.
    The Chairman. Thank you very much for your report and your 
testimony. You have talked about the string of IG reports 
finding serious deficiencies and inaccuracies within the 
appointment scheduling and the performance measures that VA 
uses. Since you have begun your investigations and found fault 
with their scheduling processes and procedures, I think the 
Committee would like to know has it gotten better. Or has it 
gotten worse? Because we have spent hundreds of millions of 
dollars in the process. What have you seen?
    Ms. Halliday. We went to four sites as part of this review. 
At three of the four sites, we found schedulers were not 
following VHA's own directives. That is a pretty compelling 
number, 75 percent. I cannot say it is getting better. I think 
that we were surprised at the delta that we saw between the 95 
percent that VHA had said they had provided timely care for 
veterans and the 49 percent that we saw for the new patients, 
and then again, the difference with the follow on appointments. 
So I cannot say it is really getting better.
    The Chairman. You may or may not be able to answer this 
question. But is it better for the veteran to accept a 
scheduling date that fits an open slot at VA? Or is it better 
for the veteran to get the care and the appointment when they 
need the care?
    Ms. Halliday. I am going to let David Daigh respond.
    Dr. Daigh. I think we would all agree it is better to get 
the care when they need to get the care.
    The Chairman. And is it your testimony just a second ago 
that that is actually not what you found they were doing? That 
they were actually filling open slots, but not necessarily when 
the veteran needed the care?
    Ms. Halliday. That is correct.
    The Chairman. Thank you. Ms. Brown?
    Ms. Brown. I guess I am concerned. Are you saying that the 
veterans, because they indicated, I guess you heard the 
testimony with the number of, did you test any of their 
stakeholders or partners that they was working with? Or you 
just did the VA?
    Ms. Halliday. We looked at the VA information to examine 
whether there was data integrity behind it. So we concentrated 
on the 10 million appointments for new patients and established 
patients. And those appointments, because they include follow 
up, really represented about 1.3 million unique veterans 
needing care.
    Ms. Brown. And your findings, would you expand on that a 
little bit? Because you said you went to four facilities.
    Ms. Halliday. We looked at scheduling procedures four 
facilities. What was the time it took to evaluate new patients 
getting care after the point of the first triage. We did feel 
VA did a good job when a patient made their first contact, 
saying they needed mental health services and there is a 
triage. And then from there they conduct a mental health 
evaluation. Based on what VA was reporting you would say that 
the majority of evaluations were accomplished in 14 days or 
less. We did not see that. And we also saw a very high number 
of patients that waited zero wait days. And it was basically 
because of the way the schedulers were inputting the 
information. What we are saying there, is that we did not think 
that information was plausible.
    Ms. Brown. Okay. And what are some of the recommendations 
that you all made?
    Ms. Halliday. We offered three recommendations in the 
report. To ensure a full mental health measurement is 
calculated from the veteran's initial contact with the clinic 
or the veteran's referral from mental health, we want VA to put 
in place an access to care measure that measured the time a 
veteran waits for that care.
    Ms. Brown. On that point, what was mentioned earlier was 
that the veterans do not always come directly to the VA. They 
may be coming through an emergency room, or some other 
resource. Were you able to measure that? In other words, 
basically they are not walking into the VA and saying, ``I need 
mental health services.'' Or calling. They are getting referred 
through other means. So did we compared that wait time?
    Ms. Halliday. No. We compared the point of when the veteran 
makes the contact, or there was a referral from a mental health 
provider that the veteran needed care. We do recognize that 
veterans seek care and come through different avenues in VA. 
But I think that our information, as I said before, was based 
on 10 million appointments nationwide and 1.3 million unique 
veterans seeking care. So it is a pretty good representation of 
what is happening in VA at this point.
    Ms. Brown. And you gave one recommendation. What were the 
other two?
    Ms. Halliday. The second was to reevaluate the mental 
health performance measures that could more accurately reflect 
the patient experience. As both Dr. Daigh and myself have said, 
VA needs a new set of performance metrics to measure to really 
know how long veterans are waiting for appointments. And then 
the third was to conduct a staffing analysis to determine if 
vacancies represent a systemic issue impeding VHA's ability to 
meet timeliness goals and if so to implement corrective action 
plans. This had been discussed well in advance of our report 
with the senior people in VHA. So, you know, it seemed logical 
to move forward on that. We believe based on what we heard at 
the sites that the vacancies for psychiatrists and mental 
health professionals were impeding the ability to provide all 
the services needed.
    Ms. Brown. I guess my last comments, but I guess you all 
did not do any evaluation on it, because I personally do not 
necessarily think that all of the services have to be in VA. VA 
could work with some of the other stakeholders. People in our 
community are providing mental health services every single 
day. They are just not getting reimbursements for it. And is 
there any way that we can measure the quality of some of these 
providers? Because the problem is that I do not necessarily 
think that we need to hire millions of psychiatrists because 
they do not even exist. But there are many levels of mental 
health professionals that could work in partnership with the VA 
and the VA making sure we have a certain standard of service, 
and working in conjunction with other stakeholders. I guess 
this is the only time I have ever supported outsourcing to some 
degree. Whew!
    Dr. Daigh. Ms. Brown, I think I would agree very much with 
you. If you take a look at the number of psychiatrists VA has 
on board, between last year and this year it actually went 
down. Over the last years, last four years, when they got a 
bonus of money they increased it by 600. So I think it will be 
difficult for them to hire new psychiatrists at any significant 
level.
    Ms. Brown. But you see, I do not necessarily think 
psychiatrists that, you are at a different level.
    Dr. Daigh. Right.
    Ms. Brown. I do not necessarily think everybody needs a 
psychiatrist.
    Dr. Daigh. Right, I----
    Ms. Brown. --they need, you know, it is the whole list of 
different kinds of services people need. When I said, when I 
went out to LA and saw the telemedicine, I was surprised that 
the veterans really like it. I would not like it at all. But 
they was very pleased with the services. But they are a 
different generation. I am old school. And the new school like 
the telehealth.
    Dr. Daigh. And we did a report a couple of years ago on 
access to mental health care in Montana. And in Montana VA had 
actually used the community mental health centers and linked up 
with them. And we showed where that made a dramatic impact on 
their access to usually not psychiatrist but the staff at the 
community mental health center. We found there thought that 
substance abuse treatment, however, was difficult to hire at 
that level. And so I think we would agree very strongly that 
there are not the resources for VA to hire as, or I am doubtful 
that they will be able to hire them as they say they will. And 
we think there are sources that they should look at within the 
community of non-VA providers.
    Another source of providers would be how their own 
employees spend their time. So VA has several missions. One 
mission is patient care. One mission is research. One mission 
is training. There are several others. A physician can allocate 
their time between several different missions. So if the 
priority mission, which it is not currently stated as the 
priority mission, were patient care then one might align their 
time more with the primary mission. The FTE data are often FTE 
allocated to patient care, not the total on the employment 
roll.
    The second area they might look at is VA has wonderful 
arrangements with academic medical centers.
    Ms. Brown. Yes.
    Dr. Daigh. All of whom have significant psychiatric staff. 
So there might be some room to, you know, to get some benefit 
there. And then the third would be outsourcing as you described 
with community mental health centers and other areas like that 
that I think would be useful.
    Ms. Brown. Or working with the universities. I mean, we 
partner with them in many different areas. But I will yield 
back my time and maybe I can get additional time to ask 
additional questions.
    The Chairman. Mr. Stearns?
    Mr. Stearns. Thank you, Mr. Chairman. You heard earlier 
that the VA was talking about the three ways they define this 
waiting time. The capacity date, the desired date, and the 
create date. When you did your report in which you said, ``our 
analysis projected that the VA provided only 49 percent, or 
approximately 184,000, of their evaluations within 14 days. On 
average for the remaining patients it took the VA about 50 days 
to provide them with their full evaluations.'' Were you using 
the create date as a model? Would that be a fair statement? Or 
is, are you using a different definition than the VA is using?
    Ms. Halliday. At the time we did the review we looked at 
the desired date. VHA's policy says the desired date should not 
be the date of clinic availability, it should be the date the 
patient requests or has a medical referral. The create date was 
used years ago and there were problems with that at that time. 
VA is now proposing to bring the create date back and use it 
again to rely on as a performance metric. I think if they 
clearly define it and put the right scheduling procedures in 
place to ensure it is at the point the veteran contacts and 
requests care, or gets the referral from a provider, it will 
improve the system.
    Mr. Stearns. So you, what I just read from your report was 
based upon when the veterans desired to be taken care of? And 
you said it actually was 50 days, whereas the VA is projecting 
14 days. And I guess they are using that 14 days, so they must 
be using the capacity date or another type of thing. Is that 
true?
    Ms. Halliday. We looked at the desired date of care.
    Mr. Stearns. Yeah. You know, if you went out to the private 
sector and you said, ``Okay, let us look at the capacity 
date.'' The capacity date is when the company could deliver the 
product, or when they could deliver the resources for the 
patient. Well, the patient is not really interested in whether 
you have the capacity. They just want to get it taken care of. 
So the whole idea of a capacity date seems to be a source of 
confusion because no one is interested when, what capacity, I 
mean, if you do not have the capacity then the date could be a 
hundred, ten years. I mean, if you do not have the capacity, 
that is not what we should be striving for. And as far as the 
create date, it seems to me that is more accurate. The desired 
date is what the customer wants, I understand that. But also 
the create date is based upon the physician recommended and 
also I guess based upon what the patient has recommended? I am 
having a little trouble understanding between the create date 
and the desired date. Go ahead.
    Dr. Daigh. Sir, the measurements are between two dates. So 
we have a time, how long it takes for something to occur.
    Mr. Stearns. Right.
    Dr. Daigh. So if you call in and say, ``I would like an 
appointment.'' That would be the create date.
    Mr. Stearns. Okay.
    Dr. Daigh. You called in and the scheduler stamps that you 
called in on that date.
    Mr. Stearns. You called in today, you will get an 
appointment in two days.
    Dr. Daigh. Right. So if you desired an appointment in two 
days, then that date would be two days.
    Mr. Stearns. Mm-hmm.
    Dr. Daigh. But if the next available appointment was in a 
week then that date would be seven days.
    Mr. Stearns. And that would be the desired date?
    Dr. Daigh. That would be, well the desired date would be 
whatever you tell the scheduler.
    Mr. Stearns. Okay.
    Dr. Daigh. And then the actual date that the appointment 
was made on would be the next available appointment date.
    Mr. Stearns. Yeah. It just seems to me that if you are 
trying to make the customer happy, which is the veteran, and we 
have, we have given the Veterans Administration more money 
every year, sometimes as much as 18 percent a year, it seems 
like you should come up with one date and that should be the 
date that basically when the customer wants to be taken care 
of, if the customer is the one we are trying to satisfy. We 
should not be talking about when the VA has the capacity 
because that is all nebulous. It could be a long time.
    Dr. Daigh. One of the considerations, sir, is the cost of 
getting data. So the scheduling systems are designed to create 
certain data streams accurately. And if you create a metric 
that the scheduling system will not easily give you a reliable 
data stream for, for example the difference between, ``I want 
to be seen on this day,'' and the appointment was actually made 
on that date, then it creates business rule problems for the 
actual schedulers. And in that it then makes the data set VA is 
using unreliable. So I am only saying, sir, that in the mix 
people need to look at what they are asking for.
    Mr. Stearns. Well I think the bottom line is you said it 
takes 50 days to provide this roughly 200,000 veterans with 
their full evaluation. That is what you are saying. And that is 
not good. And that should be changed. And I think that is, no 
matter what we are talking about, a capacity, a desired, or a 
create date, the bottom line is veterans, almost 200,000, are 
not getting serviced. And the Veterans Administration can use 
whatever terminology and definitions they want, but by golly 
these guys and gals are not getting taken care of and that is 
why we are here today. So thank you.
    Ms. Halliday. We agree.
    The Chairman. Mr. Walz?
    Mr. Walz. Thank you, Mr. Chairman. And thank you both for 
your work. And I think that, again, if there is one veteran not 
being served on time that is one too many. Following up on what 
Mr. Stearns was saying, is there a private sector comparison? 
Not just to widgets, but to people with mental health issues? I 
brought up earlier that I think this is a broader issue of 
mental health parity and access to care. One of the things that 
is hard to measure is if you are denied insurance coverage for 
this your wait time is forever. There is no denying of care in 
the VA system. Everyone, and PTSD has been there. So with that 
being said, and not to, because I still think the wait time is 
too long and I want to figure out how that scheduling nexus 
with that, do you have data to show how the private sector is 
doing this on mental health scheduling?
    Dr. Daigh. So yes, sir, we have some. We went out and 
talked to three of the larger entities that provide 
comprehensive mental health care. And talked to them about 
their metrics. The first point they made was that they have 
seen an increase in demand of 15 percent to 20 percent over the 
last couple of years as VA has, they say probably from the 
economic downturn. And then they have a variety of metrics, 
both in terms of timeliness within which you get your 
appointment. So they would say for a new patient appointment, 
you call in being day one. You get your appointment, that being 
day two. That time span ought to be about 14 days for a new 
patient appointment. And then for follow up appointments people 
often use capacity measures. For example, for PTSD it is 
desirable you get a certain set of appointments in a certain 
set of time. For oncology, for cancer therapy, it might be 
desirable----
    Mr. Walz. And those are based on best practices inside----
    Dr. Daigh. Right. So you might then say, ``How many 
appointments, did these patients with these disorders get in 
the last 65 days?'' So there are a variety of measures, usually 
driven directly off the appointment scheduling system, that are 
as close to reality and cost effective as it is to get the data 
and use it, that people use to try to manage their capacity 
being the number of patients that they can see.
    Mr. Walz. Does anybody have anywhere close to the capacity 
of the VA?
    Dr. Daigh. I do not think so, no.
    Mr. Walz. I mean, I am just wondering if there comes a 
diminishing return or if this is a program that should be 
exponentially be able to grow, to assume that. So if you have 
ten patients you should be able to schedule them the same way 
if you have 10,000 or 10 million.
    Dr. Daigh. Well the scheduling is all a very local issue. 
So if you are in charge of a clinic, your job is to manage a 
clinic, then you have to come in in the morning and see what no 
shows you have in your schedule, and how you can juggle the 
people you have to meet the demand that you have. So every 
physician's office deals with this problem, whether it is an 
institution----
    Mr. Walz. That is right. And your assessment was, though, 
it is not uniform. That there were some of these places were 
not as good at it as others. And if you rose, or pulled the 
standard up on some of these you would start to see 
improvements?
    Dr. Daigh. I think if VA would improve some of its business 
practices, and had a scheduling system that allowed it to 
leverage the data in a scheduling system accurately, I think 
they could manage their patient workload, or capacity, much 
better than they are currently doing.
    Mr. Walz. Very good. I yield back, Mr. Chairman.
    The Chairman. Thank you very much, Mr. Walz. You know, I 
think the thing that we are seeing is a very clear picture of 
VA hiding and manipulating numbers, for whatever reason. Of 
waiting times, of appointments, of statistics. Look, we all 
want the veteran to be seen when they need to be seen. We do 
not want them to be medicated with only drugs. We want them to 
get better. Thank you to the IG again for bringing these issues 
to the table. I hope somebody at VA is listening. Because if 
you are not, you are the only ones that do not hear the message 
that is being delivered by any number of people, including the 
IG. And I am sure the next round of witnesses will be bringing 
similar information to the table for us as well.
    I would ask Ms. Brown if she would waive her next round of 
questions, only because we have a series of votes coming at the 
bottom of the hour. And I would like to try, if we can, to get 
to all of the witnesses that have very patiently waited. But if 
you have a question that you need to ask I would go ahead and 
yield to you at this time.
    Ms. Brown. No, sir. But as they change maybe I could have 
30 seconds to say that I would just kind of disagree with the 
Chairman that they are trying to manipulate the numbers. Maybe 
we are reading them differently. And maybe we can get some 
clarity on how we are spelling out what the VA is saying and 
how we can better clarify.
    But basically, we all want the same thing. We want the 
veterans to get service. And there are many ways that we need 
to define that. And it is not just, like I said, and what was 
said earlier, they are coming to us from the emergency room, 
they are coming to us in many different ways. And we need to 
make sure that we are utilizing the taxpayers' dollars and 
providing the service in the best efficient way. And I am 
interested in working with our stakeholders and partners. There 
are many universities that work very closely with the VA in the 
mental health area. How, you know, I would like some 
explanation of how this is working. University of Florida in 
Gainesville and Shands in Jacksonville work very strongly with 
the VA and they work in partnership. Did we capture that in any 
way? And how can we better serve the veterans?
    You know it is a lot of, we have got a responsibility. It 
is not just the VA. It is all of us working together. And so 
Mr. Chairman, you know, I am not disagreeing with you. It is 
just that it is not us against them. It is, you know, one team, 
one fight. That is the Army's motto. And we are all in this 
fight together.
    The Chairman. I thank you very much for your comments. And 
I would say, though, that if you are the one that is designing 
the metric it is very easy to decide a positive outcome based 
on that metric. And so I have got to say that everybody else 
understands and hopefully VA will pick up on that. With that I 
would say thank you very much for your testimony and I would 
like to call the next panel forward.
    Ms. Brown. Mr. Chairman, I do know that you all agree that 
we do not need to give them no more work, though. In other 
areas, like housing or labor.
    The Chairman. I thank you very much to the next panel. 
Thank you for bearing with us while we separated the first two 
panels.
    We are joined now by Nicole Sawyer, licensed clinical 
psychologist and former local evidence-based psychotherapy 
coordinator for the Manchester VA Medical Center; Diana Rakow, 
the executive director of Public Policy for Group Health 
Cooperative; Dr. James Schuster, the chief medical officer for 
Community Care Behavioral Health Organizations; and Thomas 
Carrato, retired rear admiral for the United States Public 
Health Service, now the president of Health Net Federal 
Services.
    Thank you very much, and, Ms. Sawyer, you are recognized to 
proceed with your testimony.

STATEMENTS OF NICOLE L. SAWYER, LICENSED CLINICAL PSYCHOLOGIST; 
DIANA BIRKETT RAKOW, EXECUTIVE DIRECTOR OF PUBLIC POLICY GROUP 
  HEALTH COOPERATIVE; JAMES SCHUSTER, CHIEF MEDICAL OFFICER, 
COMMUNITY CARE BEHAVIORAL HEALTH ORGANIZATION OF UNIVERSITY OF 
 PITTSBURGH MEDICAL CENTER; THOMAS CARRATO, PRESIDENT, HEALTH 
                      NET FEDERAL SERVICES

                 STATEMENT OF NICOLE L. SAWYER

    Dr. Sawyer. Thank you.
    Members of the Committee, thank you for inviting me to 
participate in this important discussion. I am a licensed 
clinical psychologist. My primary focus is the treatment of 
trauma with both veterans and civilians.
    I have worked in a number of clinical settings. However, my 
testimony today will be focused on my work at the VA medical 
center from which I recently resigned.
    My goal today is to share with you some of the impact that 
VA culture and common practices have on our veterans as well as 
the impact it has on the ability of our skilled clinicians to 
provide effective mental health treatment.
    Let us consider the fact that many of the men and women who 
seek mental health care at VA medical centers have been faced 
with decisions and taken action on matters far exceeding the 
imaginations of most.
    But the decision to seek mental health treatment is for 
many of them an admission of failure, an inability to hack it. 
This decision feels humiliating and shameful. Many of them have 
spent years trying to hide these invisible wounds. They have 
avoided feelings and memories. They have pushed loved ones away 
and many of them have contemplated taking their own lives.
    Some of them fear the part of themselves that was so 
capable of those deeds over there. Some vow to never let anyone 
know what they have seen, who they have hurt, or how it felt to 
do it.
    Choosing treatment takes a series of gut-wrenching 
decisions. Admitting the need for help is the first one, making 
the telephone call is the second, showing up for the 
appointment is the third, but the fourth is the heaviest of 
all, actually speaking the pain.
    Endless research and certainly my experience informs me 
that the closer together these three decisions occur, the more 
likely the veteran will commit to treatment. This is not rocket 
science. The more rapid the decision making process, the less 
likely any of us are to let our doubts and fears get in the 
way.
    But VA health care facilities as was demonstrated in the 
recent OIG report leave a majority of veterans waiting more 
than 50 days to begin treatment.
    In my experience, nearly 70 percent of the work of combat 
trauma treatment is in telling the trauma. Acknowledging the 
pain, the regret, the guilt, the shame that are associated with 
their experiences marks the beginning on the road to recovery, 
but it is not the beginning of treatment.
    Treatment begins with trust. But trust for the combat 
veteran does not come easy. Trust is the belief that they will 
not be judged; that their feelings will be validated and 
accepted no matter what they are, and that despite having told 
these things to another person that he, the veteran, remains in 
control of that information.
    These are people who have done things, they have seen 
things, they have felt things that would be considered 
horrendous and evil if they happened at home.
    For many of these men and women, trust in another person is 
a myth. Now, do not get me wrong. A soldier knows trust. He 
knows what it is to believe that the man next to him cares as 
much about his life as he does.
    But to trust in a person who does not share those 
experiences is an incredible risk. Most VA clinicians 
understand this. They respect the pain. They are well-trained 
and they are dedicated. While most do not know the pain 
themselves, they do know what it takes to connect with their 
veterans and they understand the importance of trust.
    But trust takes time. I appreciate the secretary's stated 
appreciation for this in his testimony, but time is not what 
most VA clinicians have when it comes to treating their 
veterans. Psychotherapy is a process, not a prescription. It is 
work that takes time.
    For some of us, our strategies for coping and understanding 
the world and our experiences lead us astray and we find 
ourselves drifting or trapped in patterns that are harmful and 
destructive. Psychotherapy is intended to steer us back on 
track, but it requires the patient to trust in the process, and 
in the clinician to be successful. The VA fails to value the 
importance of trust.
    Trauma treatment demands a session every week or every 
other week. Too much time between sessions allows suffering to 
linger too long after wounds have been opened up. And that 
suffering can lead to retraumatization, strengthening of those 
negative patterns, and loss of trust.
    Effective treatment requires a full evaluation of needs and 
appointments should be scheduled as often as the veteran needs 
them. But both of these vital factors of effective care were 
noted to be chronic nationwide failures by the OIG report.
    We let down our veterans and we set our clinicians up for 
failure. But the hidden tragedy in this whole thing is that 
many of the veterans failed by the system blame themselves. 
Like most people, they do know what effective mental health 
care is supposed to look like, they assume that they have 
failed to get better and they are too far gone to be helped.
    As I mentioned, VA sets its clinicians up for failure too. 
Staffing is an obvious weakness in VA mental health care and 
last month's announcement of 1,900 additional staff is a 
welcome attempt at improving the situation.
    But how do we know 1,900 is enough? The VA lacks any 
expectation for clinical productivity. There is no way to 
identify a clinician's caseload as full and, therefore, it is 
impossible to know if the flow of veterans into the service 
exceeds the capacity of its providers.
    Developing a model for clinician caseload must be a 
priority for VA. Community mental health clinics and other 
mental health facilities have defined expectations for their 
clinicians. With a defined caseload, a clinician can make the 
time necessary to write session notes, do treatment plans, 
consult with other providers, and return patient phone calls.
    All of these tasks are demanded by the ethics that govern 
all of mental health professions and, yet, in my experience, 
they are seen as luxuries at the VA.
    At my former VA medical center, clinicians could easily 
have hundreds of veterans assigned to them for care and that 
number grew daily as new veterans walked through the door.
    Clinicians are virtually gagged under these circumstances. 
They cannot do their jobs. They will not rip open those trauma 
wounds only to let them fester untreated for weeks or even 
months until that next appointment. Clinicians are set up for 
failure and the veterans lose.
    The VA struggles to fill the 1,500 vacancies already out 
there and now there will be 1,900 more positions to fill. But 
this problem has an additional concern. Where are we going to 
put all these new folks? Many VA facilities across the Nation 
simply do not have the space for more clinicians.
    Where I worked, some clinicians dragged carts around the 
hallways because they did not have an office. This is not 
simply inconvenient. It is unprofessional and demeaning for the 
clinicians and has a significant impact on the veterans.
    Safety in their space and predictability in their 
environment are important to many veterans struggling with 
PTSD. Attending therapy sessions in whatever office is 
available each time they arrive can be very distressing and 
lead to dropping out of treatment.
    The VA has professionals with advanced degrees, passion, 
and the expertise to help our veterans, but often these highly-
trained clinicians must set aside their own clinical judgment 
in response to requirements dictated by central office, 
performance measures, and other mandates.
    Unfortunately, I have heard this story echoed across the 
Nation. It is not unique to just one or two facilities.
    I want to thank you again for the opportunity to share my 
experience and perspective. I hope that if there is anything I 
communicated here it is that quality, effective care cannot be 
sacrificed for quantity.
    When it comes to mental health and most anything else 
really, care that is not quality driven is not only useless, 
but it can be harmful to those who receive it.
    Thank you. I am happy to answer any questions you may have 
and I have many thoughts to share in my response to the 
secretary and his panel if it interests the Committee. Thank 
you.

    [The prepared statement of Nicole L. Sawyer appears in the 
Appendix]

    The Chairman. Thank you very much, Dr. Sawyer.
    Ms. Rakow.

                STATEMENT OF DIANA BIRKETT RAKOW

    Ms. Rakow. Good afternoon, Chairman Miller, Ranking Member 
Brown, and Members of the Committee.
    I am Diana Birkett Rakow, Executive Director of Public 
Policy at Group Health Cooperative, an integrated health care 
coverage and delivery system based in Seattle, Washington.
    Thank you for inviting me to be here this morning to 
discuss Group Health's experience managing mental health 
appointments for our members.
    I appreciate your leadership on health care issues 
affecting our Nation's veterans and want to thank you for 
inviting me to discuss Group Health's experience managing 
behavioral health appointments.
    Treating patients with behavioral health needs is a 
difficult challenge for any organization. At Group Health, we 
have created systems to ensure that our members have access to 
timely high-quality care.
    Our success stems from our belief in patient-centered care 
and coverage. This philosophy is at the heart of a model of 
care we apply to mental health services as well as every other 
type of care we provide.
    In simple terms, our model links aspects of health care: 
insurance, clinical care, information systems, and more in a 
tightly integrated system that facilitates a close relationship 
and collaboration between informed, engaged patients and 
multidisciplinary care teams.
    Group Health members seek and receive mental health care 
through primary care as well as specialty behavioral health 
services and we provide many different routes into care, 
individual appointments, phone and group visits, and e-mail 
access to your health care provider and care team.
    Our models enable us to provide high-quality care since we 
were founded in 1947, but it is the more recent implementation 
of Lean that has enabled us to achieve break-through results.
    As you may know, Lean is a management philosophy developed 
by Toyota. Applying the Lean to health care is based on 
understanding patients' needs, develop systems and processes 
around them, and tracking results in order to continually 
improve patient health.
    For patients with behavioral health issues, we look at a 
number of specific measures and goals. For example, an 
electronic medical record automatically measures how long it 
takes from the time a patient calls for an appointment to the 
time they are seen by a health care provider.
    We set goals for timeliness based specifically on the 
urgency of a patient's needs as recommended by the National 
Committee on Quality Assurance.
    We monitor access to follow-up appointments and track key 
indicators of capacity and productivity. For example, we track 
the percentage of patients seen three times within six weeks 
and patient satisfaction with their appointment frequency.
    We also know that simply tracking these measures is not 
sufficient. We must make the information visible and use it to 
ensure that we are serving our patients well.
    This is where Lean really helps. Last year, our behavioral 
health staff looked at appointment patterns and identified a 
high number of appointments that went unfilled, cancelled or 
skipped. Using this information, they developed a process 
called packaged intake, scheduling three appointments at once 
when a patient first calls to come in.
    We also started doing group visits to maximize the use of 
our existing capacity for patients who would benefit from a 
group setting.
    And a certain number of available appointments are held 
back to ensure that urgent and emergent needs are always met. 
Now clinic staff meet every morning to assess what appointments 
are still available and to reach out to waiting patients to see 
if they can come in sooner.
    This set of strategies has enabled us to meet and exceed 
the targets that we set for timely access to care. And we saw a 
statistically significant increase in patient satisfaction with 
their access.
    This is just one example of how Lean gives us the 
discipline to focus on our patients' needs and to address 
problems as they arise. These tools have enabled us to 
significantly improve how we serve our patients with behavioral 
health care needs over the last few years.
    But it is important to acknowledge that this is an ongoing 
process. Our system is built around a culture of continuous 
improvement. Putting the patients' needs first and recognizing 
that as their needs change, so, too, must our approaches to 
meeting them.
    Thank you again for the opportunity to share our experience 
and I look forward to your questions.

    [The prepared statement of Diana Birkett Rakow appears in 
the Appendix]

    The Chairman. Thank you very much.
    Dr. Schuster.

                STATEMENT OF DR. JAMES SCHUSTER

    Dr. Schuster. Thank you, and thanks for inviting me here 
today to talk about this important topic.
    My name is Dr. James Schuster. I am the Chief Medical 
Officer for Community Care Behavioral Health Organization and a 
psychiatrist. And I agree with Congresswoman Brown. Not 
everybody needs a psychiatrist.
    Community Care is a not-for-profit 501(c)(3) behavioral 
health managed care company and one of several payer insurance 
companies affiliated with UPMC, the University of Pittsburgh 
Medical Center, which is a large, integrated payer provider 
system based in Pittsburgh.
    Community Care provides managed care behavioral health 
services to more than 650,000 Medicaid eligible persons in 36 
counties in Pennsylvania and also manages behavioral health 
services based in facilities in 16 counties in New York.
    It also serves both commercial and Medicare members through 
care coordination agreements with UPMC Health Plan.
    Our data indicates that in any given year, 23 percent of 
the members in our Pennsylvania Medicaid plans are active 
consumers of behavioral health care. In light of this, little 
is more important to us than assuring that the membership has 
timely and adequate access to services.
    However, ensuring access is anything but simple. I will try 
to touch on several high points here in my allotted time.
    Ensuring that members with behavioral health needs have 
timely and adequate access begins by first deciding what is 
timely and what is adequate. In practice, these terms can mean 
different things in different circumstances.
    As has been discussed here for individuals with psychiatric 
emergencies, timely might mean right now. As such, our access 
standards require immediate appointments in emergency 
situations. In other circumstances where more routine care is 
appropriate, we allow up to a week initially between the 
initial contact and the initial appointment.
    Establishing these access standards has required a 
dedicated effort on the part of Community Care. We work in 
collaboration with a wide range of stakeholders including 
accrediting bodies like the National Council on Quality 
Assurance and the Pennsylvania Department of Public Welfare. We 
also work with local government entities, advocacy groups, and 
families.
    Among the most important collaborators, though, who help us 
establish access standards are the members themselves. We 
collect input through member surveys and through meetings with 
member advisory Committees who report directly to the board of 
directors.
    We receive additional information through monitoring of 
member complaints around access and through site visits to 
provider services.
    Defining the access standards would have somewhat limited 
value if we did not communicate them clearly to our staff, the 
providers in our network, our members and the community at 
large. We work to make sure that everyone is aware of what the 
access standards are and how they are measured.
    The true value to Community Care in terms of collecting 
data around access has been its usefulness in devising 
necessary changes and interventions.
    Over the years, we have created a wide range of changes 
related to the data. These include traditional types of 
intervention such as increasing numbers of subspecialists when 
those fall short of access requirements.
    But they have also included more systemic changes such as 
increased funding, dedicated community-based services, and an 
expanded range of services such as mobile crisis service units, 
hospital diversion programs, psychiatric rehabilitation, and 
certified peer specialist programs.
    These more systemic changes have probably had some of the 
most substantial impact on access to services broadly.
    Access feedback has also prompted us to implement newer 
types of service delivery including tele-psychiatry. We 
currently support approximately 20 tele-psychiatry units in 
rural parts of Pennsylvania using secure forms of video 
transmission.
    We have also worked with providers to create new clinical 
strategies to deliver care such as supporting shared decision-
making strategies and physician-based services.
    All of these services have created new ways to access care, 
as they are alternative to traditional inpatient and outpatient 
models.
    We have also increased access to the broad and 
comprehensive range of community-based services. During the 
past decade, funding for community-based services in the 
Medicaid programs that we work with in Pennsylvania has risen 
from about 50 percent to about 80 percent of the total dollars 
spent on care.
    In conclusion, what I would ask that the Committee take 
from my comments today is that improving and maintaining access 
to behavioral health services is, of course, critical, but it 
requires typically a broad set of efforts and collaborations 
among many stakeholders including the patients and members 
themselves.
    We have learned much through our efforts over the past 15 
years and are certainly happy to answer any questions that the 
Committee has today or in the future.
    Thank you.

    [The prepared statement of Dr. James Schuster appears in 
the Appendix]

    The Chairman. Thank you very much, Doctor.
    Admiral.

                  STATEMENT OF THOMAS CARRATO

    Rear Admiral Carrato. Thank you, and thanks for the 
invitation to appear before the Committee.
    Health Net is proud to be one of the longest-serving health 
care solution partners for the Department of Defense and 
Department of Veterans Affairs. Health Net currently serves as 
the TRICARE contractor in the TRICARE north region supporting 
three million DoD beneficiaries.
    We also deliver behavioral health and wellness services to 
military servicemembers and their families through the military 
family life counseling program, a worldwide program which 
provides short-term problem-solving situational counseling.
    Health Net also works with VA in support of veterans' 
physical and behavioral health care needs through community-
based outpatient clinics and the rural mental health program in 
select rural counties in VISNs 19 and 20.
    Appreciate the opportunity to offer our thoughts on 
addressing the growing and urgent need for veteran access to 
mental health services.
    Untreated mental illness impacts overall health and 
reintegration into the community.
    Chairman Miller, as you stated in a recent news release, 
these are wounds that cannot wait.
    We appreciate VA's efforts to enhance capacity to address 
this growing need and respect its leadership in developing and 
deploying evidence-based treatment protocols and comprehensive 
clinical practice guidelines.
    Moreover, we appreciate the fact that VA understands 
veterans' needs better than anyone else. But addressing the 
dramatic increase in the demand for VA mental health services 
is challenging. Clearly the demand has stretched VA's capacity.
    Based on current services we provide to both VA and DoD, we 
believe there are ready approaches to address this urgent need 
quickly and effectively. These proven solutions for addressing 
both short-term and ongoing access issues can be performed 
without sacrificing clinical excellence which is a priority for 
the VA.
    Health Net has collaborated with VA and DoD in delivering a 
full continuum of high-quality, flexible, and accessible 
solutions which augment existing capacity and capability.
    These programs are very flexible in meeting demand from 
supporting the surge of returning servicemembers to reaching 
out to veterans living in remote geographic areas.
    Our counselors have been carefully screened and then 
receive extensive training on military culture and relevant 
military and veteran issues. This training easily could be 
augmented with additional VA specific training.
    Our rural mental health providers are trained on VA 
benefits and on addressing specific veteran issues.
    For the military family life counseling program, we have a 
network of over 5,200 licensed counselors who are fully 
trained, highly experienced, and ready to deploy.
    This network has drawn from a Health Net pool of over 
50,000 qualified professionals which is further supported by 
over 22,000 behavioral health providers in the TRICARE provider 
network.
    We believe a path forward for VA should be based upon 
existing proven programs using available clinical resources. 
Such an approach could effectively supplement VA's capacity 
without sacrificing clinical excellence.
    Short-term actions might include deployment of clinical 
resources to alleviate short-term demand requirements at VA 
medical centers or community-based outpatient clinics using 
enhanced telephonic and Web-based counseling to provide 
veterans with easy access to ongoing support, and finally 
augmenting VA's capacity with an existing network of community-
based mental health providers.
    We commend the VA for promptly responding to the OIG report 
on access to mental health care. We also commend this Committee 
for its strong leadership over this critical issue for our 
Nation's veterans.
    I look forward to your questions. Thank you.

    [The prepared statement of Thomas Carrato appears in the 
Appendix]

    The Chairman. Thank you very much, Admiral.
    I have a question to pose to you that does not have 
anything to do with your testimony. You heard the bells ring 
just a minute ago; we are in our first series of votes. We have 
a little over two minutes to get to the floor.
    So I would like to ask, if it would be amenable to you, if 
we could recess until about 2:30, come back to give us an 
opportunity to ask our questions and not feel rushed. We have 
one other panel after this. I think 2:30 would give you an 
opportunity also to take a break maybe and do some things.
    Would that be okay with the panel?
    With that, the Committee stands in recess until 2:30.

    [Whereupon, at 1:36 p.m., the Committee recessed, to 
reconvene at 2:30 p.m., the same day.]

    The Chairman. Thank you, everybody, for returning. I 
appreciate your indulgence to allow us to go over and have a 
series of votes and I had a quick speech that I had to make. 
Fortunately, it was here on the Hill.
    I would like to begin the round of questioning first. In 
the department's written testimony, it states that no industry 
standards for accurate mental health staffing ratios exists. So 
my first question is, is this a true statement and, if so, how 
does your organization determine mental health staffing ratios? 
Is there such a thing as an industry standard out there? And if 
there is no standard, I understand that, too.
    Ms. Rakow, you are recognized.
    Ms. Rakow. Thank you, Mr. Chairman. We don't actually have 
a set standard that we use for our staffing ratios. I can't 
speak to whether or not there is one out there. So we use other 
measures of capacity and productivity, such as the number of 
slots that providers have still available to take on new cases. 
We use relative value units, which is a common measure of 
productivity in the health care industry to measure capacity, 
as well as productivity, and then use that as demand increases 
to translate whether or not we need to increase our supply.
    Dr. Schuster. Yes. But I think, generally, I would echo 
what Ms. Rakow said. There are standards in terms of access 
times, which we had talked about, but I think--and access 
availability in terms of how far someone might have to go to 
reach a practitioner. But I think the kind of productivity and 
staffing standards are probably more-- idiosyncratic is too 
strong a word, but there is not one common standard that is 
used universally.
    Dr. Sawyer. I just want to point out I think that having a 
staffing model is part of the problem. I think that we need to 
take a look at the actual productivity that a clinician can 
achieve while providing effective mental health treatment. The 
expectation right now is completely irrelevant. It is just as 
many people as you can cram into your schedule a day is your 
expected productivity.
    However, in other facilities, community mental health, 
other mental health facilities, there is a certain expectation 
of a clinician. For example, a former mental health center I 
worked at there were 22 hours of therapy per week were expected 
for your 36 hour work week.
    Now, those 22 hours could be made up of many different 
things. It could be made up of group therapy. It could be made 
up of individual therapy. You may be running a 90 minute 
session with someone, given whatever sort of methodology you 
were using. But those 22 hours were dedicated to psychotherapy 
of some form if you were a full time clinician. Now, the rest 
of the hours of the week were spent writing up notes, you know, 
providing consultation, all of the things that are important to 
providing effective care.
    Now, that allowed a case load to be developed so, if you 
are effectively seeing your people in 22 hours per week of 
therapy, then that can be extrapolated into how many veterans 
you could actually have on your case load and treat them in a 
manner that is clinically relevant.
    So approximately, in my experience with the community 
health, a full time clinician could carry about 40 people on 
their case load and treat them effectively with 22 hours of 
therapy per week because some people only need an every other 
week appointment. Some people need once a week. Some people are 
coming in for monthly check-ins.
    So the intensity of the treatment that you are providing is 
disbursed among your case load when you have about 40 people. 
And that allows room for you to manage incoming, so you are 
taking on new patients periodically when you are discharging 
others because they are getting well. So a system that actually 
has a case load and a productivity expectation for their 
clinicians allows a flow to take place because people are able 
to get better. Care is actually effectively provided.
    Dr. Schuster. If I could just add one other comment, which 
is what's optimal numbers per site might vary depending to some 
degree on the range of services that are available for a 
particular site. So, for example, if there is only outpatient 
services available, you might need more outpatient clinicians 
than if you have a broader range of services, case management, 
peer services, day hospital, etc. So it probably makes sense or 
it might make sense to look at each kind of level system in 
terms of what is available and how they can serve the 
population they are responsible for.
    Dr. Sawyer. Certainly.
    The Chairman. And if we can, let's go here because VA has 
said that they have been in consultation with other health care 
systems to, in fact, create a prototype staffing model for 
general mental health at outpatient care. Are any of you aware 
of this? Have they reached out to you or the folks that you 
represent? And if they have not, do you think it would work and 
would you be willing to work with VA to help them resolve this 
issue?
    Ms. Rakow. We would be glad to work with them. I was 
speaking to Dr. Petzel at the break and we would welcome 
members of the VA or members of the Committee and your staff to 
come visit Group Health and see what we do, if we can offer any 
lessons.
    The Chairman. Dr. Sawyer, what do you think? I thought I 
heard you say you did not think that a staffing model would 
work.
    Dr. Sawyer. Well, I guess my fear with a staffing model is 
this very global approach to, as Dr. Schuster pointed out, a 
very facility specific issue. So depending on a range of 
services that a facility is providing is what their case loads 
of their clinicians need to look like.
    So I get a little bit nervous when we start talking about 
this sort of global definition of what a staff should look 
like. It starts to make me think of mandates sort of trickling 
down onto the ground level and then we are all trying to figure 
out how to meet these demands.
    So in terms of a staffing model, I feel like we need to 
look more at a case load model for clinicians. What do we 
expect our clinicians to be doing every day and how can we 
design that so that they are actually able to provide effective 
treatment.
    Dr. Schuster. And I found that, staffing models, 
particularly in behavioral health, it is, as the panelists have 
said, it is so dependant on the type of provider for 
psychiatry, for social work, for psychologists, whether it is 
acute inpatient, day treatment. So you do come up with staffing 
guidelines that can be used as a starting point to determine 
availability and accessibility, but it is a very complex 
undertaking.
    Dr. Sawyer. Well, and you bring up an excellent point, as 
well. I am sorry. If I could continue to comment.
    On the VA's statement that they have come up with this 
number of 5.3 mental health professionals per 1,000 veterans, 
what does that mean? 5.3 mental health professionals per 1,000 
veterans, if that's 5.3 psychologists, that means I am 
responsible for 200 veterans? That is absurd. I can't provide 
adequate care to 200 veterans at a time.
    If you are a psychiatrist that is providing only 15 minute 
appointments, which no psychiatrist actually is, but if you are 
only providing 15 minute med checks, maybe you could manage a 
case load of 200 people. But a social worker, a psychologist, 
people who are providing psychotherapy, which runs in 50 minute 
increments at least, sometimes as much as 90, can't manage 200 
people.
    The Chairman. Mr. Walz.
    MR. Walz. Thank you, Chairman. Thank you all for being 
here. I really appreciate it and I tell you this not because I 
think you care, but it is a little bit of background. I 
represent the Mayo Clinic area and, as we got into this whole 
health care debate of looking at accountable care 
organizations, patient centered care, medical home models, it 
is kind of the air we breathe. And I still go back to this 
issue as much more systemic in the delivery of the mental 
health services in this country.
    Would you agree that that is looking at that? I hear you 
speaking that way, that partnering together. The VA is a 
wonderful opportunity for us to learn on the private sector 
side, too. How to deliver mental health care in some complex 
situations. But I'm trying to figure out what you can teach 
them, too, about going down the line.
    So I am going to go to Ms. Rakow first. I found some 
interesting things on GHC. They did a great commonwealth study 
on you that we were looking at in my office that I think--I 
think this sums up where VA is at and where you guys can maybe 
provide some help.
    It says, ``In recent years, however, GHC pushed to improve 
its competitiveness in the marketplace. It began to see the 
unintended consequence of a production oriented approach to 
primary patient care. Swollen patient model is reaching as high 
as 3,000 patients for a physician, increasing specialty care 
referrals, rising costs, costs of hospital care, emergency 
care, and signs of burnout in the workforce. Like other large 
health organizations, GHC was finding it difficult to recruit 
primary care physicians and struggling to improve performance 
by engaging patients in their own care.''
    But here is the good news on this. This is what your vice 
president said. ``We were on a platform that was 
unsustainable.'' In response to these challenges in 2007, GHC 
began a pilot project to define and test a medical home model 
of primary care delivery in its Bellevue Seattle suburbs there 
and went through and listed some of these things.
    Have you been there long enough, Ms. Rakow, to see this as 
it changed because, as we have talked about health care and 
health care delivery, the debate up here became that it was 
like any other commodity to be delivered. It was a supply and 
demand issue and all that and it would just work itself out in 
the marketplace. The problem with that is, especially with 
mental health care, it is not quite that simple.
    And so what I am trying to figure out here is could the VA 
employ some of the things that you did, you think, to reduce 
these wait times and to get better outcomes on patients and 
their care?
    Ms. Rakow. Thanks for the question. I would hope so. I 
think when we actually started looking at access to behavioral 
health services in 2001, we had a wait time of, on average, 
often 50 days. So we have come a long way. And, similarly in 
primary care, we piloted the medical home model a few years 
ago. It proved workable and so we rolled it out to all of our 
clinics.
    But it is really a multi-faceted strategy. On the one hand, 
we tried to maximize the use of our capacity with things like 
virtual consults with specialty providers from primary care, 
which we do with behavioral health services, as well, phone and 
group visits, email access to your doctor. We also at the same 
time are continuously working to improve. So with some of the 
tools and measures that we use, we do track supply and demand, 
but we also, at the same time, track quality and clinical 
effectiveness and we empower front line staff to actually be 
very involved in that tracking process, to visually report 
results in the clinic, to huddle every day and look at results.
    Mr. Walz. Those outcomes are what matter, what I am trying 
to get at.
    Dr. Sawyer, I am going to end. I have my last two minutes 
to leave to you this issue of value care versus volume care. It 
is a problem we have in Medicare delivery, obviously, and it is 
what is the biggest cost driver in health care is. How do we 
get to that value based care?
    Now, I am thinking two questions to you is why would a 
psychologist choose to work in VA? Why would a young 
psychologist coming out just with their doctorate now and they 
are ready to go, why would they choose to work in VA? And could 
you just briefly explain what a typical day as a VA 
psychiatrist looks like for a psychologist?
    Dr. Sawyer. Sure. Thank you. So part one of that I guess is 
why a psychologist would come to work for the VA. I think that 
right now we have a tremendous opportunity with mental health 
professionals coming directly out of school, graduate programs, 
because the VA right now is an opportunity for them to serve 
their brothers and sisters that have gone off to war. I mean, 
we are talking about a generation of graduate students coming 
out of school who have watched their cohort go off to war and 
come back in a lot of pain. This is an opportunity for them and 
we need to seize it. This is something that we can really grab 
on to to help encourage psychologists to want to come to work 
at the VA.
    The VA is not the place where they are going to make the 
biggest amount of money. It is going to be a lot of work. They 
can get a pretty good benefit package, but it is the feel good 
that comes with working at the VA that really motivates a lot 
of mental health professionals.
    Mr. Walz. Was your motivation tampered a little bit with 
some of the requirements that kept you in a box, that didn't 
allow you to practice your profession maybe?
    Dr. Sawyer. Absolutely. I mean, one of the most difficult 
things about working at a VA in its current system is that you 
are coming into this system as a professional; You feel very 
good about the training that you have taken on. You feel very 
good about your expertise.
    And then you get there and you are told, oh, no, no, no, 
that is not how we do it here. This is how we are going to 
practice. These are the treatments you are going to provide. 
This is how often you are going to see your veteran. This is 
what you are going to say to them about those treatments. I 
mean, it comes right down to how you actually practice.
    Mr. Walz. Is it your experience when you network across 
there? Because I try to get out to as many of my facilities as 
is possible and I know it is a gross generalization to say they 
are all the same, but you probably network closely with other 
professionals.
    Dr. Sawyer. Yes. In my job as the evidence based 
psychotherapy coordinator, we had contact on a monthly basis 
with our local VISN, as well as nationally. And this is common 
across the board. It is the greatest frustration of 
psychologists and social workers, as well, who are providing 
psychotherapy is that their clinical judgment is tossed out the 
window. You know, we are--everything is being dictated to us by 
the performance measures that the administration----
    Mr. Walz. Do you think that is a natural response, though, 
to cost benefits and where you are being funded? I say that as 
a professional educator where I said, wow, 51 kids in this 
class? I am not sure that is the best model for us to do this, 
but you are going to have to deliver. Do you think that happens 
in a lot of professions where you have to balance between what 
the cost is or is this one of those I have always made the case 
of whatever it takes to get it right, we need to do?
    Dr. Sawyer. Well, I think the biggest problem with taking 
the clinical judgment away, not only is it certainly 
interfering with the retention of these professionals, but it 
also means that there is this very cookie cutter approach that 
starts to happen for veterans. And mental health cannot be 
cookie cutter. I mean, I can't even imagine another medical 
issue that can be less cookie cutter than mental health. But 
the VA is trying very hard to create this structure around 
health care to provide it to these veterans and that is a major 
turnoff to the professionals that are supposed to be sort of 
disseminating this care.
    Mr. Walz. Is it your judgment that that is simply to meet 
the demand, that there is just that many people?
    Dr. Sawyer. Absolutely.
    Mr. Walz. Okay.
    Dr. Sawyer. Absolutely.
    Mr. Walz. Thank you.
    The Chairman. Ms. Brown, questions?
    Ms. Brown. I think my question is for Dr. Schuster. You 
have a medical degree. Ms. Sawyer have a educational degree. 
Both are very important, but a medical degree I guess is the 
top as far as treatment is concerned. I would imagine a person 
coming to you would have severe, severe problems as opposed to 
going to a, let's say, a social worker with clinical training, 
you know, in mental health.
    It seems as if we want--we talk about psychiatrists or 
psychologists, which is a vast difference, but I know that we 
are providing care and need to provide care in many different 
ways. I think if you are talking about a professional coming 
out of school with no experience, that is a problem dealing 
with people with severe trauma, you know.
    So can you share with me because I am pushing and I am 
going to talk to the next group that we need to have different 
tiers as far as providing care for veterans. I mean, when I see 
the soup line wrap around the kitchen and who is there are 
veterans, then we are not providing them the basic services 
that they need. And so we need a combination of working with 
our stakeholders in different levels and working with the 
professionals in a different level. And to integrate. I see the 
VA playing a major part, but I don't see them going out and 
hiring no 3,000 psychiatrists because that is not what we need.
    Dr. Schuster. Right. I mean, I think that the literature 
suggests that having a combined team of professionals available 
to treat groups of people is the most effective model, so you 
probably don't want just psychiatrists or just psychologists or 
just social workers but, really, a team of folks so that people 
can get what they need. And if people need to be seen by 
multiple professionals, then that is available to them, as well 
as I think other community based services.
    You know, again, there are models for intensive treatment 
services that can be provided actually out in the community, 
including peer support services and case management and 
thinking about a broad spectrum of services is probably the 
most effective way to go. And I know we have talked some here 
about looking at different private models of delivering care, 
but I think it probably is also useful to have some feedback or 
think about models that are used in publicly funded systems to 
local mental health center systems and other systems because 
part of the VA population is probably more like that than might 
be seen in a commercial or a private setting. Some are probably 
more typical of what you might--folks who get their services in 
publicly oriented settings.
    Ms. Brown. Okay. Ms. Sawyer, do you want to respond to 
that?
    Dr. Sawyer. I couldn't agree more. I mean, I think that 
the--there are many veterans that come through the VA that 
could be very well served in a community health setting. I 
think that the VA could be very good at doing a few very 
difficult things and then also being willing to partner with 
outside community and private providers.
    The difficulty with that is that the VA right now requires-
-first of all, it dictates how many sessions a veteran can have 
when it fees out to someone. So it may say, you know, we will 
fee you out to this psychotherapist in the community, this 
psychologist, and she is going to work with you, but we are 
going to give you eight sessions.
    Now, that psychologist on the other side wants nothing to 
do with that situation. If you are going to put the liability 
of this person's mental health care in my hands, I want to be 
in control of how that treatment is provided. This is--I am the 
one providing it.
    So the VA is saying to them, well, we are only going to 
give you eight sessions. I don't know, I haven't even met this 
person yet, whether or not I am going to be able to do anything 
for them in eight sessions.
    Ms. Brown. I understand what you are saying, eight 
sessions, but we are dictating the--we are dictating the costs 
and it is a limited amount that we are willing to pay.
    Dr. Sawyer. Mm-hm.
    Ms. Brown. So it is a catch. The VA can't--it is a very 
frustrating for the VA because they can't satisfy because of 
our demands and, of course, the user end. So if eight is not 
the appropriate number, how do we control the costs? Because 
the people up here, that is all they are interested in.
    Dr. Sawyer. Mm-hm.
    Ms. Brown. You know, that is all they are interested in. 
Costs.
    Dr. Sawyer. I certainly understand what you are saying. I 
mean, there is definitely a catch there where we can't just let 
things run wild on that side. But I think that trying to find a 
balance with that so that we actually are respecting the 
clinicians that we are trying to fee these folks out to, while 
also being mindful of the costs that will come to the facility, 
there has to be a balance. We can't just choose one. And I 
think that is what is happening right now.
    Ms. Brown. All right, Mr. Chairman. I am sure I will get a 
chance to follow up.
    The Chairman. I don't know. After that last comment, you 
may not get a chance. I would say that this Committee and the 
House has, in fact, offered up everything that the VA has asked 
for, I mean, to the point that we have got 1,500 empty 
positions right now that we can't get filled and they are 
asking for 1,900 more. And if that is what they need, this 
Congress is going to give it to them. But, again, I don't see 
how we do 3,500 positions in a timely fashion to a veteran who 
needs help today.
    Now, Dr. Sawyer, you have said in your opening statement 
that you have some comments regarding the secretary's comments 
and you would be willing to provide them to this Committee if 
we would like to hear them. Now, we would and I would like to 
ask you to please expand on it.
    Dr. Sawyer. Okay. Well, I think what struck me the most at 
one point in the secretary's statement was something that he 
said that represented clearly the problem that we face on the 
ground. The VA is not providing good care right now. We are 
trying our hardest. As providers on the ground, we are working 
as hard as we can, but we are simply not able to do the work. 
And he identified it as being we are providing good care. We 
are just not measuring it very well. That is what happens on 
the ground level. That is the message that we're getting from 
our administrators within our facility.
    When they miss a performance measure or when for some 
reason, their VISN or central office comes down on a facility 
for not doing something well, how that translates to the 
clinicians who are busting their butts every day to try to see 
as many veterans as possible is you are not working hard 
enough. You are clearly not tracking your work load well 
enough. We need you to start keeping better track of how you 
are doing this, this, and this.
    So when I heard that from the secretary, it was--we I 
guess, as clinicians, used to think it was a facility thing. 
And then, when it came directly from him, it was very 
disheartening to hear that. It is not that we are not measuring 
our work well. It is that we are actually not providing the 
work. There isn't anything to measure. We are not doing the 
work that we need to do.
    And part of that is because the clinicians are so overrun. 
They are completely incapable of providing the services that 
they are trained to do of 200 veterans per clinician, which is 
probably about average for some facilities and clinicians right 
now. Now that is going to be the expectation. We can't work 
with that now. So asking us to say, well, that is going to be 
your new norm is ridiculous. There is certainly no way that we 
can provide effective care in that way.
    I guess some other thoughts that came up were comments 
regarding, you know, trainees, that there are a lot of 
facilities that have training programs, that I think they 
mentioned having many post-docs and interns and one of the 
biggest training organizations. I'm wondering, what I would 
have liked to have asked the secretary, is what are his 
thoughts on why we are not keeping those folks in our system. 
What is happening,
    Ms. Brown. Chairman?
    Ms. Brown. Excuse me. Mr. Chairman, I am not comfortable 
with this line of questioning. I don't mind the panel making 
whatever comments they want to about the testimony, but to say 
that we are responding directly to the secretary, I think that 
is inappropriate. The secretary is entitled to his comments and 
the panel is entitled to theirs. But to say that we are 
responding directly to the secretary, I think that is 
inappropriate.
    The secretary has a broad experience and takes a broad view 
of the VA mission. You are talking about where you work and the 
environment you worked in, which is limited. So if we are 
talking about the entire system, you don't know what is going 
on in the entire system. You only know what goes on in your 
area that you were working in or the environment you worked. 
You have not talked to everybody in VA.
    So I don't want to be put on the spot that I feel like I 
need to defend the secretary, but I do not want the panel 
saying we are going to comment or critique the comments of the 
secretary. That is inappropriate.
    I have been on this Committee for 20 years. I guess I am 
the only one with institutional memory, but I never heard a 
panelist discuss what a secretary said and I don't think that 
is appropriate.
    The Chairman. Thank you, Ms. Brown, for your comments. Dr. 
Sawyer, please continue.
    Dr. Sawyer. Well, with all due respect, Congresswoman 
Brown, I actually do have a lot of contact with professionals 
across the Nation and within my system. And I am certainly not 
going to in any way imply that every facility is a disaster. 
That is certainly not the case. There are many facilities out 
there doing fantastic work. But there are a large number of----
    Ms. Brown. No. That is not appropriate. That I was not 
speaking to the panelists. I was speaking to you. And she needs 
to talk directly to you----
    The Chairman. All right.
    Ms. Brown. --and not----
    The Chairman. All right.
    Ms. Brown. Not through----
    The Chairman. Ms. Brown, she is trying to talk to you. If 
you want her to go through me, that is fine, but she is trying 
to answer my questions. And you asked me a question. She is 
trying to answer your question. She is not a member of 
Congress. She is a doctor and she is trying----
    Ms. Brown. She a educational doctor. She is not a medical 
doctor. So make sure you get the comments from the medical 
doctor, also. She is a educational. She doesn't have a medical 
degree and it is a difference between the two.
    The Chairman. I will let all my education friends know that 
you don't consider a Ph.D. a higher degree, which is what you 
just did.
    Ms. Brown. That is correct, sir.
    The Chairman. Please continue. I really want to hear what 
you have to say and I think it is very appropriate for you to 
comment about the secretary's comments. Please continue.
    Dr. Sawyer. Thank you, Chairman Miller. I guess the last--
the last thing that came to mind with one of the secretary's 
comments was that we need to maximize the staff that we have. 
And I think that is certainly reasonable to look at it this 
way, but our staff are currently maxed out. I mean, I don't 
think anyone here was denying the fact that the staff in our VA 
facilities have been working extremely hard to meet the demand. 
And so there really is nothing left to maximize at this point. 
We need more staff and we need a more efficient way of using 
our staff. It is not about maximization. It is about 
efficiency.
    The Chairman. Thank you very much. I thought you were 
leaving.
    Ms. Brown, you are now recognized.
    Ms. Brown. Mr. Schuster, can you give us some----
    The Chairman. Excuse me. It would be Dr. Schuster.
    Ms. Brown. M.D.? Yes, sir.
    Your comments on how we should move forward as far as I 
understand the work load is tremendous. And I also understand 
we don't need to hire 3,000 Ph.D.s or E.D.D.s. We need a 
combination and a team. What are some of the recommendations 
that you can give us that we can move forward with and not 
criticize or critique the secretary in this Committee. As I 
said before, it is one team, one fight, and we are all fighting 
for the veterans.
    Dr. Schuster. Yes. I am not an expert on the VA per se, so 
I can't respond directly to that. But I am happy to provide 
some feedback in terms of strategy.
    Ms. Brown. So no one in this--no one up here is an expert 
on the VA and no one out there is an expert on the VA because 
there are many, many aspects of the VA.
    Dr. Schuster. Some strategies that we--that the company I 
work for has had experience with in terms of trying to address 
access, one is certainly looking at numbers of professionals. 
So it is certainly an important item to look at.
    A second item that we would look at are access measures in 
terms of how long it takes people to receive appointments. We 
have also looked at and tried to get input from families and 
patients, as well as the people providing the care about what 
types of services seem like might be missing to help address 
people's needs because sometimes people access care through 
outpatient services, but sometimes their more urgent needs and 
sometimes there are other needs that direct therapy or even 
medications might not address.
    And then I think the one other thing that we have found 
helpful is, in addition to looking at some of the quality 
measures we talked about this morning, like time to 
appointment, we have also tried to look at some other measures, 
like time to follow up, and this was in the GAO report, time to 
follow up after a hospital stay, readmission rates, complaints 
about access, whether or not there are any concerns from the 
community about access to services.
    So we have tried to--the GAO report talks about a dashboard 
around the outpatient services and we have tried to put 
together a series of items that really look like a dashboard, 
but address some items beyond the outpatient services, as well, 
that we call our provider benchmarking process. So we look at 
lots of quality indicators, including complaints and access to 
services.
    So we found it helpful to certainly look at the items 
address here as part of to look at some other quality issues, 
as well, that might either affect this or be affected by it.
    Ms. Brown. I visited a program in the Tampa-St. Pete area 
that they work with the veterans. And one of the things that 
they did was they had some kind of horse therapy. That was, you 
know, the service organization working with the VA, but it 
proved to be very beneficial to the veterans.
    So it's all kinds of therapists and all kinds of levels of 
services that you can provide. Like I said, we have the 
University of Florida in Jacksonville, but you also have them 
working with the VA and that is the urban model.
    And how can we emphasize and support the different services 
because community health or the health department, they work 
with providing services. I do not see the VA going out and 
hiring 3,000 professionals. How can we better put together the 
teams that we need to provide immediate services? I guess that 
is the question. And we would just kind of overlook the other 
person. Would you like to respond, sir?
    Dr. Schuster. Yes, ma'am.
    Ms. Brown. Yes, sir.
    Rear Admiral Carrato. As you pointed out, the demand for 
behavioral health services is just increasing across the DoD 
and VA. And I would like to commend the VA for their work in 
developing clinical practice guidelines. And the issue is that 
the demand is just exceeding the resources. So to your point, 
we do need to involve the private sector, and community 
solutions.
    And I just had three recommendations that I would make and, 
you know, I would like to caveat of them because one thing we 
don't like to hear is, you know, this is the way we do it here 
and you ought to do it and everything will get better. But just 
some lessons learned from the Defense Department. Again, the 
same folks wearing the uniform. When they take the uniform off, 
that demand continues to grow. We developed jointly with DoD 
the military family life counseling program.
    Ms. Brown. And you said you handle TRICARE also, don't you?
    Rear Admiral Carrato. TRICARE and----
    Ms. Brown. Which is the family?
    Rear Admiral Carrato. The military family life counseling 
program is sponsored by the under secretary for Personnel and 
Readiness. And to your point with the supply issue with 
psychiatry, this is based on using primarily licensed masters 
prepared social workers.
    Now, there still is a supply issue, so we developed a 
rotational model where we are able to respond specifically to 
short term demands like the VA is facing now. So we can rotate 
social workers, psychologists around the world for 30, 60, 90, 
120 day assignments on a rotational basis and we bring folks 
back, you know, into the states or back home into their active 
practice. The benefit is we can use professionals who are in 
active practice.
    This isn't a staffing model because I know, as one of the 
panelists pointed out, when someone works up the courage to 
raise their hand and say I need behavioral health services, to 
go in to somebody who has no idea what you have gone through 
can just turn you away. So our folks get extensive training on 
military, culture, customs. They understand what it means to be 
deployed multiple times. And so a rotational model similar to 
the military family life counseling program could be effective.
    The second suggestion I have, and, again, I know the VA is 
a pioneer in this area, but it is to use technologies, web 
enabled, Skype enabled counseling, telephonic counseling, to 
reach out to veterans and some harder to reach veterans. And 
this has proven to be effective.
    And, finally, again, the point of augmenting the VA, there 
are, in the TRICARE program, the taxpayer has paid us to 
develop a network. They have paid Humana to develop a network. 
We have over 22,000 behavioral health providers in our network 
and there may be an opportunity for that network to be used to 
augment the VA.
    So those are the suggestions I would have to address the 
immediate and the ongoing issues that the VA is facing.
    Ms. Brown. One last comment. We are working real hard to 
get the Department of Defense to work kind of seamlessly with 
the VA. And what recommendations do you have that how we can 
work closer together because I don't know why we lose someone 
when, you know, and there is that period between when they are 
out and they don't think they need services. And then when we 
get to them, it is almost too late sometimes.
    Rear Admiral Carrato. You know, I think it is just the 
ongoing communication. I know when I was still on active duty 
and was at DoD, I worked very closely with colleagues at the VA 
and I just encourage--would encourage ongoing communication 
around these common issues because, as you said, one team, one 
fight.
    Ms. Brown. Thank you. And thank you, Mr. Chairman. I yield 
back the balance of my time.
    The Chairman. Dr. Schuster, how long did it take Community 
Care to develop and implement the timeliness benchmarks that 
you use? And, also, how often do you reevaluate those 
benchmarks?
    Dr. Schuster. Some of the benchmarks that we used we have 
used almost from the beginning. They were dictated by the State 
of Pennsylvania as part of its Medicaid program. Other 
benchmarks we developed and the company really started its work 
with the Medicaid program approximately 15 years ago in 
Pennsylvania. Other benchmarks we adopted from NCQA, which is a 
company that accredits insurance companies, and we have had 
that accreditation for about ten years. So we adopted some of 
those additional standards between then.
    And then we have really done evolving standards around 
access and trying to assess adequate access to care really on 
an ongoing basis in the different regions that we work in. We 
work very closely with the counties, with each county that we 
work within, and with the providers and the advocacy groups, of 
family and patient advocacy groups in that area.
    So we have ongoing discussions, really, all the time to try 
to assess, if people feel like their needs are being met or, if 
not, what do we need to do to address it.
    The Chairman. Admiral, same question. Do you, if you would, 
benchmarks, time to look at reevaluating programs.
    Rear Admiral Carrato. You know, pretty much agree with what 
Dr. Schuster said. It starts with establishing access 
standards, availability standards, and just monitoring closely. 
But as we have talked about before, in the behavioral health 
area, we are still--we are still learning.
    The Chairman. Mr. Walz, any other questions?
    Mr. Walz. No. I'm good, Mr. Chairman.
    The Chairman. Ms. Brown, anything?
    Ms. Brown. Just one last thing. I want to be clear, so when 
I read it.
    I am not saying that a person with a educational degree is 
less qualified than one with a medical degree. I am saying we 
need all of those health care providers. I want to be clear. I 
think we need all of them, including the social worker and the 
community resource person and the family and the veteran. So it 
is a team effort and I want to be clear I am not putting down 
any profession. I think they are all very important as we 
develop this model that we are trying to address this problem. 
It is one team, one fight, even though it is the, I mean, we 
are working with all of the branches. Thank you.
    The Chairman. Thank you very much. Thank you for your 
indulgence. You may be getting questions from the full 
Committee. For the record, we would ask for a timely response, 
if you would in getting those back. Thank you for being with us 
today. You are dismissed.
    The Chairman. Thank you much for hanging with us for so 
long. The final panel today at the witness table is Joy Ilem, 
the Deputy National Legislative Director for the Disabled 
American Veterans, Alethea Predeoux, the Associate Director for 
Health Legislation for the Paralyzed Veterans of American, and 
Ralph Ibson, the National Policy Director for the Wounded 
Warrior Project. We thank you so much for being here. And, Ms. 
Ilem, you are recognized for five minutes.

 STATEMENTS OF JOY ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR 
FOR THE DISABLED AMERICAN VETERANS; ALETHEA PREDEOUX, ASSOCIATE 
DIRECTOR OF HEALTH LEGISLATION, PARALYZED VETERANS OF AMERICA; 
 RALPH IBSON, WOUNDED WARRIOR PROJECT, SENIOR FELLOW FOR POLICY

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Thank you, Mr. Chairman, and members of the 
Committee. We appreciate the opportunity to offer our views on 
the problems confronting the VA in meeting the critical mental 
health needs of our Nation's veterans. For over a decade, the 
media has covered readjustment challenges that new veterans 
face upon returning home. Likewise, the House and Senate 
Veterans' Affairs Committees have held numerous hearings on VA 
mental health services, and GAO and VA's inspector general have 
evaluated and examined a number of related issues.
    Typically, coverage focuses on veterans who have fallen 
through the cracks, taken their own lives, or gaps in VA and 
DoD mental health care. It is rare to see a positive report 
about VA mental health programs.
    Nevertheless, over the past five years, VA has made 
remarkable progress in establishing a stronger foundation for 
mental health services. VA has worked hard to institute the 
principles of recovery and a national policy to ensure 
consistency and availability of mental health services 
throughout its 1,400 sites of care. State of the art 
approaches, evidence based treatments, and new technologies 
have been deployed.
    All of this progress has occurred during a time of steadily 
increasing work loads and rising demand, culminating in the 
current situation VA is experiencing as it struggles to provide 
quality mental health care in a timely manner.
    Despite significant improvements in care, the current 
environment makes it difficult to shift perception to the gains 
VA actually has made. The recent IG report and informal survey 
by the Senate Veterans' Affairs Committee continue to point out 
lingering and troubling findings. According to the IG, VA is 
only meeting its 14 day access goal for completing a full 
mental health evaluation and treatment plan for about half of 
the new patients it sees.
    Based on these findings, VA reported it has developed a 
comprehensive action plan to enhance mental health services. It 
is conducting an external focus group to better understand the 
issues raised by front line providers, as well as conducting 
site visits to each of its medical centers to evaluate all 
mental health programs.
    While VA has applied these actions, many contributing 
problems exist. For example, after more than a decade, VA's 
office of information and technology has still not completed 
development of a state of the art scheduling system that can 
effectively manage appointment scheduling or provide accurate 
tracking and reporting. Likewise, despite the addition of 
thousands of new mental health staff since 2002, demand for 
services by tens of thousands of new veterans has strained the 
system. VA recently announced it needs to hire 1,900 additional 
mental health staff, but experts have pointed out that 
increased staff alone will not fix the existing problems. We 
agree.
    So the question is what could and should be done at this 
critical juncture. Unfortunately, the problems in VA's mental 
health program are multiple, system based, longstanding, and 
complex in some cases and cannot be resolved by any single 
action. However, as VA moves forward, we urge a focus on 
correcting the root of its problems to find real solutions, not 
just applying temporary measures for a quick fix.
    We believe one of the barriers that prevents VA from being 
more effective in many of its programs is human resources 
policy and management practices surrounding them. Clinical 
leaders across the VA system have told VA for years the 
recruitment of new professionals is a lengthy and frustrating 
problem that contributes to VA's current issues. We urge the 
Committee to carefully examine VA and OPM appointment 
authorities and statute and regulation to learn how they are 
being applied and determine whether new legislation might offer 
some resolution.
    VA must develop reliable data systems, fix the flaws in its 
appointment scheduling system, develop a usable staffing model 
that allows providers to address veterans with their physical, 
mental, and social health and do all of this in a patient 
centered manner. We make a number of other specific 
recommendations in our formal statement to the Committee and 
VA, as well.
    In closing, we appreciate VA's progress in developing an 
improved mental health system of care and the Committee's 
continued funding commitment to VA mental health and its 
oversight efforts. DAV recognizes this progress and support, 
but it is eclipsed and obscured by the problems we are 
discussing here today and happening at the worst possible 
moment when expectations are the highest.
    We believe, collectively, the recommendations we are 
making, along with VA's own planning measures and Congress' 
continued oversight, can help to begin to resolve these issues. 
And we urge VA to solidify its plan, and act expeditiously.
    Mr. Chairman, that concludes my statement. I am happy to 
answer any questions.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    The Chairman. Thank you very much.
    Ms. Predeoux, you are recognized.

                 STATEMENT OF ALETHEA PREDEOUX

    Ms. Predeoux. Chairman Miller, Ranking Member Brown, and 
Members of the Committee, thank you for allowing Paralyzed 
Veterans of America to testify today on one of the most 
important health care issues facing America's veterans and the 
health care system of the Department of Veterans Affairs. PVA 
believes that when veterans have timely access to quality 
mental health care services they in turn have the opportunity 
to establish productive personal and professional lives.
    In recent years the VA has made tremendous strides in the 
quality of care and variety of services provided to veterans in 
the area of mental health. Although these improvements were 
much needed and have helped many veterans, PVA believes that 
issues of access and mental health care within the VA continue 
to exist and more must be done to make certain that all 
veterans receive mental health care that is timely and 
effective.
    The VA's Office of Inspector General report, entitled, 
``Veterans Health Administration: Review of Veterans' Access to 
Mental Health Care,'' identified many weaknesses within VA's 
Department of Mental Health that if improved upon will allow VA 
to continue in its progression of providing high quality mental 
health services to veterans. Overall, the report concluded that 
VHA's mental health performance data is not accurate or 
reliable and VHA measures do not fully reflect critical 
dimensions of mental health care access.
    The report provided recommendations that PVA believes will 
help VA better identify and address the issues of access to VA 
mental health care services. In addition to those 
recommendations, PVA believes that increased attention to 
staffing, productivity and performance of providers, and 
patient demand will further assist VA in providing care that 
makes a difference in the lives of veterans.
    The analysis and results from the VA OIG report on mental 
health access data shines light on the inconsistencies of 
policy implementation within VHA and how such inconsistencies 
can negatively impact veterans' access to quality care. For 
instance, VA requires that all first-time patients receive a 
treatment planning evaluation no more than 14 days from the 
initial request or referral for services.
    As the VA OIG report makes clear, various mental health 
offices within VA have been interpreting this policy to have 
multiple meanings, and the end result is not having reliable 
data to accurately assess veterans' access to care or the 
performance of providers. The VA must ensure that staff adheres 
to all policies that are put in place to guarantee a high 
caliber of services for veterans, and must further develop 
safeguards that ensure such policies are carried out correctly 
from day to day.
    As it relates to staffing for the past years, PVA's Medical 
Services and Health Policy department has identified consistent 
staffing deficiencies of mental health professionals within the 
Spinal Cord Injury System of Care.
    Deficiencies in mental health staffing directly impact 
veterans' access to mental health services. For example, within 
VA's SCI system, veterans receive annual examinations that 
encompass a mental health screening. This annual mental health 
screening is extremely important for veterans who have 
sustained a catastrophic injury as they have a high propensity 
to face challenges involving self-esteem, independence, and 
quality of life. The aforementioned mental health staffing 
shortages have the potential to compromise quality mental 
health screenings and treatment for veterans within the SCI 
system of care who are dealing with symptoms of mental health 
conditions.
    Another issue that impedes patient wellness involving VA 
mental health care is the inpatient mental health services 
readily available to veterans with catastrophic disabilities. 
PVA's Medical Services team has found that inpatient care is 
not always available to veterans with a spinal cord injury or 
disorder due to a lack of accessible space, or the VA not being 
able to provide the necessary physical and medical assistance 
that is often needed when a veteran has a catastrophic injury 
or illness. When this is the case, these veterans are referred 
to alternative methods of treatment that may not always 
adequately meet their needs. The VA must work to provide all 
veterans with access to mental health services when they seek 
the help. A physical disability or multiple complex health 
conditions should not prevent veterans from receiving quality, 
effective mental health care.
    PVA thanks Congress and VA for investing a great deal of 
resources into improving mental health services in recent 
years. While PVA does not believe that there is just one 
definite solution to improving veterans' access to VA mental 
health services, we do believe that a comprehensive assessment 
of veterans' needs and mental health staffing is a starting 
point for identifying both strengths and weaknesses within the 
delivery of mental health care. All veterans, regardless of 
generation should have access to timely, quality mental health 
services.
    I would be happy to answer any questions that you might 
have.

    [The prepared statement of Alethea Predeoux appears in the 
Appendix]

    The Chairman. Thank you very much.
    Mr. Ibson.

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Thank you, Mr. Chairman. Chairman Miller, 
Ranking Member Brown, and Members of the Committee. Speaking 
for Wounded Warrior Project, VA can have few higher priorities 
than providing both timely and effective care to those with 
combat related mental health conditions.
    Too often veterans are not getting either. Let me explain. 
Some weeks ago, Wounded Warrior Project initiated a survey of 
VA mental health staff to better understand the reality on the 
ground. With responses from clinicians in 17 of VA's 22 
networks, 87 percent say their clinics or programs are 
understaffed. As one put it, ``VA in this area is entirely 
overwhelmed and booked to capacity.'' 80 percent say staffing 
shortages are the reasons for the long delays veterans are 
facing, but most also indicate that staffing problems limit the 
kind of treatment they can provide. For example, 55 percent 
reported that OEF/OIF patients were either frequently or very 
frequently assigned to group therapy even though individual 
therapy would have been more appropriate. And almost 60 percent 
disagreed or strongly disagreed with the statement that they 
have leadership support to choose the most appropriate 
treatment for their patients.
    We welcome VA's plan to hire more staff, but it seems clear 
from today's testimony that the Department really has no 
reliable way to know how many staff are needed in any given 
facility. And as is also attested to, many VA facilities don't 
even have space for additional staff.
    As further discussed, with serious shortages of mental 
health professionals in this country, there are serious 
questions about the Department's ability to hire the additional 
staff and fill the many vacancies. That challenge, as earlier 
discussed, is likely to be compounded, given that most of our 
survey respondents describe their work environment as highly 
stressful and more than 40 percent said they are considering 
leaving VA employment.
    Let me share the perspective of just one of those 
clinicians. ``The reality is that VA is a top down organization 
that wants strict obedience and does not want to hear about 
problems. I have little hope there will be real improvement. 
You'll only see bandaids and more useless performance measures 
designed to make management look good.''
    Just as some clinicians feel they are not heard, we 
question whether the veteran is heard. Particularly striking is 
VA's strong promotion of the use of two PTSD therapies that 
involve repeated intense exposures to wartime trauma. Many 
veterans just do not want that kind of therapy, but are not 
getting any other choice.
    Ultimately it is critical to understand the impact the 
kinds of problems we have described today are having on the 
veteran. And let me just read a few of the observations that 
mental health staff shared with us:
    ``I have a patient who came very close to attempting 
suicide in between appointments. I strongly believe that if I 
could meet with him weekly or even more on occasion his 
suicidal ideation would have decreased and he would be less 
likely to act on his thoughts.''
    ``Even telling patients that the only therapy we can offer 
them involves prolonged exposure to the traumas they have 
experienced sends them elsewhere.''
    ``We have veterans who come hundreds of miles for their 
appointment and they get, at most, 30 minutes with us.''
    Mr. Walz's observations regarding mental health parity, I 
thought, were very telling and I think there is a real question 
as to whether or not there is mental health parity within the 
VA--parity in terms of resources, parity in terms of staffing, 
parity in terms of support for mental health care relative to 
needs of veterans.
    But let me say, acknowledging that VA has offered solutions 
and is certainly trying very hard, that there's more that can 
be done. I think Representative Buerkle said it well. VA cannot 
do it alone. It is time for VA to reach out to its medical 
school partners, to organizations of mental health 
professionals, to the faith community and far wider, and be 
clear and say we cannot do it all, we need your help.
    Certainly, as Ms. Brown and others suggested, VA must use 
community-based care options which are available on paper but 
not necessarily as widely used as they should be when it cannot 
provide Wounded Warriors timely effective treatment.
    A second point: in a very real sense the VA operates two 
mental health care systems, its Vet Center System and system of 
care through medical facilities. Those two systems need to be 
better integrated, but we can also recognize and should 
recognize, in my view, that many Vet Centers are also under 
staffed, heavily, very subscribed to and sometimes over booked. 
They need additional staffing, too, and we probably need 
additional Vet Centers.
    And a third point, again, I recognize and appreciate the 
hard work that a relatively small staff in VA Central Office is 
doing to put out some of these mental health fires and to try 
and solve these problems.
    But I think the earlier testimony we heard from Dr. Sawyer 
spoke to the strength, the dedication, the commitment, the zeal 
of those dedicated mental health clinicians at the facilities 
on the ground. Bring them into the process, too. Let them be 
part of the solutions. I think that's a critical step toward 
building the trust that is so critical to a healthy work place 
and to successful recruitment and retention.
    Let me thank you for your continued focus on these issues 
through a long day and to your dedication to the importance of 
timely effective VA mental health services for our warriors.
    I, too, would be happy to address your questions.

    [The prepared statement of Ralph Ibson appears in the 
Appendix]

    The Chairman. Thank you very much for your testimony and, 
again, bearing with us all morning and this afternoon. Ms. 
Ilem, I was struck in your testimony where you said it is a 
common practice for resource Committees to deny authorization 
to fill mental health and substance positions creating ghost 
positions that are listed in the service FTEE allocations, but 
can never be recruited. And we understand that in many 
locations the 1,900 newly allocated FTEEs will not even be 
sufficient to fill these vacancies. Would you elaborate on the 
idea of ghost positions?
    Ms. Ilem. Sure. You know, as part of preparing for the 
hearing, we reach out to different mental health providers 
around the system and we feel that their input is extremely 
important. They are the people that are on the ground facing 
the challenges that they are, and this is just some of the 
information that a couple of folks have shared with us.
    And we have heard that repeatedly. In the independent 
budget I know we have worked on some H.R. issues and asking 
what are these very long delays, why is it taking so long, and 
it seems to be at, maybe, perhaps certain facilities, you know, 
because of budget, budget concerns. That is a way to delay 
hiring someone, although it is an authorized position.
    The Chairman. I would like to ask if any of you have heard 
reports that women whose combat experience is termed 
``unofficial'' are being barred from group therapy sessions 
dealing with post-traumatic stress because they are reserved 
for combat veterans. Has this been brought to your attention? 
If so, do you think that VA needs to change the eligibility 
requirements for group therapy to include all patients 
diagnosed with combat-related PTS? And I would ask any of you 
that have heard of that, if you would comment. If you haven't, 
that is fine, too.
    Ms. Ilem. I have not heard that regarding women veterans 
specifically. But certainly this has been an ongoing problem 
that we hear. There are a number of films that have come, 
brought to light, still, the recognition or the lack of 
recognition that women really are participating in combat or 
their exposure to combat is very, you know, is very real, and 
when they are coming back, they need the same types of services 
as male veterans. And oftentimes we are told that I am not 
believed or they just don't understand. They just cannot 
comprehend that as a woman I have been exposed to these 
realities of combat.
    So I think VA needs to work very hard and I know there are 
a number of ongoing research projects in women's health 
specifically about combat related PTSD. I mean, there are some 
small groups and ongoing research that we have been very 
closely monitoring and we think that we are going to see more 
and more of that and it absolutely has to be adjusted to 
accommodate women veterans as all veterans.
    The Chairman. Thank you.
    Ms. Predeoux, have you heard of that?
    Ms. Predeoux. The same as my colleague, Joy, it has not 
been reported to me, but I have heard it through attending 
other sessions involving women veterans, and if that is the 
case with regard to VA policy, then I wholeheartedly do think 
the policy needs to be inclusive of all veterans regardless of 
gender and generation.
    The Chairman. Mr. Ibson?
    Mr. Ibson. Yes, Mr. Chairman. I believe one of the 
responses we got in our survey suggested that that was the 
experience at that particular facility. I would not be able to 
represent that that was widespread, sir.
    The Chairman. Well, I appreciate that. It will be one of 
the follow-up questions that we do send to VA because it was 
buried in some questions I was going to ask the Secretary, but 
I just wanted to know from the Veteran Service Organizations if 
you are aware of it.
    Ms. Brown?
    Ms. Brown. Thank you, Mr. Chairman. I guess my question, 
and I am glad you all were able to get lunch in that small 
window, but what do you believe is the number one barrier 
veterans are facing when they are accessing mental health 
services because we have a lot of discussion? And I really kind 
of like what the Admiral was saying the last time because I 
have been pushing that we need to have partners, and it is just 
not the VA. I don't see the VA going out hiring 3,000 people.
    I see us working with people that are already doing it and, 
for example, he said the tri-care. They have people that work 
with tri-care, so they already are very familiar with working 
with veterans/military personnel.
    Ms. Predeoux. With regard to the number one issue, they're 
all important, but I would say with regard to access, it would 
be the wait times and actually being able to get in and 
oftentimes that is due to the large patient panel and patient 
load that the mental health providers are taking on in the VA.
    We did the same as DAV, but we didn't send it out to mental 
health professionals. We sent our questions out to our national 
service officers through our benefits department, and there 
were some facilities where there were no wait times. Veterans 
were able to be seen in less than 14 days and then there were 
other facilities where it was 30 days or more before that 
initial, I guess, what was the create time from the initial 
point of contact.
    So it is more so of getting the veterans in at the initial 
time and not having wait times discourage or further escalate 
issues.
    Mr. Ibson. If I could take a shot at that, Congressman, you 
know, certainly staffing is a major issue and one could see 
that as the major barrier, and yet even to say that would be to 
oversimplify because staffing has so many elements.
    It strikes me it is not just about recruitment as heard 
today, but it is also about retention, and you have to ask 
about VA's ability to retain clinicians when they don't have 
the opportunity to provide the type of treatment they think is 
clinically appropriate or when they don't have dedicated office 
space or when, as Dr. Sawyer described, they don't feel they 
have any independent judgment, but are recipients of directives 
from on high.
    So it is a complicated question and a multi-faceted 
question as several have suggested earlier.
    Ms. Brown. Well, let me just ask you this follow up 
question because we are losing professionals in VA and in 
Federal government because lack of pay. We are not competitive 
with other areas. It is nice to think that you--pay is not a 
factor, but let us say someone goes to medical school or 
someone goes to a professional program. If there was some way 
that the student loan could be tied into working into some of 
the critical areas, then that would be incentive to encourage 
people to work in, let us say, the rural areas. You know, I 
live in Florida, so everyone wants to live in Florida, I guess.
    But I wouldn't have the same to work in maybe a smaller 
town in Georgia, but if you could tie it in some way to that 
student loan, do you think that would encourage people to want 
to work in the VA for a certain period of time?
    Mr. Ibson. I think that is certainly one possible strategy, 
but I would note Dr. Sawyer's very eloquent presentation of how 
young men and women in the health professions are motivated to 
help veterans and that pay is not necessarily the critical 
factor. Rather what seems important is the opportunity to be 
fulfilled and satisfied and work helping others, and to the 
extent that the system fosters that kind of environment, I 
think, VA would be a very conducive and attractive place to 
work, and I think that is a challenge.
    Ms. Brown. I agree with you, but I also heard someone 
coming right out of professional school, and I would think that 
some experience would be important working with, depending on 
the area of care that the person encountered. You want them to 
have experience, but you want them to have the academic book 
also. So it is a combination.
    Mr. Ibson. I would agree.
    Ms. Brown. Yes, ma'am.
    Ms. Predeoux. In our surveys that were sent out to our 
national services officers, pay was not a question. However, it 
did come up in a few responses with regard to structural issues 
and I did not have an opportunity to research further with 
regard to pay and I think it was specifically two 
psychologists. But the other side of that, also, and we also 
discussed it in the independent budget H.R. session, the VA 
currently has educational reimbursement programs and different 
scholarship programs, but they have not been increased for a 
significant period of time, so that is something to consider 
when addressing more of the systemic issues in keeping 
retention issues within VHA.
    Ms. Brown. Okay. I yield back.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, Chairman. Thank you all for your 
testimony.
    I do come back to the parity issue, Ralph, and this is a 
broader issue. I was thinking, looking at the numbers as we 
talk about access. In this country there is 340 people for 
every medical doctor. There are 3,400 for every psychologist or 
mental health practitioner. We are graduating about 18,000 to 
20,000 doctors per year and we are already experiencing a great 
shortage in general practitioners. We are graduating about 
4,000 psychologists. It is just impossible to keep up with 
those numbers. I think it goes back to where Ms. Brown and 
others were talking about of how we build this model to 
collaborate to try and drop on the resources we have. There is 
both a shortage in the private sector as well as the VA.
    My concern is, and I will start with you, Mr. Ibson, and 
maybe just ask each of you. I, for one, do believe that there 
is an opportunity here to use some other people outside the 
system. I have seen it happen. I also know one of the problems 
is, is how do we ensure that these providers are providing 
evidence-based care and the outcomes we want to see, too, 
because if we are going to ask the VA to take taxpayer dollars 
and fund it out, then we are going to be asked to be 
accountable for every penny of that just like we are doing 
today.
    How do we know that we are going to get the care there 
also, if we have to drop on outside resources? I don't know, 
Ralph. Have you had any thought on that or how that moves 
forward because I think--I just don't see the numbers here on 
the ability for us to deliver care as quickly because there is 
just not that many mental health care providers for the need 
that is going to be there. We cannot even keep our head above 
water and it is going to get worse.
    Mr. Ibson. Well, at the risk of ducking your question, I 
did want to observe the importance of your earlier emphasis and 
reemphasis on outcomes because it is one thing that VA is not 
measuring, and given a department that is so committed to being 
a leader, this is an area where leadership is desperately 
needed in terms of developing measures of outcomes. Ultimately, 
having performance measures which give us indicators of inputs 
and throughputs and numbers and percentages, but don't tell us 
whether veterans are getting better. Such measures are not 
going to advance our veterans' well being.
    I think that would be an important step to VA's solving its 
own problems.
    Mr. Walz. You are not as concerned on this evidence-based 
outcome because you are not convinced it is happening inside 
the VA as it stands. I don't want to put words in your mouth, 
but----
    Mr. Ibson. I think that is fair, sir. But I think you are 
certainly quite right. We can't just willy-nilly put veterans 
in the hands of individuals who don't have the clinical 
competence or the cultural competence to provide them effective 
treatment.
    Mr. Walz. Any of us who have been at this for a while 
experiences this. We have the psychologist or the care provider 
who has worked with veterans for decades, starting with Vietnam 
and they do it brilliantly and then they don't get the ability, 
in some cases to get fee for service. They come to us with 
their veterans and say, I want to see Dr. So-and-so who is 
outside the system and then they see it as the VA being, you 
know, kind of provincial, kind of holding their stuff in and 
they don't want to help anybody, but for every good Doctor A, 
there may be one out there that doesn't have that experience or 
isn't providing evidence based, so I am trying to find that 
rationale of where we set those guidelines.
    Mr. Ibson. You know, I think one step forward in the spirit 
of this being a larger problem than just VA's, would be for VA 
to provide training to community clinicians in terms of just 
the military culture issues which are such an important part of 
connecting with the veteran and developing the kind of trust 
that Dr. Sawyer's testimony suggested was so important.
    Mr. Walz. Do the rest of you have any comments on this as a 
concern as we try and broaden the provider base for our 
veterans?
    Ms. Predeoux. I think it is a very complex issue, 
especially when you are dealing with holes that are evident 
within the VA system, and rather than being able to quick fix, 
in the meantime we have veterans who need care. I do think that 
making sure that there are standards and safeguards in place so 
that there is accountability, is very important, and along the 
same lines of not necessarily training, but making sure that 
there are actual levels of literal standards that providers 
must meet before the VA is able to enter into that type of 
agreement for outside care.
    Ms. Ilem. And I would just add, I think, from the previous 
panel, it was noted, we have some of our tri-care provider 
networks that obviously have that connection, the veteran 
cultural competency in place. VA does have, I believe, a few 
small pilots with a couple of them related to mental health. I 
think it is more in rural health right now, at least they are 
attempting to. It just has not been on any significant scale.
    And given all of the remarks, you know, from all of the 
panels today, we are hoping that VA will come away with at 
least keeping an open mind to trying to address this problem. I 
have had a couple of, you know, experts say we don't think VA 
can buy their way out of this issue in terms of, you know, just 
ramping up the numbers. We know how long it is taking them to 
get actual people online----
    Mr. Walz. Well, I think the potential is great here to run 
both ways. As I said, my meetings with Mayo Clinic of looking 
for partnerships on Tele-Health and those types of things, I 
think, show that the private sector is willing to be there, and 
I think at least the overtures from VA is their willingness to 
go both ways.
    I think there is a potential here for us to expand that 
care in both sides, and I think there is a lot of good lessons 
learned from our VA practitioners that can apply into the 
public sector, whether it is domestic violence issues or 
whatever they might be.
    So, well, thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much, Mr. Ibson. Would you--in 
your testimony you talked about cultural problems facing VA. We 
know that there are cultural problems facing VA, but you talked 
about a perception that leadership employs, and I am not 
talking about any particular secretary. I am talking about 
leadership as a whole, employs a command and control model 
without regard to whether the facility's clinical staff 
actually has the means to carry them out, and what I would like 
to ask you to do is expand a little bit about that statement.
    Mr. Ibson. Well, I am attempting in that statement to echo 
the sentiments of many providers who responded to our survey 
conveying that thought. This was an anonymous survey, but of 
those who expressed a willingness to speak and with whom I 
followed up, this was a common theme. I think Dr. Sawyer 
expressed it perhaps better than I am. But it's about a 
workplace climate, which is perhaps born of good will, but 
which stems from centrally directed performance measures which 
ultimately as they find their way to the clinic level, overtake 
good clinical judgment and come across as mandates and 
directives, and seem difficult to understand.
    I am thinking, for example, of a provider who reflected on 
a requirement to discuss smoking cessation therapy with 
patients and who commented that ``I have a veteran sitting 
across the table from me whose wife just died and how ludicrous 
it is to think that I should set those compelling issues aside 
to discuss his smoking habit with him.''
    It is, again, I think, a matter of well intended measures 
that are proxies for good care, but which at the clinic level, 
at the provider level, don't necessarily translate to good care 
and overtake and impede good care.
    The Chairman. Ms. Brown, Mr. Walz, any other comments?
    Ms. Brown. I do have one last question. How do you all 
feel--I personally feel that the VA cannot go it alone. We need 
to work with our partners and stakeholders and in that there 
was a discussion about having a series of one-day conferences 
to bring in the partners that were with us. How do you feel 
about how we can get the community more involved? For example, 
Jacksonville and CSX was the first wounded warrior program in 
the country and I am very proud of that, but how do we get 
more--because I don't see government just doing it alone.
    I think we have to work with our partners and stakeholders 
in the private sector and the universities and the community 
colleges. It is really a team effort. And to think that the VA 
can just do it by themselves is ludicrous. It is too many 
veterans. It is too many issues. I mean we are talking about 
mental health, mental health. It affects my mental health if I 
can't pay my mortgage and I am about to lose my home. It 
affects my mental health--many, many things affect my mental 
health. When you lose a spouse, it is many things. It is not 
just one. So it is the whole village, and how do we engage the 
community and how do we get different stakeholders to 
participate. And so any comments on that?
    Mr. Ibson. I think this hearing offers a wonderful 
opportunity to advance that theme. I think I hear it as a 
bipartisan matter and I think Admiral Mullen has spoken so 
eloquently of that sea of goodwill out there. I think it is a 
matter of harnessing that spirit and offering some leadership, 
and I think this Committee is in a position to do that.
    Communities are desperate for avenues of engagement and I 
don't know that the Department of Veterans Affairs feels it has 
the clear signal to acknowledge its limitations and to reach 
out in a way in which it, I think, very effectively could to 
those communities such efforts would look different, community 
to community, but there are, I think, enormous opportunities to 
advance those goals through partnerships.
    Ms. Brown. I think you all play a very important part 
working with us to push for these efforts that I think is like 
one team, one fight. I think you all, you all, the service 
organization, play a very important part.
    Mr. Ibson. It is certainly our view.
    Ms. Ilem. And I would just add, I think the community over 
seven or eight years ago, I mean, we have seen it repeatedly on 
occasion to have, you know, them come and group together saying 
we want to know how we can help our veterans and what we can 
do.
    I think one of the things VA might do--as we know, many 
people choose not to go to VA for whatever reason. Not 
everybody is going to go, but certainly they may need mental 
health and touch the community and it may be a family member or 
other people within the family that are struggling along with 
that veteran, so if VA does have an opportunity to share their 
expertise through their national center for PTSD for, you know, 
perhaps in some cases for those who suffered trauma through 
military sexual trauma and other traumas, it could be very 
helpful if VA was able to offer that in some way for those that 
are seeing people in the community already.
    Ms. Brown. In closing, let me just say that I have 
participated in numerous workshops and town hall meetings and 
hearings that we had with women veterans and, you know, part of 
the problem a lot of women are experiencing, that they 
indicated, is the culture of the VA and the culture of the 
military. So I suggested, well, maybe we could farm this out 
using different organizations, outsource--oh, I hate that 
word--but maybe we can outsource this to different providers. 
And they said, no, we want the VA to provide it.
    So basically we have this culture that I don't think is as 
conducive to women, which is the fastest growing group, but 
they want the VA to provide it and one example that they talked 
about when they walked in, but you know, they had cat calls. 
Well, you know, when you walk down the street, you may get cat 
calls, but how do you change not the people that work there, 
but the other people that are there in the facilities? How do 
you not integrate the services to provide the kinds of services 
that the female veterans want?
    And I am not saying it for an answer. I am just spelling 
out some of the challenges that the VA experienced and it is 
going to take all of us working together to solve some of these 
problems. It is not just the VA. It is us, you all and us, 
Members of Congress, working bipartisan to try to solve these 
challenging issues that are so many, many, many. Whether it is 
our community getting together doing the stand downs that I 
participate in or working to eradicate the homelessness among 
veterans. You can't expect just veterans to do it, but it is 
veterans, VA hard labor, all of us working together, everybody 
doing their job, everybody being on their A game and not just 
expecting the VA to go it alone. It is a team effort. Thank 
you, and I yield back the balance of my time.
    The Chairman. I thank you very much. I would ask unanimous 
consent that all members would have five legislative days to 
revise and extend their remarks.
    And without objection, so ordered.
    And I want to again thank the witnesses for remaining with 
us. Dr. Petzel, thank you, sir, for remaining the entire time 
of this lengthy hearing. We know that it is important to you 
and we appreciate you being here.
    And with that, this hearing is adjourned.

    [Whereupon, at 3:58 p.m. the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

            Prepared Statement of Hon. Jeff Miller, Chairman
    The Committee will come to order.
    Good morning, and welcome to today's Full Committee hearing ``VA 
Mental Health Care Staffing: Ensuring Quality and Quantity.''
    Two weeks ago yesterday, the VA Inspector General (IG) released a 
report reviewing veterans' access to mental health care.
    To say that the findings in that report are troubling would be a 
serious understatement.
    Perhaps most disturbing is IG's discovery that more than half of 
the veterans who seek mental health care through VA wait an average of 
FIFTY days to receive a full mental health evaluation.
    Let me be very clear--a veteran who comes to VA for help should 
never--under any circumstance--have to wait almost two months to 
receive the evaluation they have asked for and begin the treatment they 
need. There is no excuse for this.
    Given the gravity of the issues we will discuss this morning, I 
invited Secretary Shinseki to participate in today's hearing.
    Sir, I was concerned, based on a letter from you last week, that 
you would not be joining us this morning.
    I am very glad that is not the case.
    As you know, leadership and accountability begin at the top.
    These hearings are much more than just opportunities for the 
Committee to hear from the Department.
    They are also opportunities for the Department to hear from us.
    And, in both respects, there is no one better positioned to 
represent VA than you are.
    Thank you for being here this morning.
    Interestingly, just days before the IG report was released, VA made 
a surprise announcement that VA would be increasing their mental health 
staff by nineteen hundred--adding approximately sixteen hundred 
clinicians and three hundred support staff to their current roster of 
just over twenty-thousand mental health professionals.
    Ensuring VA is staffed adequately to fulfill the care needs of our 
veterans and their families is a priority of mine. On its face this is 
an encouraging step.
    However, I remain deeply concerned by the timing and implication of 
this announcement.
    The IG's report clearly illustrates that the VA does not have 
meaningful or reliable data to accurately measure a veteran's access to 
care or a facility's mental health staffing needs.
    The IG states--and I quote--``. . . the complexity of the 
computations and inaccuracies in some of the data sources, limits the 
usability of productivity information to fully assess current capacity, 
determine optimal resource distribution, evaluate productivity across 
the system, and establish mental health staffing and productivity 
standards.''
    Which begs the question--if VA doesn't even have a complete picture 
of the problem, how confident can we be that access will be increased 
and care enhanced by VA's knee-jerk reaction?
    This is not the first time we have been here.
    There is a long history of IG, Government Accountability Office 
(GAO) and stakeholder reports that have found serious deficiencies with 
the VA mental health system of care, including appointment scheduling 
processes and procedures, PROVIDER performance measures, and data 
collection efforts.
    There is an equally long history of Congressional oversight.
    Strides have been taken, but they are far from enough.
    I would like to give the Department the benefit of the doubt.
    I believe that we all have the best interests of our veterans at 
heart.
    But, I am afraid that VA's response in this instance is yet another 
example of a Federal bureaucracy providing a quick-fix, cookie-cutter 
solution to a very serious, multifaceted problem.
    A true definition of access to care can be found in a 1993 
Institute of Medicine report which reads, in part, ``[t]he most 
important consideration is whether [patients] have an opportunity for a 
good outcome--especially in those instances in which medical care can 
make a difference.''
    The one point three million veterans who sought mental health care 
through VA last year deserve better.
    The very least we owe our veterans is a chance.
    VA can make a difference and VA must make a difference.
    Thank you all for being here today. I now yield to the Ranking 
Member, Ms. Brown.

                                 
          Prepared Statement of Robert L. Jesse, M.D., Ph. D.
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee, I appreciate the opportunity to address access to, and 
quality of, VA's mental healthcare. I am accompanied today by Mary 
Schohn, Ph.D., Director, Office of Mental Health Operations, Antonette 
Zeiss, Ph.D., Chief Consultant, Office of Mental Health Services, and 
Annie Spiczak, Assistant Deputy Under Secretary for Health for 
Workforce Service, supporting all of VHA.
    Over the past several years VA has been transforming its mental 
health delivery system in response to the growing demand for these 
services. Over the previous year, VA has learned a great deal about 
both the strengths of our mental healthcare system, as well as areas 
that need improvement. VA's Office of Inspector General (OIG) recently 
completed a review of our mental health programs and offered four 
recommendations. The OIG cited a need for improvement in our wait time 
measurements, improvement in patient experience metrics, development of 
a staffing model, and provision of data to improve clinic management. 
VA is using the OIG results along with our internal reviews to 
implement important enhancements to VA mental healthcare. VA constantly 
strives to improve, and any data and assessments--positive or 
negative--will be used to help enhance services provided to our 
Veterans.
    The OIG confirmed that Veterans seeking an initial mental health 
appointment did generally receive the required rapid triage evaluation 
in a timely manner. This is an important step to identify high risk 
patients who need immediate intervention. While a mental health 
evaluation within 14 days following the triage referral generally 
occurs, we agree with the OIG that not all Veterans were able to 
receive a full diagnostic and treatment evaluation required by VA 
policies, especially for some intensive services such as beginning a 
course of evidence-based psychotherapy. While the explanations for 
these findings are varied, none are satisfactory--VA must do more to 
deliver the mental health services that Veterans need in a time period 
that supports their care.
    Based on these findings, we are enhancing staffing and recruitment 
efforts, updating scheduling practices, and strengthening performance 
measures to ensure accountability. By taking these steps, we are doing 
more than ever to deliver accessible, high quality mental healthcare to 
Veterans. My written statement describes how we have traditionally 
evaluated access to mental healthcare and how we propose to evaluate 
access in the future. It will then explain how we assess the quality of 
care delivered and potential new considerations on this topic. In light 
of these discussions, I will conclude with an explanation of VA's 
recent enhancement of mental health staffing.
Access to Care
    Ensuring access to appropriate care is essential to helping 
Veterans recover from the injuries or illnesses they incurred during 
their military service. Access can be realized in many ways: through 
face-to-face visits, telehealth, phone calls, online systems, mobile 
apps, and community partnerships. Over the last several years, VA has 
enhanced its capacity to deliver needed mental health services and to 
improve the system of care so that services can be more readily 
accessed by Veterans. VA believes that mental healthcare must 
constantly evolve and improve as new research knowledge becomes 
available. As more Veterans access our services, we recognize their 
unique needs and needs of their families--many of whom have been 
affected by multiple, lengthy deployments. In addition, proactive 
screening and an enhanced sensitivity to issues being raised by 
Veterans have identified areas for improvement.
    In an effort to increase access to mental healthcare and reduce the 
stigma of seeking such care, VA has integrated mental health into 
primary care settings. Since the start of fiscal year (FY) 2008, VA has 
provided nearly two million Primary Care-Mental Health Integration (PC-
MHI) clinical visits to more than 575,000 unique Veterans. Primary care 
physicians systematically screen Veterans for depression, post-
traumatic stress disorder (PTSD), problem drinking, and military sexual 
trauma to identify those at risk for these conditions. Research on this 
integration shows that as a result, Veterans who would not otherwise be 
likely to accept referrals to separate specialty mental healthcare are 
now receiving mental health treatment. Among primary care patients with 
positive screens for depression, those who receive same-day PC-MHI 
services are more than twice as likely to receive depression treatment 
than those who did not. These are important advances, particularly 
given the rising numbers of Veterans seeking mental healthcare.
    In August 2011, VA conducted an informal survey of line-level staff 
providers at several facilities and learned of concerns that Veterans' 
ability to schedule timely appointments may not match data gathered by 
VA's performance management system. These providers articulated 
constraints on their ability to best serve Veterans, including 
inadequate staffing, space shortages, limited hours of operation, and 
competing demands for other types of appointments, particularly for 
compensation and pension or disability evaluations. In response to this 
finding, VA took three major actions. First, VA developed a 
comprehensive action plan aimed at enhancing mental healthcare and 
addressing the concerns raised by its staff. Second, VA conducted 
external focus groups to better understand the issues raised by front-
line providers. Third, VA is conducting a comprehensive first-hand 
assessment of the mental health program at every VA medical center. As 
of April 25, 2012, 63 of 140 (45 percent) site visits have been 
completed, and the remainder will be completed by the end of the fiscal 
year.
    Historically, VA has measured access to mental health services 
through several data streams. First, VA defined what services should be 
available in VA facilities in the 2008 VHA Handbook 1160.01 entitled 
Uniform Mental Health Services in VA Medical Centers and Clinics, and 
tracks the availability of these services throughout the system. 
Moreover, VA has added a five-part mental health measure in the 
performance contracts for VHA leadership, effective starting in October 
2011. The new performance contract measure holds leadership accountable 
for:

      The percentage of new patients who have had a full 
assessment and begun treatment within 14 days of the first mental 
health appointment;
      The proportion of Operation Enduring Freedom/Operation 
Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans with newly 
diagnosed PTSD who receive at least eight sessions of psychotherapy 
within 14 weeks;
      Proactive follow-up within 7 days by a mental health 
professional for any patient who is discharged from an inpatient mental 
health unit at a VA facility;
      Proactive delivery of at least four mental health follow-
up visits within 30 days for any patient flagged as a high suicide 
risk; and
      The percentage of current mental health patients who 
receive a new diagnosis of PTSD and are able to access care 
specifically for PTSD within 14 days of referral for PTSD services.

    VA policies require that for established patients, subsequent 
mental health appointments be scheduled within 14 days of the date 
desired by the Veteran. This has been a complicated indicator, as the 
desired date can be influenced by several factors, including:

      The Veteran's desire to delay or expedite treatment for 
personal reasons;
      The recommendation of the provider; and
      Variance in how schedulers process requests for 
appointments from Veterans.

    VA understands virtually every healthcare system in the country 
faces similar challenges in scheduling appointments, but as a leader in 
the industry, and as the only healthcare system with the obligation and 
honor of treating America's Veterans, we are committed to delivering 
the very best service possible. As a result, VA will modify the current 
appointment performance measurement system to include a combination of 
measures that better captures each Veteran's unique needs throughout 
all phases of his or her treatment. Some Veterans may need to be seen 
more frequently than within 14 days (for example, if they need weekly 
sessions as part of a course of evidence-based psychotherapy), while 
others may not (for example, if they are doing well after intensive 
treatment and will benefit most from a well-designed maintenance plan 
with far less frequent meetings). VA will ensure this approach is 
structured around a thoughtful, individualized treatment plan developed 
for each Veteran to inform the timing of appointments.
    VA has formed a work group to examine how best to measure Veterans' 
wait time experiences and how to improve scheduling processes to define 
how our facilities should respond to Veterans' needs. In the interim, 
the work group has recommended a return to the use of the ``create 
date'' metric (the metric used by the OIG during its review), which 
will minimize the complexity of the current scheduling process. The 
``create date'' refers to the date on which a Veteran requested an 
appointment, and the wait time will be measured as the numbers of days 
between the create date and the visit with a mental health 
professional. The work group is currently developing an action plan to 
be reviewed by the Under Secretary for Health by June 1, 2012. 
Performance measurement and accountability will remain the cornerstones 
of our program to ensure that resources are being devoted where they 
need to go and being used to the benefit of Veterans. Our priority is 
leading the Nation in patient satisfaction regarding the quality and 
timeliness of their appointments.
Quality of Care
    VA has made deployment of evidence-based therapies a critical 
element of its approach to mental healthcare. Mental health 
professionals across the system must provide the most effective 
treatments for PTSD and other mental health conditions. We have 
instituted national training programs to educate therapists in two 
particularly effective exposure-based psycho-therapies for PTSD: 
cognitive processing therapy and prolonged exposure therapy. The 
Institute of Medicine and the Clinical Practice Guidelines developed 
jointly by VA and the DoD have consistently concluded the efficacy of 
these treatment approaches.
    Not everyone with PTSD who receives evidence-based treatment may 
have a favorable response. Although VA uses the most effective 
treatments available, some Veterans will need lifetime care for their 
mental health problems and may see slow initial improvement. Almost 
everyone can improve, but some wounds are deep and require a close, 
consistent relationship between VA and the Veteran to find the most 
effective individualized approaches over time. Veterans and their 
families should not expect ``quick fixes,'' but they should expect an 
ongoing commitment to intensive efforts at care for any problems.
    A recent analysis of data shows that Veterans with the most severe 
PTSD are least likely to benefit from a standard course of treatment 
and to achieve remission. Other factors that predicted poor response 
were unemployment, co-morbid mood disorder, and lower education. In 
other words, those with the worst PTSD are least likely to achieve 
remission, as is true with any other medical problem.
    Even when Veterans are able to begin and sustain participation in 
treatment, timing, parenting, social, and community factors all matter 
a great deal. Treatment, especially treatment of severe PTSD, may take 
a long time. Evidence also shows that whereas a positive response to 
treatment may reduce symptom severity and increase functional status 
among severely affected Veterans, the magnitude of improvement may not 
always be enough to achieve full clinical remission. This is no 
different than what is found with other severe and chronic medical 
disorders. Providing the best treatments with the strongest evidence 
base is crucial to care, but is only one piece of a broader, ongoing 
commitment to rehabilitative care and treatments for other co-occurring 
mental health problems or other psychosocial problems that may develop.
    Based on ongoing surveys, we know that all VA facilities have staff 
trained at least in either prolonged exposure or cognitive processing 
therapy, and usually both. In addition, one of the preliminary results 
of our site visits found that many facilities have a strong practice of 
training more staff in these and other evidence-based therapies for a 
wide array of mental health problems.
    As more providers are trained in these approaches to care, 
facilities are shifting from their more traditional counseling approach 
to these newer treatments. We have not always communicated well enough 
to Veterans the nature or reason behind these changes. These new 
programs emphasize a recovery model, which is strengths-based, 
individualized, and Veteran-centered. A recovery-oriented model does 
not focus exclusively on symptom reduction, but has as its goal helping 
Veterans achieve personal life goals that will improve functioning 
while managing symptoms. These efforts have been recognized as 
successful in the academic literature and through a Government 
Performance and Results Act review conducted by RAND/Altarum, which 
concluded that VA mental healthcare was superior to other mental 
healthcare offered in the United States in almost every dimension 
evaluated.
    Before the development of these evidence-based approaches, VA made 
every effort to offer clinical services for PTSD based on clinical 
experience and innovation. Some of these approaches have developed into 
the evidence-based approaches we have now, while others have not been 
shown to offer the help that was expected. Even those therapies that 
did not help in truly alleviating PTSD could come to feel like 
``lifelines'' to those receiving them. For example, some sites hold 
group educational sessions to help Veterans understand PTSD symptoms 
and causes, and these sometimes developed into ongoing groups. While 
group therapy for PTSD can be effective and is cited in the VA/DoD 
Clinical Practice guidelines, group therapy is understood (and 
validated) as possible only in fairly small groups--usually fewer than 
10 participants. Educational groups often have far more members, 
sometimes up to 50 or more; while this can be an effective way to 
conduct psycho-education, it cannot be considered ``group therapy.''
    Veterans who have used some of the PTSD services previously adopted 
by VA may not be familiar or comfortable with newer approaches, and we 
must continuously educate Veterans and others about what treatments are 
most likely to be effective and how Veterans can access them. Some of 
our own providers have not understood these changes. The National 
Center for PTSD has been providing guidance through the PTSD mentoring 
program to help facilities collaborate with providers and Veterans in 
the transition. We have developed educational processes to help clarify 
the need for and rationale behind efforts to change clinical practice 
patterns to ensure best possible care for VA.
    VA's realignment of VHA last year created an Office of Mental 
Health Operations with oversight of mental health programs across the 
country. This has aligned operational needs and connected resources 
across the agency with data collection efforts to bring the full 
picture of VA's mental health system into focus. In fiscal year 2011, 
VA developed a comprehensive mental health information system that is 
available to all staff to support management decisions and quality 
improvement efforts. This year, a collaborative effort between VA 
Central Office and field staff is underway to review mental health 
operations throughout the system and to develop quality improvement 
plans to address opportunities for improvement through dissemination of 
strong practices across the country.
Enhancing Mental Health Staffing
    Decisions concerning staffing and programs were determined 
historically at the facility level to allow flexibility based on local 
resources and needs. In the past year, as evidence accumulates, it has 
become clear that sites can benefit from more central guidance on best 
practices in determining needed mental health staff. While no industry 
standards for accurate mental health staffing ratios exist, VA 
developed and is piloting a national prototype staffing level model for 
general mental health outpatient care. This staffing level model uses a 
methodology that considered findings in academic literature, 
consultation with other healthcare systems, and utilization and 
staffing data. This staffing model will be further refined as VA 
monitors its effectiveness and incorporates team-based concepts. VA 
will build upon the successes of the primary care staffing model and 
apply these principles to mental health practices. The model is based 
on the following guiding principles:

      Delivering quality comprehensive mental healthcare;
      Coordinating mental healthcare across all MH disciplines 
and the integration with primary care;
      Ensuring effectiveness and efficiency of service delivery 
by having all staff working at their highest level possible;
      Promoting team staffing to support all providers to 
function at the highest level;
      Dedicating time for indirect patient care activities (for 
example, care planning and team coordination); and
      Supporting a team response to emergent and non-emergent 
patient and family needs (for example, unscheduled phone calls).
    The model's clinical staffing ratio is as follows:

 
----------------------------------------------------------------------------------------------------------------
                                                          Full Time Employee Equivalent for Mental Health Clinic
                   Employee Category                                      Panel Size of 1,000
----------------------------------------------------------------------------------------------------------------
Total Mental Health Clinician                                                                           5.1-5.5
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Administrative Clerical Support                                                                           0.5-1
----------------------------------------------------------------------------------------------------------------
Clinical Support Direct                                                                                       1
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                                Total FTEE                                                              6.6-7.5
----------------------------------------------------------------------------------------------------------------

    Applying this model and these ratios, VA determined an additional 
1,700 mental health staff members (including administrative and 
clerical staff) were needed to augment existing resources across the 
country. Clinical staff will represent all specialties, including 
psychologists, psychiatrists, social workers, mental health nurse, 
licensed professional counselors (LPC), licensed marriage and family 
therapists (MFT), and others. In addition, VHA projected an additional 
100 compensation and pension examiners would be needed. Each Veterans 
Integrated Service Network (VISN) is receiving some additional support 
in either clinical or clerical staff or compensation and pension 
examiners. VA is also adding 100 staff to the Veterans Crisis Line to 
support projected increases in the use of this service. These 
enhancements in total will add more than 1,900 employees to VA's 
existing mental health staff of more than 20,500. VA Central Office is 
providing technical assistance to VISNs to help them with 
implementation and is providing additional funding to aid recruitment 
and hiring. VA's Office of Mental Health Operations will obtain monthly 
updates from facilities receiving funding to ensure implementation is 
timely and that resources are used appropriately.
    We are testing this model through a pilot program in VISNs 1, 4, 
and 22, and we anticipate national implementation of this new model by 
the end of this fiscal year. While the model may be refined as a result 
of the pilot testing, it provides a clear basis for assessing staffing 
for mental health services, and shows that currently there are 
shortfalls at some sites nationally that VA is addressing. We will use 
this staffing level model, with refinements made over time, to guide 
staffing decisions in the future. This will be combined with a review 
of revised clinical outcome measures, to be developed in consultation 
with other subject matter experts from VHA and the OIG, to evaluate 
whether enhanced staffing results in enhanced performance on more valid 
measures. We will reassess levels of care needs and specialty services 
based on these multiple data sources.
    Despite the national challenges with recruitment of mental 
healthcare professionals, VA continues to make significant improvements 
in its recruitment and retention efforts. Specialty mental healthcare 
occupations, such as psychologists, psychiatrists, and others, are 
difficult to fill and will require a very aggressive recruitment and 
marketing effort. VA has developed a strategy for this effort focusing 
on the following key factors:

      Implementing a highly visible, multi-faceted and 
sustained marketing and outreach campaign targeted to mental healthcare 
providers;
      Engaging VHA's National Health Care Recruiters for the 
most difficult to recruit positions;
      Recruiting from an active pipeline of qualified 
candidates to leverage against vacancies; and
      Ensuring complete involvement and support from VA 
leadership.

    VA anticipates the majority of hires for this effort will be 
selected within approximately 6 months, with the most ``hard-to-fill'' 
positions filled by the end of the second quarter of FY 2013. A VHA 
task force is targeting the recruitment and staffing requirements to 
bring these new employees into VA as effectively and efficiently as 
possible to meet our goals leveraging all available tools to bring 
needed providers on board.
    Implementation of the model will also support linking patients to 
their Patient Aligned Care Team (PACT) for care management (including 
medication maintenance and monitoring), enhance care transitions, 
expand peer-led services and community engagement for supportive care, 
and increase access to evidence-based individual and group 
psychotherapies, family and marital psychotherapies, and psycho-
pharmacological treatments. The model will guide optimal team 
composition and provider-to-patient ratios assessed based on facility 
complexity levels and patient care needs.
    VA Central Office began collecting monthly vacancy data in January 
2012 to assess the impact of vacancies on operations and to develop 
recommendations for further improvement. In addition, VA is ensuring 
that accurate projections for future needs for mental health services 
are generated. Finally, VA is planning proactively for the expected 
needs of Veterans who will separate soon from the Department of Defense 
(DoD) as they return from Afghanistan. We track this population to 
estimate the number of such Veterans, how many are anticipated to seek 
VA care, and how many who seek care are anticipated to need mental 
health evaluation and treatment services. These processes will 
continue, with special attention to whether patterns established up to 
this point may change with the expected increase in separations from 
active duty military.
    As part of VA's efforts to implement section 304 of Public Law 111-
163 (Caregivers and Veterans Omnibus Health Services Act of 2010), VA 
is increasing the number of peer specialists working in our medical 
centers to support Veterans seeking mental healthcare. These additional 
staff will increase access by allowing more providers to schedule more 
appointments with Veterans. Simultaneously, VA is providing additional 
resources to expand peer support services across the Nation to support 
full-time, paid peer support technicians. While providing evidence-
based psychotherapies is critical, VA understands Veterans benefit from 
supportive services other Veterans can provide.
    Finally, VA's efforts to nurture and sustain our academic 
affiliations provide opportunities across the country for residents in 
different disciplines, including psychiatry and psychology, to continue 
their education while helping our Veterans. VA currently supports more 
than 2,500 training positions in mental health occupations (including 
psychiatry, psychology, social work, and clinical pastoral education 
residency positions).
Conclusion
    By adding staff, offering better guidance on appointment scheduling 
processes, and enhancing our emphasis on patient and provider 
experiences through specific performance measures, we are confident we 
are building a more accessible system that will be responsive to the 
needs of our Veterans while being responsible with the resources 
appropriated by Congress. OEF/OIF/OND Veterans have faced more and 
longer deployments than previous generations of Servicemembers, and 
their families have shared these challenges. Many of these Veterans 
also have survived battlefield injuries that previously would have been 
fatal. Other challenges are presented by Vietnam era Veterans who seek 
mental healthcare at far higher levels than prior generations of older 
adults. In part, that is because we did not have the effective 
treatments for them when they returned from service more than 40 years 
ago. We know that the therapies discussed previously are effective for 
this population, and we welcome their search for mental healthcare. As 
VA reaches out to serve all generations, and as our intensive, 
effective outreach programs bring in greater numbers of Veterans to 
VA's healthcare system, we must constantly find ways to keep pace with 
the need for expanded capacity for mental health services and for those 
services to be based on the best possible known treatments.
    Mr. Chairman, we know our work to improve the delivery of mental 
healthcare to Veterans will never be done. We appreciate your support 
and encouragement in identifying and resolving challenges as we find 
new ways to care for Veterans. This concludes my prepared statement. My 
colleagues and I are prepared to respond to any questions you may have.

                                 
             Prepared Statement of John D. Daigh, Jr., M.D.
INTRODUCTION
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to discuss the results of a recent Office of Inspector 
General (OIG) report, Veterans Health Administration--Review of 
Veterans' Access to Mental Health Care, on veteran access to mental 
healthcare services at VA facilities. We conducted the review at the 
request of the Committee, the VA Secretary, and the Senate Veterans' 
Affairs Committee. The OIG is represented by Ms. Linda A. Halliday, 
Assistant Inspector General for Audits and Evaluations; Dr. John D. 
Daigh, Jr., Assistant Inspector General for Healthcare Inspections; Dr. 
Michael Shepherd, Senior Physician in the OIG's Office of Healthcare 
Inspections; and Mr. Larry Reinkemeyer, Director of the OIG's Kansas 
City Office of Audits and Evaluations.
BACKGROUND
    Based on concerns that veterans may not be able to access the 
mental healthcare they need in a timely manner, the OIG was asked to 
determine how accurately the Veterans Health Administration (VHA) 
records wait times for mental health services for both initial (new 
patients) and follow-up (established patients) visits and if the wait 
time data VA collects is an accurate depiction of veterans' ability to 
access those services.
    VHA policy requires all first-time patients referred to or 
requesting mental health services receive an initial evaluation within 
24 hours and a more comprehensive mental health diagnostic and 
treatment planning evaluation within 14 days. The primary goal of the 
initial 24-hour evaluation is to identify patients with urgent care 
needs and to trigger hospitalization or the immediate initiation of 
outpatient care when needed. Primary care providers, mental health 
providers, other referring licensed independent providers, or licensed 
independent mental health providers can conduct the initial 24-hour 
evaluation.
    VHA uses two principal measures to monitor access to mental 
healthcare. One measure looks at the percentage of comprehensive 
patient evaluations completed within 14 days of an initial encounter 
for patients new to mental health services. Another method VHA uses is 
to calculate patient waiting times by measuring the elapsed days from 
the desired dates \1\ of care to the dates of the treatment 
appointments. Medical facility schedulers must enter the correct 
desired dates of care in the system to ensure the accuracy of this 
measurement. VHA's goal is to see patients within 14 days of the 
desired dates of care.
---------------------------------------------------------------------------
    \1\ The desired date of care is defined as the earliest date that 
the patient or clinician specifies the patient needs to be seen
---------------------------------------------------------------------------
REVIEW RESULTS
    Our review focused on how accurately VHA records wait times for 
mental health services for initial and follow-up visits and if the wait 
time data VA collects is an accurate depiction of the veterans' ability 
to access those services. We found:

      VHA's mental health performance data is not accurate or 
reliable.
      VHA's measures do not adequately reflect critical 
dimensions of mental healthcare access.

    Although VHA collects and reports mental health staffing and 
productivity data, the inaccuracies in some of the data sources 
presently hinder the usability of information by VHA decision makers to 
fully assess current capacity, determine optimal resource distribution, 
evaluate productivity across the system, and establish mental health 
staffing and productivity standards.
VHA's Performance Data Is Not Accurate or Reliable
    In VA's fiscal year (FY) 2011 Performance and Accountability Report 
(PAR), VHA reported 95 percent of first-time patients received a full 
mental health evaluation within 14 days. However, the 14-day measure 
has no real value as VHA measured how long it took VHA to conduct the 
evaluation, not how long the patient waited to receive an evaluation. 
VHA's measurement differed from the measure's objective that veterans 
should have further evaluation and initiation of mental healthcare in 
14 days of a trigger encounter. VHA defined the trigger encounter as 
the veteran's contact with the mental health clinic or the veteran's 
referral to the mental health service from another provider.
    Using the same data VHA used to calculate the 95 percent success 
rate shown in the FY 2011 PAR, we conducted an independent assessment 
to identify the exact date of the trigger encounter (the date the 
patient initially contacted mental health seeking services, or when 
another provider referred the patient to mental health). We then 
determined when the full evaluation containing a patient history, 
diagnosis, and treatment plan was completed. Based on our analysis of 
that information, we calculated the number of days between a first-time 
patient's initial contact in mental health and their full mental health 
evaluation. Our analysis projected that VHA provided only 49 percent 
(approximately 184,000) of first-time patients their evaluation within 
14 days.
    VHA does not consider the full mental health evaluation as an 
appointment for treatment, but rather the evaluation is the 
prerequisite for VHA to develop a patient-appropriate treatment plan. 
Once VHA provides the patient with a full mental health evaluation, VHA 
schedules the patient for an appointment to begin treatment. We found 
that VHA did not always provide both new and established patients their 
treatment appointments within 14 days of the patients' desired date. We 
reviewed patient records to identify the desired date (generally 
located in the physician's note as the date the patient needed to 
return to the clinic or shown as a referral from another provider) and 
calculated the elapsed days to the date of the patient's completed 
treatment appointment date.
    We projected nationwide that in FY 2011, VHA:

      Completed approximately 168,000 (64 percent) new patient 
appointments for treatment within 14 days of their desired date; thus, 
approximately 94,000 (36 percent) appointments nationwide exceeded 14 
days. VHA data reported in the PAR showed that 95 percent received 
timely care.
      Completed approximately 8.8 million (88 percent) follow-
up appointments for treatment within 14 days of the desired date; thus, 
approximately 1.2 million (12 percent) appointments nationwide exceeded 
14 days. VHA data reported in the PAR showed that 98 percent received 
timely care for treatment. Although we based our analysis on dates 
documented in VHA's medical records, we have less confidence in the 
integrity of this date information because providers at three of the 
four medical centers we visited told us they requested a desired date 
of care based on their schedule availability.
Scheduling Process
    Generally, VHA schedulers were not following procedures outlined in 
VHA directives and, as a result, data was not accurate or reliable. For 
new patients, the scheduling clerks frequently stated they used the 
next available appointment slot as the desired appointment date for new 
patients. Even though a consult referral, or contact from the veteran 
requesting care, may have been submitted weeks or months earlier than 
the patient's appointment date, the desired appointment date was 
determined by and recorded as the next available appointment date. For 
established patients, medical providers told us they frequently 
scheduled the return to clinic date based on their known availability 
rather than the patient's clinical need. Providers may not have 
availability for 2-3 months, so they specify their availability as the 
return to clinic time frame.
    OIG first reported concerns with VHA's calculated wait time data in 
our Audit of VHA's Outpatient Scheduling Procedures (July 8, 2005) and 
Audit of VHA's Outpatient Wait Times (September 10, 2007). During both 
audits, OIG found that schedulers were entering an incorrect desired 
date. Nearly 7 years later, we still find that the patient scheduling 
system is broken, the appointment data is inaccurate, and schedulers 
implement inconsistent practices capturing appointment information.
Workload and Staffing
    According to VHA, from 2005 to 2010, mental health services 
increased their staff by 46 percent and treated 39 percent more 
patients. Despite the increase in mental healthcare providers, VHA's 
mental healthcare service staff still do not believe they have enough 
staff to handle the increased workload and to consistently see patients 
within 14 days of the desired dates. In July 2011, the Senate Committee 
on Veterans' Affairs requested VA to conduct a survey that among other 
questions asked mental health professionals whether their medical 
center had adequate mental health staff to meet current veteran demands 
for care; 71 percent responded their medical center did not have 
adequate numbers of mental health staff.
    Based on our interviews at four VA medical centers (Denver, 
Colorado; Spokane, Washington; Milwaukee, Wisconsin; and Salisbury, 
North Carolina), staff in charge of mental health services reported 
VHA's greatest challenge has been to hire and retain psychiatrists. We 
analyzed access to psychiatrists at the four visited medical centers by 
determining how long a patient would have to wait for the physician's 
third next available appointment. Calculating the wait time to the 
third next available appointment is a common practice for assessing a 
provider's ability to see patients in a timely manner. On average at 
the four VA medical centers we visited, a patient had to wait 41 days.
VHA's Measures Do Not Adequately Reflect Critical Dimensions of Mental 
        Health Care Access
    The data and measures needed by decision makers for effective 
planning and service provision may differ at the national, Veterans 
Integrated Service Network, and facility level. No measure of access is 
perfect or provides a complete picture. Meaningful analysis and 
decision making requires reliable data, on not only the timeliness of 
access but also on trends in demand for mental health services, 
treatments, and providers; the availability and mix of mental health 
staffing; provider productivity; and treatment capacity. These demand 
and supply variables in turn feed back upon a system's ability to 
provide treatment that is patient centered and timely.
    Decision makers need measures that:

      Are derived from data that is reliable and has been 
consistently determined system-wide.
      Are based on reasonable assumptions and anchored by a 
reasonable and consistent set of business rules.
      Are measureable in practice given existing 
infrastructure.
      Are clinically or administratively relevant.
      Provide complementary or competing information to other 
measures used by decision makers.
      Measure what they intend to measure.
Measuring Access to VHA Mental Health Care
    Included in the FY 2012 Network Director Performance Plan are the 
following measures: the percentage of eligible patient evaluations 
documented within 14 days of a new mental health patient initial 
encounter; a metric requiring a follow-up encounter within 7 days of 
discharge from inpatient hospitalization; a measure requiring four 
follow-up encounters within 4 weeks of discharge from inpatient 
treatment for high risk patients; and a measure of the percentage of 
new Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
veterans receiving eight psychotherapy sessions within a 14-week period 
during 1-year period.
    VHA's 14-day measure calculates the percentage of comprehensive 
patient evaluations documented within 14 days of an initial encounter 
for patients new to mental health services. In practice, the 14-day 
measure is usually not triggered until the veteran is actually seen in 
a mental health clinic and a comprehensive mental health evaluation is 
initiated. For example, a new-to-VHA veteran presents to a primary care 
clinic, screens positive for depression, and the primary care provider 
refers the veteran for further evaluation by a mental health provider. 
The ``clock'' for the 14-day follow-up measure will start when the 
veteran is actually seen in a mental health clinic and a comprehensive 
mental health evaluation is initiated, not at the time of the primary 
care appointment. Consequently, the data underlying this measure only 
provides information about the timeliness within which comprehensive 
new patient evaluations are completed but not necessarily the 
timeliness between referral or consult to evaluation.
    Veterans access VHA care through various routes, such as VA medical 
center emergency departments, primary and specialty care clinics, 
women's clinics, or mental health walk-in clinics. Alternatively, they 
may seek services at community based outpatient clinics or Vet Centers 
in their communities. They may also initiate mental health services 
with private providers and later come to VA seeking more comprehensive 
services. The 14-day measure does not apply to veterans who access 
services through Vet Centers or non-VA-based fee basis providers.
    A series of complementary and competing timeliness and treatment 
engagement measures that better reflect the various dimensions of 
access would provide decision makers with a more comprehensive view of 
the ability with which new patients can access mental health treatment.
    The timeframe immediately following inpatient discharge is a period 
of high risk. The 7-day post-hospitalization and the four follow-up 
appointments in 4 weeks for high-risk patient measures are clinically 
relevant. The eight psychotherapy session in 14 weeks measure attempts 
to be a proxy for whether OEF/OIF patients are receiving evidence-based 
psychotherapy. The measure is clinically relevant but the utility is 
presently marred by inaccurate data or unreliable methodology.
    Beyond measures of timeliness (or delay) to mental healthcare, user 
friendly measures that incorporate aspects of patient demand, 
availability and mix of mental health clinical staffing, provider 
productivity, and treatment capacity, anchored by a consistent set of 
business rules, might provide VHA decision makers with more information 
from which to assess and timely respond to changes in access 
parameters.
Recommendations
    Our report contained four recommendations for the Under Secretary 
for Health:

      Revise the current full mental health evaluation 
measurement to ensure the measurement is calculated from the veterans 
contact with the mental health clinic or the veteran's referral to the 
mental health service from another provider to the completion of the 
evaluation.
      Reevaluate alternative measures or combinations of 
measures that could effectively and accurately reflect the patient 
experience of access to mental health appointments.
      Conduct a staffing analysis to determine if mental health 
staff vacancies represent a systemic issue impeding the Veterans Health 
Administration's ability to meet mental health timeliness goals, and if 
so, develop an action plan to correct the impediments.
      Ensure that data collection efforts related to mental 
health access are aligned with the operational needs of relevant 
decision makers throughout the organization.

    The Under Secretary for Health concurred with our recommendations 
and presented an action plan. We will follow-up as appropriate.
CONCLUSION
    VHA does not have a reliable and accurate method of determining 
whether they are providing patients timely access to mental healthcare 
services. VHA did not provide first-time patients with timely mental 
health evaluations and existing patients often waited more than 14 days 
past their desired date of care for their treatment appointment. As a 
result, performance measures used to report patient's access to mental 
healthcare do not depict the true picture of a patient's waiting time 
to see a mental health provider.
    While no measure will be complete, meaningful analysis and decision 
making requires reliable data. A series of paired timeliness and 
treatment engagement measures might provide decision makers with a more 
comprehensive view of the ability with which new patients can access 
mental health treatment.
    Mr. Chairman, thank you for the opportunity to discuss our work. We 
would be pleased to answer any questions that you or other members of 
the Committee may have.

                                 
              Prepared Statement of Nicole L. Sawyer, PSYD
    Chairman Miller, Ranking Member Filner and Members of the 
Committee:
    Thank you for inviting me to participate in this important 
discussion regarding the ``quality versus quantity'' dilemma facing VA 
mental healthcare.
    I want to convey my appreciation for the efforts of this Committee 
and its clear commitment to the mental healthcare of our veterans. I 
recognize that mental health is only one of the vast concerns under 
your authority and I value your diligence in this matter.
    I am a licensed clinical psychologist with a primary focus on the 
treatment of trauma in both the veteran and civilian population. In 
addition to having worked at a VA medical center, I have worked in a 
number of clinical settings including Federal prison, an urban 
psychiatric inpatient facility, a college campus, two community mental 
health centers, and currently in my own private practice where the 
majority of my caseload consists of combat veterans and adult survivors 
of such traumas as childhood sexual abuse, domestic violence and sexual 
assault.
    In addition to my clinical practice I am an appointed member of the 
New Hampshire Legislative Commission on (military service-connected) 
PTSD and TBI (SB102), an active member of the New Hampshire 
Psychological Association Continuing Education Committee, and I am also 
a training board member and mentor for psychology interns and post-
doctoral fellows working in my local community mental health center.
    In October of 2009, in addition to my established private practice, 
I took a part-time position as the Local Evidence-Based Psychotherapy 
Coordinator for the mental health service line at the Manchester VA 
Medical Center in Manchester, NH. My job was to coordinate clinician 
training and implementation of the Evidence-Based Psychotherapies 
(EBPs) the VA had been rolling out since 2005. I soon found that I 
needed to be more involved with the structure and function of the 
service to do my job effectively, so I took a significant role in the 
Mental Health Systems Redesign Committee and began working on several 
projects important to improving the function of our service line and 
thus the application of EBPs in our clinic. In these roles I had the 
opportunity to work closely with our veterans and also work intimately 
with the clinicians on the service. I met with clinicians regularly, 
both formally and informally, to discuss their needs as providers and 
the problems they were encountering clinically and with regard to self-
care. In addition, my roles brought me into close and frequent contact 
with the leadership of our mental health service where I worked to get 
training opportunities approved and lobbied for clinic and clinician 
availability to provide the treatments required by the Uniform Mental 
Health Service Handbook. My role also required at least monthly contact 
with other EBP Coordinators in the network and nation-wide as well as 
attendance at required conferences and trainings that brought all of us 
together to discuss the successes and failures we were facing at our 
respective facilities.
    Due to increasing ethical concerns about the care and treatment of 
our veterans in Manchester, I chose to resign my position this recent 
February. I hope to share with you here some of the concerns that led 
to this difficult decision, as well as the impact that VA culture and 
common practices have on the ability of dedicated clinicians to provide 
quality mental healthcare to our veterans.
PTSD and the Veteran's Dilemma
    Many of the men and women that cross the threshold of a VA medical 
center have been faced with decisions, and taken action, on matters far 
out reaching the imaginations of most. Many have made choices, and 
followed orders, that carry weight impossible to endure alone, though 
they try. For most, the decision to seek mental health treatment is an 
admission of failure, an inability to ``hack it.'' For many, the 
decision feels humiliating and shameful; it is the admission of 
weakness and the declaration of vulnerability.
    Many combat veterans spend years trying to cover their invisible 
wounds; they carefully tend the scabs they have created to protect 
those exposed places. Many of the symptoms of PTSD are reinforced 
through misguided attempts to tend and protect their mental injuries. 
They may avoid things that remind them of experiences and actions they 
would rather forget. They may push loved ones away in order to ensure 
no one sees their weakness. They may drink to numb the memories, the 
nightmares, and the pain. And tragically some take their own lives to 
escape the hurt, or to protect others from the hurt that they believe 
they will inevitably cause.
    ``If she only knew . . . '' is an all too common phrase I hear in 
my therapy sessions with combat veterans. The deep belief, and fear, 
that if others, especially loved ones, ``knew'' what they had done, 
they would no longer love them. They would be ashamed, angry, and worst 
of all, afraid of them.
    Most of us have only the vaguest sense of the experience of combat 
and war. The successful military leaves its civilians largely ignorant 
of war's horrors. Combat veterans are no longer ignorant, but try to 
play along, because for them, even at home, the job never ends.
    Entering into mental health treatment is wrought with gut-wrenching 
decisions. Admitting the need for help is the first one, making the 
telephone call is the second, showing up for the appointment is the 
third; but the fourth is the heaviest of all, speaking the pain.
    Endless research, and certainly my experience, informs me that the 
closer together decisions 1 through 3 occur, the more likely the 
veteran will commit to the task. This is not rocket-science: the more 
rapid the decision-making process the less likely any of us are to let 
our doubts and fears derail us. But VA healthcare facilities too often 
fail our veterans before they are even faced with the critical fourth 
decision--unburdening themselves of the trauma they have experienced. 
This was clearly demonstrated in the recent OIG report that identified 
the lack of timely access to mental healthcare, resulting in a majority 
of veterans having to wait more than 50 days to begin treatment.
The Fourth Decision: Speaking the Pain
    In my experience, and from my perspective, nearly 70% of the work 
of combat trauma treatment is in the telling. The telling doesn't have 
to be to the therapist, though it often is at first. But the telling 
must occur. Speaking the story, the pain, the regret, the guilt, and 
the shame that are fixed to the experiences that drive a veteran into 
treatment marks a beginning on the road to recovery, but it is NOT the 
beginning of treatment.
    Treatment begins long before the story is told. It begins with 
trust. Our veterans must trust in the system meant to serve them, trust 
in the process of therapy, and trust in the clinician assigned to their 
care.
    Trust for the combat veteran does not come easy. Trust is the 
belief that one's story will not be judged, that the individual's 
feelings will be validated and accepted, and that despite having spoken 
one's pain to another soul, the veteran remains in control of that 
information. For a person who has done things, seen things and felt 
things that--if they had occurred at home--would be considered 
monstrous and evil, trust is a myth. Don't get me wrong, a soldier 
knows trust, he knows what it is to believe that the person next to him 
cares as much about his life as he does, but to trust in a person who 
does not share your pain is a risk exceeding all manner of bravery. 
Fear of judgment tends to lead the pack of fears held by those 
considering mental health treatment. They fear that their actions and 
the feelings attached to them are rare and will be misunderstood by 
those unfamiliar with war.
    Most VA clinicians are ready to hear the pain. They are well 
trained, dedicated, committed and passionate about veterans. They 
understand the fears and reservations and are prepared to knock them 
out at a pace that provides safety and comfort for the veteran sitting 
across from them. Most do not know the pain themselves, but they know 
what it takes to connect with their veterans and they know what it 
means to trust.
    But trust takes time, and time is NOT what most VA clinicians have 
when it comes to the treatment of their veterans.
The Clinician's Dilemma: Professional Ethics or Performance Measures
    Mental health is subjective. It is not easily defined and nearly 
impossible to measure. It does not fit neatly into a medical model the 
way the diagnosis and treatment of hypertension or diabetes often does, 
and the stigma associated with the need for care is nearly unmatched by 
any other health issue. But the VA, like most managed care 
organizations, attempts to squeeze mental healthcare into a medical 
framework. Inevitably, corners are cut in order to make it fit.
    Psychotherapy is a process, not a prescription. It is work that 
takes time and builds upon the successes and failures of the previous 
sessions, and life lived in between. The professional psychotherapist 
is trained to help the patient identify needs, feelings, and goals that 
are often hidden or buried under old habits, experiences, and beliefs 
about themselves and the world. We are all shaped by our experiences 
and we all develop methods for understanding and coping with those 
experiences, for better or for worse. For some, our strategies for 
coping and understanding lead us astray and we find ourselves drifting 
or trapped in patterns that are harmful and destructive. Psychotherapy 
is intended to steer us back on track with new strategies and better 
understanding that will lead to acceptance. Some types of psychotherapy 
are strictly guided and directed, other types are more evolving and 
flowing; both have their place in quality mental healthcare, and both 
require the patient to trust in the process and in the clinician, to be 
successful.
    The VA struggles to understand and value the importance of trust in 
the success of mental health treatment. We all value trust in our 
lives. We trust our children with babysitters, we trust our accountants 
with our money. We took time to develop trust in these individuals. Why 
is it not obvious and a priority to value the development of trust in 
the service of mental health treatment? It is not a difficult task to 
achieve, hire competent staff and give them the time to do their jobs 
well: trust will follow.
    Given a small mental health staff relative to the ever-growing 
numbers of veterans seeking mental healthcare, the dedicated clinicians 
with whom I worked at the Manchester VA Medical Center faced a daily 
ethical dilemma: the veterans sitting before them were often in great 
need, and might be motivated and anxious to open up old wounds, air 
them out, and begin the healing process. But often, the clinicians 
could not join them in this journey. Ethically, they could not rip open 
those wounds. Faced with a patient caseload that was growing 
exponentially, and no open appointments in sight, that clinician could 
not, and rightfully would not, open a wound only to let it fester 
untreated for the weeks or months it might take to see that veteran 
again.
    As I said, psychotherapy builds upon the successes and failures of 
the previous sessions; it requires consistency and predictability in 
scheduling and frequency of appointments. Trauma cannot be treated 
haphazardly based on random blocks of availability. Trauma treatment 
demands a session every week or every other week. Too much time between 
sessions allows suffering to linger too long after wounds have been 
opened. Too much lingering leads to re-traumatization and bolstering of 
the negative patterns the treatment is intended to dismantle.
    It is apparent that at many facilities across the country, VA 
clinicians are overrun with veterans in need. Mental Health Service 
Lines are pushing as many veterans into clinician schedules as possible 
to meet their performance measures, but those veterans are not getting 
effective treatment. Effective treatment takes time. It requires a full 
and timely evaluation of needs, a chronic and nationwide deficit noted 
by the recent OIG report. It requires a frequency of sessions in a 
timely manner consistent with the clinical needs identified by that 
full evaluation, another chronic deficit noted by the OIG. It requires 
trust and predictability. Too often, under the circumstances which VA 
facilities and mental health clinicians are working, an emphasis on 
addressing ``quantity'' is overtaking a commitment to the quality of 
treatment.
    The effects of a ``quantity over quality'' approach to mental 
health treatment has obvious and not-so-obvious repercussions for 
veterans. Some veterans cling to the hope for years that somehow those 
randomly occurring sessions with their therapist will help them find 
relief from their demons. They arrive for every appointment, but as I 
have discussed, little in the way of demons can be explored. Others 
drop out quickly, angrily muttering about the ``waste of time'' and 
conclude that therapy can't help them. Often, they never return, to the 
VA or elsewhere, for mental health treatment. But what is most tragic 
is that many of those veterans blame themselves for not getting better. 
Like most people, they do not know what effective mental healthcare is 
supposed to look like. They assume, deep in that place where their 
guilt and shame lay, that they have failed to get better, that they are 
too far gone to be helped. I have heard those words from the mouths of 
the veterans I have had the honor to treat, on the off-chance that they 
gave psychotherapy one more try.
Caseload and Productivity
    Staffing is an obvious weakness in VA mental healthcare and 
Secretary Shinseki's announcement last month of 1900 additional mental 
health staff is a welcome attempt at strengthening this service. But 
how do we know if 1900 is enough?
    In order for a service to be able to evaluate its need for staff 
and resources it must be able to assess the demand on its clinicians. 
The VA, however, lacks any definitive expectation for clinical 
productivity. Without such parameters it is impossible to identify a 
clinician's caseload as ``full'' and therefore it is impossible to 
determine if the flow of veterans into the service exceeds the capacity 
of the clinic. Without this critical information a service struggles to 
know how many clinicians it needs to meet the demand.
    Determining clinician caseload is exceedingly important and must be 
a priority for VA. Community mental health clinics and other mental 
health facilities, including group practices in the private sector have 
defined the expectations for their clinicians. The factors that go into 
making these determinations exceed the scope of my testimony, but the 
benefits to clinicians, patients, and to organizations are clear. When 
a clinician has a productivity expectation, that is, a clear 
expectation of how many hours per week he or she is expected to be 
providing direct services to veterans, he or she can build into their 
day the time necessary to meet the administrative demands essential to 
effective treatment. The clinician can plan for writing of session 
notes, treatment plan reviews, formal consultation with other providers 
on a case, and returning patient phone calls. The clinician might even 
have the flexibility to see more urgently, an established patient who 
is on the verge of a crisis, and stave off an emergency. All of the 
tasks I noted here are basic requirements of effective mental 
healthcare. They are tasks demanded by the ethics that govern all 
mental health professions, and yet, in my experience, they are seen as 
luxuries at the VA. These important tasks are given no priority because 
the system relies on so-called ``workload'' data, and this important 
work is not easily captured.
    When productivity for a clinician is defined, a caseload definition 
easily follows. The size of a clinician's caseload can be somewhat 
flexible when consideration is given to the intensity of treatment 
needed by each veteran. When a clinician's productivity is measured 
based on the number of hours they spent providing therapy that week, 
the caseload is defined by how many veterans that clinician can treat 
in a clinically responsible way. For example, in a community mental 
health center in which I worked, clinicians in the adult outpatient 
department were expected to provide 22 hours of psychotherapy per 36 
hour work week. This productivity expectation rounded out to roughly 40 
patients on a full-time clinician's caseload. The caseload would 
inevitably be composed of some patients in need of weekly sessions, 
some in need of every other week sessions, some coming only for monthly 
maintenance check-ins and still others who were not yet committed to a 
treatment schedule. The challenge for the clinician and the service was 
to juggle the number of outgoing (discharged) patients who had achieved 
their goals and were no longer in need of services with the number of 
new patients to accept into their caseload. This particular mental 
health center simply required all clinicians to conduct two ``intakes'' 
per week to be included in their 22 hours of productivity. It wasn't a 
perfect system, but it provided an access expectation along with a 
productivity expectation that easily communicated our staffing needs 
and allowed us to prepare for and predict seasonal influxes of 
referrals. In contrast, at the Manchester VA and other facilities, a 
clinician could easily have hundreds of veterans on his or her 
``caseload.'' Caseloads grew exponentially for a number of reasons: 
among them, 1) Incoming veterans were doled out like cards in a deck 
with no regard for the number of veterans each clinician was already 
trying to serve, no regard for availability of appointments, or 
expertise in the area of need. 2) When a veteran is only able to be 
seen on a sporadic basis with weeks and even months between 
appointments, psychotherapy is impossible and little clinical progress 
is made. With little clinical progress veterans do not achieve their 
goals and/or find relief from their symptoms, and without these markers 
a clinician cannot effectively discharge veterans from care. 3) Chronic 
understaffing, clinician turnover, and facilities refusing to backfill 
positions lead to other clinicians having to ``pick up'' hundreds of 
veterans left abandoned when a clinician resigns.
    This lack of administrative management of caseload interferes with 
the quality of care a clinician can provide. While trying to attend to 
the veteran in front of them, clinicians are forced to think about how 
far out they are booked before asking a question, challenging a 
thought, exploring a perception. Knowing that the veteran is not likely 
to make his or her way back into their office for several weeks, if not 
months, is enough to derail what might have been a poignant 
intervention with big potential for healing. Clinicians are virtually 
gagged under such circumstances and stressed by the helplessness they 
face with unfettered inflow of veterans and minimal potential for 
outflow. This ongoing experience creates a chronic sense of failure and 
undermines the expertise and skill required to be an effective 
psychotherapist.
    In short, development of productivity expectations and clinician 
caseload definitions are essential to the accurate determination of 
staffing needs at the facility level. Without this data there is no way 
to determine if 3, 5, or 20 additional clinicians will be enough to 
meet the demand of an individual mental health service. And without 
these parameters, there is no way a clinician and a service can ensure 
adequate frequency and timely access for a veteran to get the kind of 
care they deserve.
Why VA Can't Fill Vacancies
    Veterans, particularly combat veterans and victims of military 
sexual trauma, are an intense population to treat. From my perspective 
the rewards are unmatched, but in order to reap the rewards a provider 
has to be in a position to help.
    The VA has 1500 vacant mental health positions for which they are 
currently recruiting. Secretary Shinseki recently approved 1900 more 
positions. I have already discussed the difficulty in knowing if this 
number will be enough, but one can reasonably ask how VA will fill 
these new positions when 1500 positions are currently sitting empty, 
and have been for months and even years.
    But this is not the only pertinent question. Many VA facilities 
across the Nation simply do not have space for more clinicians. 
Buildings are outdated, space is poorly distributed among specialty 
departments; services have simply outgrown their walls. At Manchester, 
for example, clinicians hired recently spend time dragging carts full 
of paperwork and other necessary resources around the hallways because 
they lack offices. They show up to work each day unsure whose, if 
anyone's, office they might be able to use for the afternoon or maybe 
for an hour. This is not simply inconvenient, unprofessional and 
demeaning for the clinician, but it has a significant impact on the 
patient. Continuity and predictability are important aspects of quality 
clinical care. In particular, safety in their space and predictability 
in their environment are important to many veterans struggling with 
PTSD. Attending therapy sessions in a different office, possibly on a 
different floor of the building, every time they arrive, is distressing 
and can impede progress, possibly even contribute to abandonment of 
treatment. The lack of space is a significant barrier not only to 
quality care for veterans, but for the hiring and retention of staff.
    Psychologists and psychiatrists, in particular, have among the 
highest turnover rates in the VA for mental health service. These 
higher rates are likely a result of the pay versus ``hassle'' ratio 
that is difficult to overcome in the current VA system. VA compensation 
for psychologists and psychiatrists, in most regions, is comparable, if 
not less, than what the same professional could make in another 
facility or on his or her own. It is not surprising that some 
psychologists and psychiatrists will choose to go elsewhere for 
employment. Those that do choose to work for the VA often become 
overwhelmed and frustrated by what some feel are ethical compromises 
and minimal respect.
    Clinical social workers, on the other hand, face a different 
dilemma. VA compensation for a clinical social worker, in most regions, 
is well above, even double, what he or she could make at another 
facility in the community. The compensation can become a trap for these 
dedicated professionals. Seeking employment elsewhere is not typically 
an option but the chronic disrespect and ethical compromises some 
experience lead to burn-out and high levels of personal stress.
    Much of the stress and disrespect felt by many clinicians stems 
from the very limited clinical independence most are afforded. In most 
facilities, clinicians have little or no control over their schedule or 
how their time is allotted, have no control over their caseload, and 
are required to provide services and use methodology that they believe 
clinically inappropriate for their veteran. And worst of all, many VA 
mental health clinicians must set aside their own clinical judgment in 
response to the overriding requirements dictated by Central Office 
performance measures and other mandates that direct how veterans are to 
be treated. The need to meet numbers motivates facilities to abandon 
some treatment modalities in favor of others, regardless of the 
clinical indication for the veteran. Clinicians are generally helpless 
to fight against this, though they try, as many clinicians at my 
facility did. This can be humiliating for a mental health professional 
with an advanced degree, passion, and experience in helping those in 
need.
    Without a real effort to address these cultural issues, the VA will 
be hard pressed to hire and retain the quality professionals our 
veterans deserve.
Conclusion
    In conclusion, I want to thank the Committee again for the 
opportunity to share my experience and insights. I hope that if there 
is anything I have communicated here, it is that quality care--and by 
that I mean effective care--must not be sacrificed for quantity. VA has 
a responsibility to provide veterans timely, effective mental 
healthcare. Among the critical steps it must take to meet that 
responsibility is to establish a productivity and caseload model for 
mental health clinicians and ensure that adequate space is available to 
provide treatment. But it must go further: in raising the standard of 
care, it must also reinstate trust--a critical element in making VA a 
place where veterans in need want to get their care, and where 
dedicated, skilled clinicians want to be employed.
    I am happy to answer any questions you may have.
    Thank you.

                                 
               Prepared Statement of Diana Birkett Rakow
    Good morning, Chairman Miller, Ranking Member Filner, and members 
of the Committee. I am Diana Birkett Rakow, Executive Director of 
Public Policy at Group Health Cooperative, an integrated healthcare 
coverage and delivery system based in Seattle, Washington.
    Thank you for inviting me to be here this morning to discuss Group 
Health's experience managing mental health appointments for our 
members. We recognize and appreciate your leadership in ensuring our 
Nation's veterans receive the high-quality mental healthcare they 
deserve. While our patient population and the context in which we 
provide care differ from the Veterans Health Administration, we share a 
commitment to ensuring that patients get the care they need, in a 
timely and effective manner, to improve and preserve their health. We 
are grateful for the opportunity to share our best practices, and hope 
this information is useful as the Committee and the Veterans 
Administration work to continually improve mental healthcare for our 
Nation's veterans.
    Group Health Cooperative is a nonprofit health system that provides 
both coverage and care. Directly and through our subsidiaries, we cover 
more than 660,000 residents of Washington State and northern Idaho, 
about 60 percent of whom receive care in Group Health owned and 
operated medical facilities. Over 1,000 physicians are part of the 
Group Health group practice, and we contract with more than 9,000 
providers throughout the state. We offer health coverage through public 
programs and in the commercial market--in Medicare, Medicaid, the State 
Basic Health Plan, State and Federal employee programs, in the 
individual market, and to small, medium, and large employer groups. We 
also support employers who have elected to self-fund their employee 
health coverage.
    Today I will discuss how Group Health has created a model and 
systems that have allowed us to provide, track, and ensure timely 
access and high-quality care for our patients, in particular those with 
mental health needs. Our success in this area is due to the interaction 
of our philosophy, our model of care, and the tools we employ to 
establish processes and systems to track and continuously improve 
performance.
    Group Health is committed to patient-centered care and coverage, a 
philosophy that guides our approach to mental health services, the 
subject of this hearing, as well as every other type of healthcare we 
provide. This philosophy provides a foundation for our model of care, 
which is based on the Chronic Care Model. This model, designed by Dr. 
Ed Wagner--the founding Director of the Group Health Research 
Institute--is an evidence-based framework for healthcare that delivers 
safe, effective, and collaborative care to patients. In simple terms, 
this means that our model is designed to link all aspects of the 
healthcare system together--health insurance, healthcare providers, 
clinical information systems, and more--to facilitate productive, 
continuous interaction between engaged, informed patients and a multi-
disciplinary care team.
    This philosophy and model of care have been critical to our 
success, but it has been the more recent implementation of Lean tools 
and processes that have enabled us to take our work to a new level. 
Lean is a management method made famous by companies like Toyota, and 
in healthcare it provides the discipline and focus to commit to 
understanding the needs of patients, to building systems and processes 
designed around the patient's needs, and to continuously track outcomes 
and improve processes to meet to meet quality and performance goals.
Behavioral Health at Group Health
    Research shows that 25 percent of people have a diagnosable 
behavioral health issue--whether a mental health issue or a chemical 
dependency--arise within a given year, and 50 percent over the course 
of a lifetime. Among those with a behavioral health issue, about 80 
percent seek help in the primary care environment. This can be for 
several reasons: because the patient is more comfortable in that 
environment, because his condition has presented as or alongside a 
physical ailment, or because primary care services are most readily 
available. About one-third of patients with a behavioral health issue 
ultimately access help in Behavioral Health Services.
    At Group Health, the Behavioral Health Services department is 
responsible for delivering mental healthcare in seven of our own 
outpatient clinics, managing behavioral healthcare delivered by our 
contracted network providers, and providing consultative specialty 
services to primary care physicians who provide care through our 
Patient-Centered Medical Home.
    We employ over 150 behavioral health professionals including 
psychiatrists, clinical psychologists, Masters-level psychotherapists, 
nurses, care managers, and chemical dependency providers. In addition, 
we have contracts with approximately 800 behavioral health specialists 
in the network. Together, these providers offer a full continuum of 
mental health and chemical dependency treatment services from 
outpatient to acute inpatient care. In 2011, Group Health provided 
specialty behavioral healthcare to over 50,000 members, about 8 percent 
of our patient population. Approximately 45 percent (22,550) of members 
receiving specialty behavioral health services are served in the group 
practice clinics and 55 percent (27,561) were served in the network. 
The majority of chemical dependency services and all inpatient services 
are provided in the network.
    The combination of philosophy, model of care, and Lean tools 
described above has enabled Group Health to address and improvements in 
three areas critical to mental health services: initial appointment 
access, follow-up appointment access, and provider capacity and 
productivity.
Initial Appointment Access
    For some patients, ensuring timely access to behavioral health 
services can literally be a matter of life or death; for all patients, 
timeliness is important. Our data have shown that timely appointing is 
one of the top drivers of a patient's satisfaction with her behavioral 
healthcare experience. But timely access--both initially and for 
follow-up care--requires collaboration, sound clinical judgment, 
rigorous processes, and consistent measurement and evaluation.
    Collaboration is illustrated by the close relationship developed 
between primary care providers, specially-trained appointing and triage 
staff, and behavioral health professionals. When a patient contacts us 
seeking an appointment, either directly or after having been referred 
by his primary care provider, a standard process to assess the urgency 
of the patient's needs is triggered. Appointing staff ask the patient a 
series of evidence-based questions and rate the patient's level of 
urgency as routine, urgent, or emergent. A routine patient is of low to 
moderate risk and verbalizes that she can wait between 7 and 14 days to 
be seen. An urgent patient is in severe emotional distress but able to 
wait 48 hours for an appointment. A patient considered emergent may be 
psychotic, suicidal, have withdrawal symptoms, or a sense of 
desperation, and needs to be seen within 6 hours.
    Under our standard process, patients who convey a sense of urgency 
on the initial call are immediately transferred to a care coordinator--
a Master's level counselor--to further assess the urgency of her needs. 
At this stage, clinical judgment is critical. Patients judged to be at 
immediate risk for a suicide attempt, who are going through acute 
withdrawal, or who are gravely disabled are sent to the emergency room 
or urgent care. In some cases the police are called.
    These standards for scheduling an initial appointment were adopted 
from the National Committee for Quality Assurance's (NCQA) standards 
for behavioral health appointment access. Group Health has maintained 
an NCQA ``excellent'' level of accreditation since the late nineties, 
based upon a set of measures that includes access to behavioral health 
services. At Group Health, we aim to ensure that 90 percent of our 
patients with emergent needs receive an appointment within 6 hours, 85 
percent of patients with urgent needs receive an appointment within 48 
hours, and 80 percent of patients with routine needs receive an 
appointment within 14 days. These targets were set based on the 
clinical urgency of the patients and to factor in patient preferences 
and scheduling needs.
    We are able to measure access to routine appointments that occur in 
our group practice model electronically, thanks to our system-wide 
electronic medical record, and do so monthly. For routine patients who 
seek care within our contracted network, we do not have an automated 
way to measure initial access, but review claims data at the end of the 
year to monitor access.
    Collaboration comes into play in one other area related to initial 
appointing access, and that is in collaboration between primary and 
behavioral healthcare providers. For some patients, primary care is 
their preferred source of mental healthcare; for others, it is simply 
an essential complement. In 2010, Group Health researcher and physician 
Elizabeth Lin developed a model called TEAMcare, \1\ an intervention 
for multiple chronic conditions, which has been integrated into 
standard care in the Group Health Patient-Centered Medical Home. Within 
one year--compared with the standard care control group--patients with 
the TEAMcare intervention were significantly less depressed and also 
had improved levels of blood glucose, low-density lipoprotein (LDL) 
cholesterol, and systolic blood pressure. A recent study showed that by 
starting medications sooner and managing them more effectively, primary 
care physicians and nurses could improve their patients' outcomes for 
both medical and mental health conditions. \2\
---------------------------------------------------------------------------
    \1\ New England Journal of Medicine 2010 Dec 30; 363(27):2611-20
    \2\ Annals of Family Medicine January/February 2012 10:6-14; 
doi:10.1370/afm.1343
---------------------------------------------------------------------------
Follow-up Appointment Access
    The ability to be seen in a timely manner for follow-up 
appointments is as important to patients as timely intake appointments. 
Our patient-centered approach, combined with proactive planning and, 
again, rigorous tracking, has led to our positive outcomes in this 
area. We track the use of group therapy (a measure that leads to 
increased capacity and improved follow-up access), the percentage of 
new patients seen three times in the first six weeks of treatment, and 
patient satisfaction with access to follow-up appointments.
    Since behavioral health is a continuous, as well as episodic, 
concern--different from many medical issues but similar to other 
chronic illnesses--we have developed several ways that patients can 
access mental healthcare, increasing the likelihood that one or more of 
these routes will lead to timely access. Through our electronic health 
record system, patients can send secure messages back and forth via 
email with members of their care team, including mental health 
providers. Patients can also set up phone visits for times when getting 
into the clinic is either unnecessary or not feasible. And, responding 
to a need among a certain sub-group of patients, in 2010 our staff 
designed a group psychotherapy program for patients with anxiety and 
depression.
    In 2011, we established a goal of seeing at least 70 percent of 
patients three times within a six-week period. This measure is 
objective, based on what our patients said they wanted and what is 
indicated in relevant research literature. Over the last year, we have 
met and exceeded our target in this area, thanks to strategies and 
processes monitored by many of the other measures described here.
    We have also begun tracking access as a part of our patient 
experience survey. We know that a positive therapeutic relationship 
significantly contributes to patient experience, but have found, not 
surprisingly, that access matters too. Like many things at Group 
Health, we have decided to approach access from an evidence-based 
perspective, as illustrated by the measure above, but also from a 
patient-centered one. To assess patient satisfaction, we have chosen to 
ask whether patients are getting back into the office in a timeframe 
suitable to them. For some patients, this could mean a matter of days--
others, weeks. But over the last year we have seen a statistically 
significant increase in this measure, with patients saying that they 
were seen again by a behavioral health provider when they needed to be.
Supply & Demand, Measures of Capacity and Productivity
    Behavioral health is a poignantly human issue, but access to care 
can also be a simple one of supply and demand. To meet the demand for 
care, we must ensure that there is adequate supply, as measured by 
capacity in the system, and productivity to make the most of existing 
capacity.
    In a group practice model, such as Group Health, unused capacity in 
the system (such as unfilled appointment slots and providers being less 
productive than benchmarks) leads to waste that can ultimately impact 
patient access. Therefore, we track a number of capacity and 
productivity measures, including appointment fill rate, number of new 
cases per provider, and relative value units (RVU). (RVUs are a measure 
of value used in the Medicare reimbursement formula for physician 
services. They are nonmonetary standard units of measurement that 
indicate the value of services provided by a healthcare provider.)
    We seek to fill at least 90 percent of the appointments available 
in a provider's schedule on a given day. Each morning, clinic 
administrative staff members try to fill any open slots in a provider's 
schedule first by calling patients who are on a waiting list for an 
earlier appointment, and then by calling patients who are scheduled 
beyond 14 days to see whether they are available to come in earlier. 
Through this process, we have seen a reduction in wasted appointment 
slots and are currently filling 91 percent of all appointment slots. We 
have also set standards for new case targets. Each Masters-level 
counselor and psychiatrist has a weekly target number of new cases to 
ensure adequate initial patient access.
Developing and Monitoring the Measures
    While measurement is critical, measurement in a vacuum is 
worthless. The Lean approach starts with a focus on assessing and 
working around the needs of the patient, then developing systems and 
processes to meet those needs, developing measures to assess 
performance, and continuously looking for and developing new ways to 
improve. Leadership, in commitment to this system, is key, but so is 
listening to patients, and to the people on the front lines who are 
caring for them and working with them directly.
    To continuously track performance and to make it visible and 
transparent to staff at all levels, visual systems and checking tools 
are developed to monitor metrics on a daily, weekly and monthly basis, 
and to reflect whether targets are met. Lean suggests what are called 
``tiered checking tools'' to ensure that information is shared up and 
down a management chain. For example, an identified metric will be 
measured at the tier one level by the staff doing the work; at the tier 
two, or departmental, level; and at tier three by primary care 
leadership. The highest-priority metrics are reflected and reviewed in 
tiers four and five by our CEO and Executive Leadership Team. These 
tiers refer to visual illustration of performance on these measures, 
over time and by clinic in the form of charts, graphs, and other tools, 
which are posted conspicuously on the walls in our clinics so that 
performance is visible to staff doing the work and to unit managers. 
Clinic staff meet each morning to review challenges for the day and 
discuss how to address them. Departmental leaders conduct ``rounds'' on 
the clinics' visual systems at least monthly to monitor performance, 
and more importantly, to coach the staff in solving problems that 
arise.
    These tools can help give patients, staff, and leaders confidence 
that performance is high, but they can also identify gaps. Our culture 
supports continuous improvement through the identification of gaps and 
the application of countermeasures to ameliorate these gaps. For 
example, last year a group of behavioral health staff tracked 
appointment patterns and identified a high number of appointments that 
went unfilled, were cancelled, or weren't attended by the patient. They 
used these data to develop a new process of monthly checks and 
adjustments of appointments across the week and time of day to increase 
the probability of increasing the number of appointments kept, and they 
began to review medical records monthly to identify and track patient 
preferences for appointment times. These strategies and others have 
allowed us to meet challenges as they arise, to address the needs of a 
broad range of patients, and to significantly improve the access to and 
quality of behavioral healthcare in our system over the last several 
years.
    Group Health's journey with Lean began in 2007, and in behavioral 
health we first began using Lean to develop a care management system 
for our most vulnerable patients. Lean offered us a method for making 
work standard, visible and actionable via the coordinated efforts of 
individuals and teams. Although there were some significant challenges 
in changing and adapting to new processes and a new culture, the 
results were unquestionably positive. Patients received better care 
that reduced their suffering and improved their lives. And, our total 
cost of care (per member per month) was less in 2009 than 2008. In part 
that was a result of better management of inpatient care--our largest 
controllable expense.
    Over the last five years, our systems, processes, and measures have 
continued to develop and improve. We are proud of our model and its 
ability to provide timely, high-quality access to behavioral 
healthcare--and all health services--for our members. But we also 
acknowledge that this is a journey. Our system is built around a 
culture of continuous improvement--putting the patient and her needs 
first. Thank you again for the opportunity to share our experience and 
for your attention. I welcome your questions.

                                 
             Prepared Statement of James Schuster, MD, MBA
INTRODUCTION
    I begin by first providing some background information as to the 
context from which I approach the very important topic of adequate and 
timely access to behavioral health services here today. I am the Chief 
Medical Offer for Community Care Behavioral Health Organization of 
UPMC.
    Community Care Behavioral Health Organization is a 501(c)(3) tax 
exempt, nonprofit Pennsylvania-based behavioral health managed care 
organization. Community Care was created primarily to respond to the 
behavioral health needs of members of HealthChoices, Pennsylvania's 
mandatory behavioral health managed care program for Medicaid 
recipients. Community Care also serves UPMC Health Plan's commercial 
and Medicare members, via service cooperation agreements. Community 
Care currently employs more than 500 people to serve individuals in 36 
counties in Pennsylvania and 16 counties in New York. We manage the 
behavioral health services for over 650,000 Medicaid eligible persons, 
approximately 23% of whom are active consumers of care.
    Community Care's approach to behavioral health managed care is 
grounded in public sector commitment, expert clinical competencies, and 
both program and fiscal accountability. It is and has long been 
Community Care's philosophy that, in the end, quality is best measured 
by the improved health and well-being of the communities that we serve. 
Community Care is committed to continuous and systematic quality 
improvement across all domains.
    UPMC is an integrated payer-provider headquartered in Pittsburgh, 
Pennsylvania, which includes a comprehensive provider-based clinical 
delivery system, a suite of health insurance and health management 
companies, and a longstanding collaboration with the University of 
Pittsburgh, a premier academic institution. With 20 hospitals, more 
than 55,000 employees, 2,700 employed physicians, 2,500 independent but 
affiliated physicians, thousands of mid-level providers, 400 clinical 
locations, and insurance companies offering commercial, Medicare and 
Medicaid products, all of which have large contracted networks, UPMC 
operates amongst the largest integrated delivery and financing systems 
in the Nation.
    UPMC is organized into four major operating units: Physician 
Services, Hospital Operations, Insurance Services, and International 
and Commercial Services. Community Care is in the UPMC Insurance 
Services Division which also includes physical health plans that 
operate in the Commercial, Medicare and Medicaid markets. Collectively, 
Community Care and the associated companies of the UPMC Health Plan 
offer health coverage products and services to nearly 1.8 million 
members.
    UPMC Health Plan, the second-largest health insurer in western 
Pennsylvania, offers a full range of commercial and government products 
and services, including commercial group health insurance, Medicare, 
Medical Assistance, Special Needs (SNP), and Children's Health 
Insurance (CHIP), as well as disease management and behavioral health 
programs. The UPMC Health Plan's provider network includes more than 90 
hospitals (including academic, advanced care, and specialty hospitals), 
cancer centers, physician practices (including more than 9,800 
physicians), and long-term care facilities. Collectively, the network 
represents one of the largest and most diverse teams of healthcare 
professionals in Pennsylvania.
ACCESS AND BEHAVIORAL HEALTH SERVICE DELIVERY AND PAYMENT
    Achieving and maintaining only the highest quality over a wide-
range of metrics has been a goal toward which Community Care, UPMC 
Health Plan, and UPMC have long dedicated their efforts, including 
ensuring that members have adequate and timely access to behavioral 
health services.
    We believe that ensuring such access requires concerted effort 
across five areas: (1) defining the criteria that are reliable and 
valid measures of adequate and timely access; (2) developing measures 
to accurately capture variability within chosen criteria; (3) training 
and educating individuals tasked with applying chosen measures to do so 
in a consistent and systematic manner that produces meaningful results; 
(4) identifying patterns, progress, and opportunities for improvements; 
and (5) targeting meaningful solutions and/or corrective action plans 
for those areas in which the need for improvement is identified. We 
have found that a problem in any of the aforementioned functional areas 
can render our best intentions to ensure adequate and timely access 
meaningless. Accordingly, through various internal initiatives as well 
as through stakeholder partnerships and collaboration, all of which are 
focused on outcomes, we systematically address all 5 requisite areas.
    I'd like to talk a little bit about the steps we at Community Care 
and UPMC Health Plan have taken to implement best practices in each of 
these areas mentioned above. While the majority of my comments below 
will be provided from a payor perspective, many if not most are 
fundamentally applicable and relevant from a provider vantage as well.
Defining Criteria that are Representative of Timely and Adequate Access
    Most would agree that, insofar as healthcare delivery is concerned, 
adequate and timely access to services is a critical component of 
quality. If members cannot access a service, that service is of little 
or no use. In the context of access, however, ``adequacy'' and 
``timeliness'' are relative terms that do not necessarily lend 
themselves to standard definitions, particularly in the behavioral 
health arena. Whereas a 24-hour access standard may seem like nothing 
short of overkill for most healthcare services, anything longer would 
simply not be sufficient in the face of potential lethality or other 
psychiatric emergency. As such, identifying timely and adequate access 
as a marker of quality is merely a first-step; establishing measurable 
standards necessarily follows.
    Despite the relative nature of ``timeliness'' and the endless array 
of factors that impact this relativity, a failure to settle upon a 
measurable standard or to allow each unique circumstance to define or 
determine its own standard were not options for Community Care or UPMC; 
specific adequacy and timeliness standards had to be identified. To 
assist in this end, Community Care turned to other stakeholders, 
accrediting bodies (including NCQA and the Pennsylvania Department of 
Public Welfare), and existing statutory and regulatory requirements for 
guidance in setting appropriate timeliness benchmarks. Through these 
efforts and collaborations, Community Care has derived a comprehensive 
set of timeliness standards, beginning, for example, with a 24-hour 
telephonic triage and referral team assembled to assess members' 
immediate needs and determine the most appropriate levels of 
intervention. Team members assist callers with emergent or urgent needs 
and ensure that provider visits are arranged as quickly as possible and 
always within the following timeframes: immediately for life-
threatening emergencies; within one hour for non-life-threatening 
emergencies; and within 24 hours for urgent referrals.
    While identifying these specific and/or mandatory timeframes as 
``quality-indicators'' based upon objectively defined urgency standards 
is critical and important, Community Care recognized early in the 
process that members' opinions of accessibility were equally important. 
While, for example, a 14-day timeframe within which to be seen for an 
evaluation has a certain appeal, it is equally (if not more) important 
to ascertain what members view as reasonable or adequate timeframes; 
members are our best barometers of what should be. As described in the 
section below, Community Care and UPMC developed a number of different 
means by which to capture such subjective input.
    After identifying the timeframes within which it thought members 
should be seen and surveying members for additional input, Community 
Care considered the additional factors that could directly or 
indirectly impact adequate and timely access. It was important that 
Community Care and UPMC Health Plan as payors (and UPMC as a provider) 
not lose sight of the fact that timeframes are not met (or missed) in a 
vacuum. To the contrary, often a timeframe is little more than the 
consequence of competing variables. For Community Care these variables 
include things such as penetration rates, which identify the proportion 
of a member population who are actually utilizing services. The higher 
the penetration rate, the higher number of providers necessary to 
satisfy access standards. Additional variables include network 
adequacy, the member's self-identified needs, the member's clinical 
condition(s), and the array of available services. On the UPMC 
provider-side, variables such as staff-to-patient ratios and the type 
and range of staff employed are critical. Failing to recognize the 
interrelationship between these variables and timeliness could result 
in a failure to satisfy timeliness standards going forward; as such, a 
multi-dimensional assessment and approach to timely and adequate access 
is essential.
Measuring the Quality Metric ``Timely and Adequate Access''
    After identifying those standards and indicators that Community 
Care and UPMC Health Plan considered to be quality indicators with 
respect to timely and adequate access, it was necessary to develop 
valid and reliable means by which to measure and track those 
indicators. Community Care and UPMC Health Plan employ a number of 
different strategies to accomplish this end.
    Community Care and UPMC Health Plan both include timeliness access 
standards within their respective network provider agreements; 
contracting entities are expected to maintain established timeframes or 
will be considered in breach of the agreement. Timeliness standards 
vary based upon urgency of care, i.e., emergent, urgent, and routine. 
Providers are additionally required to notify Community Care 
immediately when they are unable to accept new members into treatment. 
While contractually imposing these requirements may seem severe, 
Community Care and UPMC Health Plan believe that clearly delineating 
timeliness standards in advance is preferable to allowing contracting 
parties to be uncertain about amorphous standards.
    Providers contracted with Community Care and UPMC Health Plan 
additionally agree to allow us to audit their compliance with these 
contractual requirements. Pursuant to these audit requirements, 
Community Care and UPMC Health Plan routinely audit contracting parties 
for compliance with these standards. Site visit surveys are conducted 
for non-licensed or non-accredited facilities (both at time of 
credentialing and at recredentialing), or whenever Community Care 
receives three or more site complaints within a 6-month period. If 
deficiencies are identified, quality improvement plans are required.
    As set forth above, while auditing contractual compliance is an 
efficient means by which to measure the more objective timeliness 
standards imposed by Community Care and UPMC Health Plan, particularly 
those contractually required, Community Care/UPMC utilizes member 
satisfaction surveys to assess member sentiments in terms of timely and 
adequate access. Over the past few years, Community Care has seen an 
increase in member-reported satisfaction as to timely access (76.1% in 
2008 to 78.2% in 2011).
    Another means by which Community Care/UPMC tracks member 
satisfaction (or dissatisfaction) with access standards is via member 
complaints. Community Care, for the purposes of member complaints, 
defines dissatisfaction with access to services as ``difficulty 
obtaining an appointment within a certain time period or within a 
certain distance, or the failure of a provider to meet the above 
required timeframes for providing a service.'' In 2011, less than 1% of 
all Community Care complaints were related to access to services. 
During the same time period, UPMC Health Plan received no complaints 
related to access.
    Given that timely access is impacted directly and indirectly by 
variables such as network adequacy, member need, and array of providers 
within provider network, Community Care tracks and measures these 
variables as well. Here again, Community Care relies upon requirements 
and benchmarks imposed by accrediting bodies such as NCQA and the 
Department of Public Welfare to serve as a guide to minimum 
sufficiency. For example, NCQA requires that Community Care contract 
with inpatient, residential, and ambulatory providers. As detailed more 
fully below, simply monitoring a timeliness standard alone would not be 
productive. Instead, Community Care carefully measures the sufficiency 
of and changes in the many ancillary factors that collectively result 
in or impact timeliness overall.
Training and Educating Those Measuring Access
    Evaluating the success (or lack of success) of Community Care and 
UPMC Health Plan's efforts to define and measure timely and adequate 
access standards could be undermined absent the comprehensive training, 
education, and outreach of all of those individuals tasked with 
measuring chosen criteria. It appears that this is one of the 
confounding factors experienced by the Veteran's Administration despite 
its efforts to adequately track and monitor access.
    Community Care/UPMC utilizes a broad array of means by which to 
make certain all stakeholders measure access in a consistent and 
standardized manner. Information about access requirements is included 
in both our provider manual and provider newsletters. We also routinely 
disseminate supplemental information during provider meetings and at 
any time upon request. All new providers are required to attend a 
comprehensive provider orientation, during which both the member access 
requirements and the means by which to capture and measure adherence 
are detailed.
    Community Care uses its audit and site-visit process as yet another 
educational touch point with providers. Included in Community Care's 
``Site Visit Tool'' is a requirement to review the provider's policy on 
appointment availability. Among the requirements are that (i) routine 
appointments are provided within 7 calendar days of request, (ii) life 
threatening emergencies are given immediate appointments; (iii) non-
life threatening emergency are seen within 1 hour of contact; and (iv) 
members with urgent needs are seen within 24 hours of first contact. 
Community Care is of the mindset that the audit process is not a 
punitive process or a process aimed necessarily at identifying 
problems. Rather, it is valuable opportunity to share information and 
to work with providers toward understanding the myriad requirements 
facing them, including accurately and consistently tracking and 
measuring access.
    In addition to educating providers on the standards expected of 
them, we inform members of what they can expect regarding access 
timeframes. We believe that members equipped with adequate information 
in this regard are in the best position to provide real-time, 
meaningful feedback as to how successful our providers and we are in 
meeting requisite standards. We rely on the member-complaint process as 
well as the care-management process for additional information 
regarding access performance. Furthermore, we routinely review triage 
and other referral calls to ensure access.
    While adequately educating all stakeholders upfront is of critical 
importance, Community Care and UPMC Health Plan have learned that 
consistent monitoring thereafter cannot be overstated. A failure to 
reinforce the specific access requirements or the means by which to 
measure and track those requirements could weaken all of our efforts in 
these regards. As such, we employ a dedicated staff across multiple 
departments to accomplish these ends.
Analyzing Data Collected
    The data gathered and maintained by Community Care and UPMC Health 
Plan is useful only to the extent that it tells us something about how 
we are performing with respect to access benchmarks. Here again, we 
engage a dedicated staff to analyze the information gathered via the 
myriad sources mentioned above. Such analyses are performed both for 
specific providers and sub-populations and for our collective provider 
networks; identifiable and aggregate reporting and analyses provide 
different but equally critical types of information. Where, for 
example, targeted information can inform us as to a given provider's 
progress in meeting requisite benchmarks and serve as an indicator of 
compliance with contractual obligations, aggregate data provides 
insight into broader systemic trends.
    As discussed above, our analyses are not limited merely to 
resultant timeliness. In addition, we routinely track and analyze 
provider sufficiency, both in terms of overall network capacity and 
within specific provider-types, such as psychiatrists or psychologists. 
We also closely monitor existing and anticipated member need (including 
diagnostic trends and condition prevalence) to anticipate and predict 
where added specialists may be required going forward. As discussed 
below, this information is then used for targeted contracting and/or 
hiring purposes.
    Community Care and UPMC Health Plan track penetration rates to 
determine the rates at which members are accessing services. We believe 
that increased use, for example, of ambulatory and/or outpatient 
services ultimately contributes to decreasing the use of more 
restrictive levels of care. Generally, we have witnessed a trend toward 
increased penetration rates for less restrictive services. Over the 
past decade the percentage of dollars spent for inpatient services in 
Community Care's behavioral health HealthChoices contracts has fallen 
from about 50% to just over 20%. In fact, when reviewing the results of 
the Community Care approach to care management, we have succeeding in 
significantly increasing overall number of users of service, while 
holding costs steady or even decreasing costs per member served.
    Among Community Care's routine reports is an ``availability of 
providers'' report, prepared by plotting the location of each member 
using address and zip code information and then comparing it to 
similarly plotted provider information. The resulting report shows the 
overall coverage for various provider types of service overlaid with 
the geographic location of our members. The report demonstrates the 
travel time for each member and then summarizes the precise percentage 
of members with access within the established drive time standards for 
each level of care. This information is used to enhance network 
development activities.
    Our quality Committees share analyses and results such as those 
described above both with targeted providers and with broader groups of 
stakeholders, including county administrators, accrediting bodies such 
as the Department of Public Welfare and NCQA, provider groups, and 
members. We believe strongly that, until this feedback is looped back 
to those providing, funding, and receiving care, it is of limited 
value.
Using Analyses to Prompt Change
    While data for data's sake may be interesting to some, its true 
value to Community Care and UPMC Health Plan is its usefulness in 
targeting necessary change and intervention. Over the years, data-
analyses have prompted a wide range of change. These changes include 
traditional type of interventions such as targeted increases in certain 
types of providers, e.g., psychiatrists, as well as systematic planned 
development, such as increased funding dedicated to community-based 
services. If upon analyses, it is determined that timely access is only 
problematic within certain sub-specialties, Community Care may target 
its employment and/or contracting efforts to increase providers of this 
type. Hiring and/or contracting with more professionals, however, has 
been only one of many solutions implemented by us over time. A one-
dimensional approach to change would be ineffective, particularly given 
the finite number of professionals in any given area, particularly in 
more rural regions. Moreover, records maintained by UPMC's human 
resources department suggest that the time it takes to fill at least 
some behavioral health positions can be substantially longer than 
positions of other types.
    Access feedback has also prompted Community Care/UPMC to explore 
and implement newer potentially revolutionary types of service-
delivery, including telepsychiatry initiatives. Community Care now 
supports approximately 20 telepsychiatry sites throughout Pennsylvania 
using secure forms of video transmission. Psychiatrists working across 
locations within the same agency staff some sites. Other sites are 
staffed by UPMC psychiatrists who are supporting service providers in 
more rural parts of Pennsylvania. Community Care has tracked both 
provider and member satisfaction of these services with very positive 
results. Published research on telepsychiatry indicates that patient 
satisfaction is generally as high as with in-person services.
    Mobile service delivery is another creative solution garnering 
increased interest by Community Care. Mobile therapy is particularly 
useful with those populations least likely to leave their homes to seek 
care, including the frail and elderly and individuals living in rural 
areas, as well as those whose behavioral health conditions render 
routine outpatient care difficult. An ample network is meaningless 
unless those persons who need services are able to access them. We have 
also worked with other stakeholders to substantially expand the range 
of services available to members. These additions include crisis 
services, hospital diversion programs, psychiatric rehabilitation, and 
certified peer services. All of these services have created new ways to 
access services and alternatives to traditional inpatient and 
outpatient models.
    Community Care routinely works with a wide-range of stakeholders, 
including providers, county authorities, and members, in all 
implementation efforts. We feel strongly that collaboration is 
essential to sustainability.
CONCLUSION
    Adequate and timely access to services is a critical component of 
quality. Ensuring access to services requires a sustained, systematic, 
and coordinated approach. We at Community Care, UPMC Health Plan, and 
UPMC believe that we have made great strides in these regards. I 
personally would like to thank you for the opportunity to discuss the 
work that we have done to improve access to services for members. I 
speak for Community Care and all UPMC affiliates when I offer any and 
all assistance that may be helpful going forward.

                                 
           Prepared Statement of Thomas Carrato, USPHS (Ret)
Biography of RADM Thomas Carrato, USPHS (Ret)
    Thomas Carrato is President of Health Net Federal Services, 
responsible for the daily leadership and management of Health Net's 
Government Services Division. His responsibilities include the 
management and oversight of Health Net's Department of Defense and 
Department of Veterans Affairs lines of business to include the DoD's 
TRICARE program for the North Region and the worldwide Military & 
Family Life Counseling contract.
    Mr. Carrato has over 30 years of experience, success and 
accomplishments in both the public and private healthcare sector as 
senior executive, chief operating officer and clinician. He served as 
Assistant Surgeon General of the United States, Regional Health 
Administrator for the U.S. Department of Health and Human Services, 
Deputy Assistant Secretary of Defense for Health Plan Administration, 
and Group Vice President for a publicly traded government services 
company. Mr. Carrato joined Health Net in March 2006 as Vice President 
and DoD Program Executive.
    Previously, Mr. Carrato served as Deputy Assistant Secretary of 
Defense for Health Plan Administration and Executive Director of the 
TRICARE Management Activity where he directed and managed worldwide 
operations and performance of the TRICARE health plan. In an earlier 
role as the Department of Health and Human Services' Regional Health 
Administrator for Region IV, Mr. Carrato was the Department's principal 
representative, providing advice and participating in policy 
development and implementation of key healthcare initiatives in the 
southeastern United States. He managed regionally based programs of the 
Office of Public Health and Science including the Offices of Emergency 
Preparedness, Minority Health, Women's Health, and Population Affairs.
    Mr. Carrato holds a Master of Science in Accounting from Georgetown 
University and is a licensed Certified Public Accountant. In addition, 
he holds a Master of Social Work from the University of South Carolina 
and is a licensed clinical social worker.
    Mr. Carrato, retired as a Rear Admiral in the Commissioned Corps of 
United States Public Health Service. His decorations include the 
Defense Distinguished Service Medal and the Public Health Service 
Distinguished Service Medal.
A Partnership History
    Chairman Miller, Ranking Member Filner and Members of the 
Committee, I appreciate the opportunity to testify on Veterans' access 
to mental healthcare services.
    Health Net is proud to be one of the largest and longest serving 
healthcare administrators of government and military healthcare 
programs for the Departments of Defense (DoD) and Department of 
Veterans Affairs (VA).
    In partnership with DoD, Health Net serves as the Managed Care 
Support Contractor in the TRICARE North Region, providing healthcare 
and administrative support services for three million active duty 
family members, military retirees and their dependents in 23 states. We 
also deliver a broad range of customized behavioral health and wellness 
services to military services members and their families, including 
Guardsmen and reservists. These services include the Military Family 
Life Counseling (MFLC) Program providing non-medical, short-term 
problem solving counseling, financial counseling, rapid response 
counseling to deploying units, victim advocacy services, and 
reintegration counseling.
    In collaboration with VA, Health Net supports Veterans' physical 
and behavioral healthcare needs through Community Based Outpatient 
Clinics and the Rural Mental Health Program. The Rural Mental Health 
Program was launched by VA in 2010 to provide access to community 
mental health services in select rural counties in three Veterans 
Integrated Service Networks (VISNs). Health Net delivers these services 
for VA in VISNs 19 and 20.
    While helping VA meet the needs of Veterans, Health Net also has 
collaborated with VA in its efforts to ensure efficiency in the non-VA 
care (Fee) program, helping VA save and recover millions of dollars 
since 1998. The monies recovered through these programs (less program 
expenses) are available to provide or enhance services for our Nation's 
Veterans.
    Health Net also is proud to support a number of VA's national 
sports and rehabilitation programs, such as the Disabled Veterans 
Winter Sports Clinic and the National Veterans Summer Sports Clinic. At 
the summer clinic, we provide behavioral health coaches who conduct 
education sessions designed to help Veterans take what they learn at 
the summer clinic home with them and apply it to their everyday lives.
    It is from this long-standing commitment to serving servicemembers, 
Veterans and their families that we offer our thoughts on addressing 
Veteran access to mental health services.
Call to Action
    According to the Department of Veterans Affairs, the number of 
Veterans seeking mental health services has climbed by a third. VA 
faces a significant challenge with respect to providing access to care 
with more and more servicemembers returning from Iraq and Afghanistan 
with mental health issues stemming from their military service \1\. It 
is imperative that Veterans receive care in a timely manner. With the 
rising tide of suicides \2\, access to timely care can mean the 
difference between life and death. Untreated mental illness impacts 
overall health and reintegration into the community, as well as the 
long term security, productivity, and well-being of this generation of 
Veterans, their families, and their communities. Chairman Miller, as 
you stated in a recent news release, ``These are wounds that cannot 
wait.''
---------------------------------------------------------------------------
    \1\ GAO VA Mental Health Report to Ranking Member, HVAC: Number of 
Veterans Receiving Care, Barriers Faced, and Efforts to Increase 
Access; 10/14/11.
    \2\ Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using 
VA Health Care: Facts and Figures; Congressional Research Service; 8/
16/11.
---------------------------------------------------------------------------
    As this Committee knows, the VA Office of Inspector General (OIG) 
recently released a report that was critical of VA's methods for 
recording patient wait times for both initial and follow up mental 
health visits, as well as its ability to provide access to these 
services in a timely manner. VA has been quick to respond to the April 
2012 OIG report. Likewise, we understand the urgency of the situation 
identified in the OIG report and the need for a prompt response.
    Addressing the dramatic increase in the demand for VA mental health 
services is challenging. Clearly, the demand has stretched VA's 
capacity to its limits. We appreciate VA's efforts to enhance capacity 
for the unique care needs of today's Veterans and respect its 
leadership in developing comprehensive guidelines for ensuring clinical 
quality, particularly in the area of Post Traumatic Stress Disorder 
(PTSD).
    VA has led in the validation of evidence-based treatment and, in 
collaboration with the DoD, in the development of clinical practice 
guidelines and provider educational materials addressing PTSD. VA also 
has taken steps to address access and to reduce the stigma associated 
with seeking these services. The DoD and VA are both actively training 
behavioral health providers in the delivery of these treatment 
modalities, and the VA has endeavored to make evidence-based mental 
health services available to Veterans across the range of treatment 
settings.
    Based on current services we provide to VA, as well as the DoD, we 
believe there are ready approaches to address this urgent need quickly 
and effectively. Moreover, these proven solutions for addressing both 
short-term and ongoing access issues can be performed without 
sacrificing clinical excellence which is so appropriately a priority 
for VA.
Access Pressure Points
    The demographics of the Veteran population are changing. There are 
more Veterans living in rural areas and a growing number of female 
Veterans. For example, of the over 8.3 million Veterans currently 
enrolled in the VA Health System, about 41 percent live in rural or 
highly rural areas, and approximately 30 percent of rural enrolled 
Veterans have served in Operation Enduring Freedom and Operation Iraqi 
Freedom (OEF/OIF). \3\ Currently, women Veterans comprise over eight 
percent of the total United States Veteran population, and their 
numbers have grown by 31 percent since 2006. \4\ It is expected that 
the proportion of women Veterans will continue to grow--VHA projects 
that women will represent ten percent of the total Veteran population 
in 2020, increasing to nearly 14 percent by 2030. \5\ Women comprise 
nearly 12 percent of OEF/OIF Veterans. \6\
---------------------------------------------------------------------------
    \3\ Presentation for National Rural Health Day: Caring for Rural 
Veterans; Dr. Mary Beth Skupien, Director of VHA Office of Rural 
Health; 11/17/11.
    \4\ http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
    \5\ Women Veterans by the Numbers, Lisa Foster and Scott Vince; 
California Research Bureau; 9/09/09.
    \6\ http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
---------------------------------------------------------------------------
From Surge to Rural Access
    Building upon over 20 years of experience serving active duty 
military servicemembers, their families, and Veterans, Health Net has 
developed a full continuum of programs to meet the behavioral health 
needs of this population. Throughout the design and implementation of 
these various programs, Health Net has collaborated with VA and DoD in 
delivering high quality, accessible programs which augment existing 
capacity and capability, both within VA and DoD.

               Overview of Programs Offered by Health Net
------------------------------------------------------------------------
         (please refer to Attachment 1 for detailed description)
-------------------------------------------------------------------------
 Military & Family Life Counseling Program (MFLC) Program:
 Provides short-term, problem-solving situational counseling; program
 includes a network of more than 5,000 credentialed, trained, and
 experienced counselors supporting 320 military installations in 50
 states, 4 territories, and 13 countries
 TRICARE North Region: Provides managed care support services to
 3 million activity duty servicemembers, military retirees, and their
 families in 23 states and the District of Columbia, provider network
 includes 22,500 licensed, credentialed behavioral health providers and
 392 facilities, have offered web-enabled, video short-tem counseling
 Community Based Outpatient Clinics: Provides primary care,
 mental health and preventive health services to Veterans
 Rural Mental Health Program: Provides care to Veterans close to
 home, behavioral health services provided by a network of clinicians
 and peer support specialists
------------------------------------------------------------------------

    These programs are very flexible in meeting demand, from supporting 
a ``surge'' of returning servicemembers to reaching out to Veterans 
living in remote geographic areas located many hours away from a VA 
Medical Center. We are able to deliver a full spectrum of services from 
preclinical to clinical, using a combination of face-to-face, 
telephonic, and video counseling with licensed clinicians to help 
servicemembers and their families and Veterans to address the unique 
issues of the military lifestyle and the challenges of transitioning 
from active duty to Veteran status. In addition, these programs are 
further enhanced through educational training and workshop 
presentations led by clinicians for patients and community providers.
    The success of these various programs has been noted by military 
leaders and beneficiaries. For example, the Military Family Life 
Counseling Program was the subject of a recent independent study 
performed on behalf of the Deputy Assistant Secretary of Defense 
(Military Community and Family Policy) by Virginia Tech University. In 
this study, recipients of MFLC support were asked to complete a brief 
survey, which indicated that 96 percent were mostly or completely 
satisfied with MFLC services. \7\
---------------------------------------------------------------------------
    \7\ DoD Counseling Program Evaluation, Partner: Virginia Tech; 
Examining the Perceived Effectiveness of Two Innovative Models of 
Mental Health Service Provision to Service Members and Their Families: 
Military One Source (MOS) and the Military Family Life Consultants 
(MFLC); January, 2001.
---------------------------------------------------------------------------
Established Best Practices
    The Department of Defense has engaged private sector firms like 
Health Net as partners in addressing the needs of servicemembers and 
their families up to the point of discharge from the service. Many of 
the services developed for servicemembers and their families as a 
result of this partnership are innovative, proven effective, and now 
considered ``best practices'' throughout the military. Among the ``best 
practices'' developed through this partnership are the following:

      The development and deployment of a standby capacity that 
is delivered when and where it is needed on a temporary basis. This 
``surge'' capability can provide brief, non-medical, problem-oriented 
counseling to address issues that arise in connection with deployment-
demobilization-re-deployment cycles of the troops and their families. 
This standby capacity is comprised of a network of highly trained, 
credentialed mental health professionals who are willing to serve in 
this standby force.
      The engagement of civilian and community-based networks 
of trained, credentialed, mental health professionals to reach the 
servicemembers and their families who are not in the vicinity of a 
Military Treatment Facility. This is often the case for the National 
Guard and Reserve components. The networks also meet the clinical 
behavioral health needs of military beneficiaries assigned to a 
Military Treatment Facility when the demand for behavioral health 
services exceed the capacity or the scope of care which can be provided 
within the military facility.
      The use of telephonic and web-based tools to provide fast 
access to resources that can assist with identifying serious cases 
early, before anything dramatic can occur.
    The Department of Veterans Affairs, likewise, has developed a 
number of innovations and ``best practices'' to deliver quality 
clinical services to Veterans.
      Through the Rural Mental Health Program, Veterans may 
access mental health or peer support services through a network of 
licensed behavioral health specialists and peer support specialists. 
All providers are trained on VA benefits and are able to address 
specific Veteran issues and conditions which occur among the Veteran 
population, including traumatic brain injury (TBI) and PTSD. VA 
specific training covers the mission of VA, describes the patient 
population, explains VA customer service, instructs providers on VA 
documentation of health records and outlines VA patient rights.
      Through the Claims Repricing Program, Health Net has 
helped VA reduce Fee Program claims costs by identifying more than $650 
million in discounts since the program's inception in August 1999. 
These discounts are the result of applying claims pricing available 
with Health Net's nationwide provider networks.
      Through a national recovery audit program, Health Net has 
helped VA in identifying over $113 million in overpayments for 
inpatient and outpatient care.
Access to Care Solutions
    Recruitment and training of clinical staff is paramount to the 
effective delivery of behavioral health services. Overall, Health Net 
has a national network of over 50,000 behavioral health providers. For 
the Military Family Life Counseling Program, we have a network of over 
5,200 licensed counselors who have been carefully selected, are fully 
trained, and ready to deploy on short notice as needed. These networks 
are further supported by 22,500 behavioral health providers in the 
TRICARE provider network.
    In this program, Military Family Life Counselors provide brief, 
problem-oriented non-clinical counseling services. They are required to 
assess risk in the context of non-medical interactions and to make 
referral into clinical behavioral health services when indicated. They 
have particular expertise in engaging servicemembers and their families 
in ways that minimize or mitigate stigma.
    Military Family Life Counselors are deployed on an as needed basis. 
When they are not deployed in support of the MFLC program, many of 
these masters-level behavioral health providers maintain clinical 
behavioral health practices in their home communities.
    As part of our program, MFLC counselors receive extensive core 
training and orientation. To ensure clinical approaches are current, we 
have established an independent Expert Curriculum Review Panel composed 
of an expert panel of retired military and academic researchers who 
specialize in deployment related psychology and military family 
resiliency.
    Health Net also has recognized the need to educate and train 
community providers about the unique needs of the military and Veteran 
population. Health Net, along with the American Red Cross and the Penn 
State Hershey College of Medicine, sponsored 1-day conferences 
targeting primary care and behavioral health providers. The conference 
was designed for primary care and behavioral health-care professionals 
to improve understanding, assessment, and treatment of the invisible 
wounds of war: PSTD and TBI.
    Providers expressed satisfaction with the content, based on a 
survey performed 6-12 months following participation: 84 percent of 
respondents expressed increased confidence in caring for returning 
servicemembers; 41 percent had implemented new strategies of asking 
about military service in their clinical practice. Additional programs 
are planned for 2012 in New York, Washington, D.C., and Ohio.
    As an industry leader in behavioral health, Health Net has 
committed extensive resources to developing effective programs to 
support the military and Veteran populations. Our highly trained and 
credentialed provider network is the foundation for healthcare 
delivery, whether on a military installation, in nearby population 
centers, or in rural, hard -to-reach locations.
A Path Forward
    We believe that these same clinical resources--a highly trained, 
credentialed mental health surge capacity, along with community-based, 
specially trained mental health providers--could effectively supplement 
VA's capacity to quickly and effectively address the access issues 
identified by the OIG without sacrificing VA's clinical excellence.
    In addition, enhanced use of telephonic and web-based tools, many 
of which VA has pioneered, offer Veterans with easy access to ongoing 
support, helping to de-stigmatize the care, as well as facilitating 
access for harder to reach Veterans.
    Specifically, we believe the urgent need created by today's 
environment--increased demand, strained resources, stressed facility 
capacity--requires a comprehensive approach, one that is designed to 
augment and enhance VA, based on the specific needs of each VA Medical 
Center. The components of this approach should include:

      A standby capacity to address urgent, short-term demand, 
similar to models used by the Department of Defense. Such an approach 
would be an effective and efficient model to provide rapid deployment 
of resources to alleviate short-term demand requirements at a VA 
Medical Center (VAMC) or a Community Based Outpatient Clinic (CBOC). In 
short, it would be an effective means to address the urgent mental 
health needs of today's Veterans, ``wounds that cannot wait.''
        These rapid-response or surge providers would work alongside VA 
providers, using the same clinical guidelines. In addition, this 
standby capacity would enable the early identification of Veterans who 
might be at risk for suicide or have other serious mental health 
issues. Such Veterans could then be triaged into a high priority 
process to gain access to VA providers and facilities as soon as 
possible.
      Telephonic and web-based tools that would offer the 
possibility of reaching deeper into the Veteran population to identify 
and serve those in need.
      A network of community-based mental health providers that 
would augment VA's capacity and reach, enabling VA to meet the needs of 
Veterans who do not live near a VA Medical Center or a Community Based 
Outpatient Clinic. Since this capacity already exists, it could be 
brought to bear almost instantaneously. An added benefit of using 
community-based provider networks similar to the ones we use for the 
Military Family Life Counseling Program and TRICARE is that they 
include a number of female clinicians to support treating the special 
needs of women Veterans.
    Specific considerations for VA to consider in developing this 
approach include:
      Deploy only a cadre of supplemental providers who are 
professionally competent and credentialed, as well as specifically 
trained in military culture.
      Exploit existing network and standby capacity to 
implement the solution very quickly. Time is critical here.
      Utilize surge techniques to concentrate the mobilization 
of the supplemental capacity in areas where the demand arises quickly 
as a consequence of force downsizing.
      Use of a single VA medical record system to record all 
services provided to ensure that care is delivered in close 
coordination with other VA providers.

    Taken together, the components of this model could transform the 
experience of Veterans in gaining access to their earned benefits in a 
timely fashion.
Conclusion
    We commend the VA for promptly responding to the VA OIG report on 
Veterans' access to mental healthcare. As VA seeks to address this 
urgent issue, we strongly encourage consideration of a comprehensive 
approach that builds upon VA's strengths in clinical quality 
excellence; one that draws upon best practices of not only the 
Department of Veterans Affairs, but also other Federal agencies and the 
private sector. Doing so provides VA with the fastest means for 
providing more immediate results for this Nation's well-deserving 
Veterans.
    Chairman Miller and Ranking Member Filner, thank you again for the 
opportunity to testify before this Committee today. More importantly, 
thank you for your strong leadership over this critical issue for our 
Nation's Veterans. I am happy to answer any questions you may have of 
me.
Background on Health Net, Inc.
    Health Net, Inc. is one of the Nation's largest publicly traded 
managed healthcare companies and is currently ranked #179 on the 2011 
Fortune 500. Health Net's government services division is one of the 
largest and longest performing administrators of government and 
military healthcare programs. Our health plans and government contracts 
subsidiaries provide health benefits to approximately six million 
individuals across the country through DoD, VA, as well as group, 
individual, Medicare, and Medicaid programs. As a leader in behavioral 
health, Health Net provides behavioral health benefits to approximately 
five million individuals across the U.S. and internationally through 
its subsidiaries, MHN, Inc. and MHN Government Services.
    Health Net Federal Services manages several large contracts for the 
government operations' division of Health Net, Inc. and is proud to be 
one of the largest and longest serving healthcare administrators of 
government and military healthcare programs for the DoD and VA.
    In partnership with DoD, Health Net serves as the Managed Care 
Support Contractor in the TRICARE North Region, providing managed care 
services for three million active duty family members, military 
retirees and their dependents in 23 states. In collaboration with VA, 
Health Net supports Veteran healthcare to meet the physical and 
behavioral health needs of Veterans through CBOCs and the Rural Mental 
Program. Additionally, Health Net also supports VA by applying sound 
business practices to achieve greater efficiency in claims auditing, 
recovery and re-pricing.
    MHNGS delivers a broad range of customized behavioral health and 
wellness services to the military services' members and their families 
and to Veterans. These services include military family counseling, 
financial counseling, rapid response counseling to deploying units, 
victim advocacy services, and reintegration counseling.
Attachment 1

 
------------------------------------------------------------------------
                  Program                         Brief Description
------------------------------------------------------------------------
Military & Family Life Counseling (MFLC)     Develop and manage
 Program                                     a network of more than
                                             5,000 credentialed,
                                             trained, and experienced
                                             licensed counselors,
                                             including 1000 qualified
                                             personal financial
                                             counselors, who serve 320
                                             installations in 50 states,
                                             4 territories, and 13
                                             countries
                                             Deploy on average
                                             1,400 consultants world-
                                             wide in any given month to
                                             provide private and
                                             confidential, non-medical
                                             and financial short-term,
                                             situational, problem-
                                             solving counseling
                                             assistance and support
                                             services to Service Members
                                             (including the National
                                             Guard) and their families
                                             An additional 280
                                             MFLCs [on average, per
                                             month] travel throughout
                                             geographically dispersed
                                             areas to ensure access to
                                             care for National Guard
                                             families; these MFLCs
                                             provide support at Pre-
                                             Deployment training events,
                                             welcome home ceremonies,
                                             departure ceremonies, and
                                             Yellow Ribbon events on
                                             weekends through the On
                                             Demand component of the
                                             MFLC Program
                                             Provide problem-
                                             solving, situational
                                             counseling in support of
                                             active duty service, guard,
                                             and reserve members and
                                             their families, during
                                             reunion/reintegration and
                                             mobilization/de-
                                             mobilization; non-medical
                                             problem-solving counseling
                                             support is intended to
                                             augment existing military
                                             and civilian support
                                             services
                                             Develop and support
                                             other components: the
                                             Marine Individual Ready
                                             Reserve (IRR) Outreach
                                             program and Joint Family
                                             Support Assistance Program
                                             (JFSAP), Child and Youth
                                             Services, Personal
                                             Financial Counseling, DoDEA
                                             Summer Enrichment Program,
                                             Victim Advocacy Support,
                                             Purple Camps, Recruiting
                                             Command, Victory
                                             Resilience, and the U.S.
                                             Army Recruiting Command
                                             effort
                                            -- Marine IRR Outreach--
                                             Provide support to Marine
                                             Reservists who often live
                                             far from their command
                                             structure and other
                                             Reservists, with limited
                                             support network to address
                                             the experiences of combat
                                             and the inevitable changes
                                             that have occurred while at
                                             war; provide telephone
                                             outreach to homecoming IRR
                                             citizen warriors; Address
                                             administrative issues
                                             associated with activation/
                                             deactivation, as well as
                                             life issues typical for
                                             returning servicemembers,
                                             such as readjusting to
                                             family life, reestablishing
                                             sleep habits, and
                                             rebuilding relationships at
                                             work; Placed over 22,000
                                             outreach calls to Marine
                                             Reservists
                                            -- JFSAP--Provide services
                                             at geographically dispersed
                                             and rural locations; Bring
                                             behavioral health and
                                             financial support services
                                             to active duty
                                             servicemembers, Guardsmen,
                                             and Reservists and their
                                             family members who might
                                             otherwise be unable to
                                             access such support through
                                             MFLCs personal financial
                                             counselors; Help reduce
                                             deployment and
                                             reintegration stress, teach
                                             coping skills, build
                                             resiliency, develop
                                             community resources, and
                                             support mobilization and
                                             reintegration activities
TRICARE North Region                         Serve over 3
                                             million active duty
                                             servicemembers, military
                                             retirees, and family
                                             members in 23 states and
                                             the District of Columbia
                                             Provide behavioral
                                             health services contracting
                                             and credentialing
                                             Established network
                                             of 22,500 licensed,
                                             credentialed, behavioral
                                             health providers, and
                                             contracts with 392
                                             behavioral health
                                             facilities
                                             Awarded original
                                             TRICARE North Region
                                             contract in 2004 (post DoD
                                             consolidating 12 regions
                                             into three: North, South,
                                             and West); re-awarded
                                             contract in May 2010
                                             Provided healthcare
                                             and associated services in
                                             California and Hawaii
                                             through CHAMPUS Reform
                                             Initiative (CRI), first
                                             contract awarded in 1988
                                             and became the foundation
                                             for future TRICARE
                                             contracts
                                             Awarded three
                                             contracts for five regions
                                             in 11 states to provide
                                             managed healthcare services
                                             to over 2.5 million
                                             beneficiaries following CRI
------------------------------------------------------------------------

    table continued on following page.

    table continued

 
------------------------------------------------------------------------
                  Program                         Brief Description
------------------------------------------------------------------------
TRIAP Program                                Provided expert
                                             short-term services
                                             available on demand to help
                                             beneficiaries cope with
                                             normal reactions to
                                             abnormal/adverse situations
                                             Delivered short-
                                             term, solution-focused
                                             counseling for situations
                                             resulting from deployment
                                             stress, relationships,
                                             personal loss, and parent-
                                             child communications
                                             Tested the use of
                                             web-based technologies to
                                             quickly provide information
                                             and short-term services to
                                             beneficiaries, and
                                             determined if services and
                                             platform increase DoD's
                                             ability to:
                                            -- Identify beneficiaries in
                                             need of medical mental
                                             healthcare at an early
                                             stage
                                            -- Refer beneficiaries
                                             quickly or facilitate
                                             access to appropriate level
                                             of mental healthcare
VetAdvisor Support Program (subcontractor    Provided behavioral
 to a SDVOSB)                                health counseling, military
                                             family counseling, and
                                             rapid response counseling
                                             to deploying units, victim
                                             advocacy services, and
                                             reintegration counseling
                                             programs for this pilot
                                             program
                                             Provided telephonic
                                             outreach offering benefits
                                             and behavioral-health risk
                                             assessments for returning
                                             Veterans
Rural Mental Health (VISNs 19 and 20)        Delivers care to
                                             Veterans at locations
                                             closer to the Veteran's
                                             home than the nearest VA
                                             Medical Center or Community
                                             Based Outpatient Clinic
                                             Veterans are
                                             eligible to receive therapy
                                             services as well as peer
                                             support services
                                             All providers are
                                             trained on VA benefits, and
                                             on addressing specific
                                             Veteran issues (i.e.,
                                             Military sensitivity, women
                                             Veteran issues, TBI, and
                                             PTSD)
                                             Peer support
                                             specialists are certified
                                             through a nationally
                                             accredited organization;
                                             network providers are
                                             licensed psychiatrists,
                                             psychologists, and master's
                                             level therapists
                                             Available to OEF/
                                             OIF Veterans within certain
                                             counties
Rural Mental Health (VISN 6)                 Used excess funds
                                             to establish a Rural Mental
                                             Health program that
                                             mirrored many of the pilot
                                             program's requirements (the
                                             VISN 19/20 Rural Mental
                                             Health program is a pilot
                                             program)
                                             Veterans were
                                             eligible to receive therapy
                                             services (peer support was
                                             not included).
                                             All providers were
                                             trained on VA benefits, and
                                             on addressing specific
                                             Veteran issues (i.e.,
                                             Military sensitivity, women
                                             Veteran issues, TBI, and
                                             PTSD)
                                             Program was
                                             available to all Veterans
                                             (not just OEF/OIF Veterans)
                                             within certain counties
                                             Program ended in
                                             December 2011 due to lack
                                             of funding
Warrior Care Support                         Provide complete
                                             healthcare planning and
                                             coordination services for
                                             warriors severely injured
                                             or with combat-related
                                             behavioral health
                                             diagnoses, and support for
                                             their families through
                                             TRICARE Program
                                             Assist Veterans
                                             transition from military to
                                             VA care
                                             Provide warrior
                                             with a ``Health Care
                                             Coordinator''--acts as
                                             single point of contact for
                                             healthcare services and
                                             works with military and VA
                                             to achieve a seamless
                                             transition
------------------------------------------------------------------------

                                 
                   Prepared Statement of Joy J. Ilem
    Mr. Chairman and Members of the Committee:
    Thank you for inviting Disabled American Veterans (DAV) to testify 
at this important hearing. We appreciate the opportunity to offer our 
views on the problems confronting the Department of Veterans Affairs 
Veterans (VA) and its Veterans Health Administration (VHA) in meeting 
the critical mental health needs of some of our Nation's veterans--
particularly newer veterans now struggling with post-deployment mental 
health challenges. As requested by the Committee, we focus this 
testimony on mental healthcare staffing; barriers to access; quality of 
care; reliability of data; and, systemic issues impeding care, wellness 
and recovery.
    Over the past five years both the House and Senate Committees on 
Veterans' Affairs have held numerous hearings on VA mental health. 
Topics included access to care; closing the gaps; waiting times; 
invisible wounds; suicide and its prevention; treatment of post-
traumatic stress disorder (PTSD); and, VA's Mental Health Strategic 
Plan and its Uniform Mental Health Services Handbook. \1\ Both the 
Government Accountability Office (GAO) and VA's Office of Inspector 
General (OIG) have evaluated and examined many of these issues, 
sometimes at the request of Congress, including the latest report, 
issued on April 23, 2012--Review of Veterans' Access to Mental Health 
Care. Likewise, for over a decade the print and electronic media has 
widely and repeatedly covered the many challenges new war veterans face 
with physical and mental health--including the perception that VA seems 
unable or has failed to help some of them. Predictably, this coverage 
focuses predominantly on veterans who have fallen through the cracks, 
taken their own lives, or has highlighted gaps in VA and DOD care, 
documented particular mistakes and failures in individual cases, cited 
the ever-present bureaucracy, and made observations examining barriers 
to care, including mental health stigma that prevents some veterans 
from even seeking VA care. It is rare to see media coverage of VA 
mental health in a positive light although over the past five years it 
has made remarkable progress in establishing a strong foundation of 
mental health services. DAV continues to be concerned about the 
constant negativity of the reports on VA mental health. Without proper 
balance in reporting we fear many veterans who need care the most may 
not come to the system designed to meet their unique needs.
---------------------------------------------------------------------------
    \1\ April 25, 2012, Senate Veterans Affairs Committee, ``VA Mental 
Health Care: Evaluating Access and Assessing Care.'' http://
veterans.senate.gov/hearings.cfm?action=release.display&release--
id=b030f350-2b9f-4e85-9903-0731e03be8e1
    November 20, 2011, Senate Veterans Affairs Committee, ``VA Mental 
Health Care: Addressing Wait Times and Access to Care.'' http://
veterans.senate.gov/hearings.cfm?action=release.display&release--
id=a9c9fd7c-36e8-4e4b-a9a4-dbff47a4fe5d
    July 14, 2011, Senate Veterans Affairs Committee, ``VA Mental 
Health Care: Closing the Gaps.'' http://veterans.senate.gov/
hearings.cfm?action=release.display&release--id=a005eefd-f357-4f33-
b702-196597a9a187
    June 14, 2011, House Veterans Affairs Committee, ``Mental Health: 
Bridging the Gap Between Care and Compensation for Veterans.'' http://
www.gpo.gov/fdsys/pkg/CHRG-111hhrg67193/pdf/CHRG-111hhrg67193.pdf
    March 3, 2010, Senate Veterans Affairs Committee, ``Mental Health 
Care and Suicide Prevention for Veterans.'' http://veterans.senate.gov/
hearings.cfm?action=release.display&release--id=d1a8548c-de2c-49a8-
b7f9-d0855265d435
    April 30, 2009, House Veterans Affairs Committee, Subcommittee on 
Health, ``Charting the US Department of Veterans Affairs' Progress on 
Meeting the Mental Health Needs of Our Veterans: Discussion of Funding, 
Mental Health Strategic Plan, and the Uniform Mental Health Services 
Handbook.'' http://veterans.house.gov/hearing-transcript/charting-the-
us-department-of-veterans-affairs-progress-on-meeting-the-mental
    June 4, 2008, Senate Veterans Affairs Committee, ``Systemic 
Indifference to Invisible Wounds.'' http://veterans.senate.gov/
hearings.cfm?action=release.display&release--id=74f01638-542e-49d7-
b3bb-f0ac55671f28
    May 5, 2008, House Veterans Affairs Committee, ``The Truth about 
Veterans' Suicides.'' http://veterans.house.gov/hearing/the-truth-
about-veterans%E2%80%99-suicides
    April 1, 2008, House Veterans Affairs Committee, Subcommittee on 
Health, ``Post Traumatic Stress Disorder Treatment and Research: Moving 
Ahead Toward Recovery.'' http://veterans.house.gov/hearing/post-
traumatic-stress-disorder-treatment-and-research-moving-ahead-toward-
recovery
    December 11, 2007, House Veterans Affairs Committee, ``Stopping 
Suicides: Mental Health Challenges Within the US Department of Veterans 
Affairs.'' http://veterans.house.gov/hearing/stopping-suicides-mental-
health-challenges-within-the-us-department-of-veterans-affairs
---------------------------------------------------------------------------
    As noted, the unprecedented efforts made by VA over recent years to 
transform itself and improve consistency, timeliness, and effectiveness 
of VA's mental health programs, provide evidenced-based treatments and 
care that bring veterans hope for recovery, and reduce stigma 
associated with mental health, are rarely discussed and virtually never 
applauded. Likewise, published reports and research on the tens of 
thousands of dedicated VA healthcare professionals and staff who 
provide specialized mental health services to troubled and ill veterans 
frequently go without any recognition, thanks or gratitude. 
Unfortunately, in the current environment it is difficult to shift 
public perception to the positive gains VA has actually made. Compared 
to the private sector, VA's mental health and substance abuse system 
gets high marks. However, given the troubling findings of the Senate's 
informal July 2011 mental health query of mental health providers \2\ 
and the most recent OIG report \3\ pointing out lingering and 
significant flaws and limits, VA seems to have fallen short of its own 
goals to provide the best possible accessible care to veterans, many of 
whom are in desperate need of receiving VA's specialized mental health 
services. VA is not meeting its access standards and has not provided 
the needed services consistently to every veteran in every VA facility 
across the country. While not true in most cases, VA bears the brunt of 
this perception and consequently pays a high price in the minds of the 
public and the veteran community.
---------------------------------------------------------------------------
    \2\ United States Senator Patty Murray, Official News Release, 
``VETERANS: After VA Survey Shows Long Wait Times for Mental Health 
Care, Chairman Murray Calls for Action.'' October 4, 2011. http://
www.murray.senate.gov/public/index.cfm/newsreleases?ID=87890f52-e2dd-
4f01-af31-43329f09adec
    \3\ VA Office of the Inspector General, Offices of Audits and 
Evaluations and Healthcare Inspections, ``Veterans Health 
Administration, Review of Veterans' Access to Mental Health Care.'' 
April 23, 2012 http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf
---------------------------------------------------------------------------
    The informal query VA conducted at the request of your counterparts 
in the Senate found that mental healthcare providers did not agree that 
veterans' ability to schedule timely appointments matched data reported 
by VA's performance management system and identified a number of 
constraints on their abilities to best serve veterans, including 
inadequate staffing, space shortages, limited hours of operation and 
competing demands for scarce appointment slots. Seventy-one percent of 
those survey respondents indicated that their medical centers had 
inadequate numbers of mental health staff. VA recently testified that 
it was taking two major actions as a result of the findings of this 
survey. VA developed a comprehensive action plan to enhance services 
and to address the VA staffs' concerns and it conducted an external 
focus group to better understand the issues raised by front-line 
providers. VA also stated it is conducting site visits to each VA 
medical center this year to evaluate mental health programs. \4\
---------------------------------------------------------------------------
    \4\ Senate Veterans Affairs Committee, ``VA Mental Health Care: 
Evaluating Access and Assessing Care,'' April 25, 2012. http://
veterans.senate.gov/hearings.cfm?action=release.display&release--
id=b030f350-2b9f-4e85-9903-0731e03be8e1
---------------------------------------------------------------------------
    The OIG was asked to determine how accurately VHA documents waiting 
times for mental health services for new and established patients, and 
whether the data VA collects is an accurate depiction of veterans' 
ability to access needed services. VHA policy requires new patients who 
are referred to, or who are requesting, mental health services, to 
receive initial evaluations within 24 hours of request, and be provided 
a more comprehensive diagnostic and treatment planning evaluation 
within 14 days of request. VA has reported that 95 percent of its 
first-time patients receive a full mental health evaluation within VA's 
14-day goal. Nevertheless, the OIG report found that VHA's mental 
health performance data is not accurate or reliable and that VHA's 
measurement of first-time access to a full mental health evaluation was 
not a meaningful measure of waiting times.
    The OIG conducted its own analysis and projected that in VHA only 
49 percent of patients (versus 95 percent) received full evaluations, 
to include patient history, diagnosis, and treatment plan, within 14 
days and for the remainder of patients, it took 50 days on average. 
Additionally, VHA could not always provide existing patients their 
treatment appointments within 14 days of their desired dates. DAV began 
an informal, anonymous online survey for veterans in December 2011, 
asking about their experience seeking and receiving VA mental health 
services. To date, nearly 1,050 veterans from all eras of service have 
responded to the survey, and our findings were close to those reported 
by the OIG on waiting times for follow up appointments. A complete 
report of DAV's survey results can be found on line at http://
www.standup4vets.org. The OIG report also noted that several mental 
health providers whom inspectors interviewed had requested desired 
dates for patients for follow up care based on their personal schedule 
availabilities rather than the patients' requests, or based on observed 
clinical need in some cases. Likewise, VHA schedulers did not 
consistently follow VHA policy or procedures but scheduled return 
clinic appointments based on the next available appointment slots, 
while recording the patients' ``desired'' and actual dates as if they 
were compliant with VA policies. Since the OIG had found a similar 
practice in previous audits nearly seven years earlier, and given that 
VHA had not addressed the long-standing problem, OIG urged VHA to 
reassess its training, competency and oversight methods and to develop 
appropriate controls to collect reliable and accurate appointment data 
for mental health patients. The OIG concluded that the VHA `` . . . 
patient scheduling system is broken, the appointment data is inaccurate 
and schedulers implement inconsistent practices capturing appointment 
information.'' These deficiencies in VHA scheduling system have been 
documented in numerous reports. After more than a decade, VA's Office 
of Information and Technology has still not completed development of a 
state-of-the-art scheduling system that can effectively manage the 
scheduling process or provide accurate tracking and reporting.
    The OIG also recommended that VHA conduct a comprehensive analysis 
of staffing to determine if mental health provider vacancies were 
systemic issues impeding VA's ability to meet its published mental 
health timeliness standards. Most importantly, the OIG report noted 
that meaningful analysis and decision making required reliable data, 
not only related to veterans' access but on shifting trends in demand 
for services, the range of treatment availability and mix of staffing, 
provider productivity and treatment capacity of the facilities. 
References were provided by the OIG to VHA on managing a better 
response to a number of shifting dynamics, through ``dashboard 
reports'' used in the private sector that incorporate patient demand, 
clinic capacity and provider productivity in a consistent set of 
business rules in which to assess and respond quickly to changes in 
access parameters. The OIG made four major recommendations to VHA on 
the above noted issues. Similar to previous external reviews, the VA 
Under Secretary for Health has agreed with all these recommendations 
and stated that a number of measures are currently underway. \5\
---------------------------------------------------------------------------
    \5\ Ibid.
---------------------------------------------------------------------------
    As we noted earlier in this testimony, despite obvious progress, it 
is clear to us that much still needs to be accomplished by VHA to 
fulfill the Nation's obligations to veterans who are challenged by 
serious and chronic mental illness, and particularly to those with 
post-deployment mental health and transition challenges. VA's duty is 
clear--all enrolled veterans, and especially servicemembers, Guardsmen 
and reservists returning from current or recent war deployments, should 
be afforded maximal opportunities to recover and successfully readjust 
to civilian and domestic life. They must gain user-friendly access to 
VA mental health services that have been demonstrated by current 
research evidence to offer them the best opportunity for full recovery.
    We must stress the urgency of this commitment. Sadly, we have 
learned from our experiences in other wars, notably in the post-Vietnam 
period, that psychological reactions to combat exposure are not 
unusual: they are common. If they are not readily addressed at onset, 
they can easily compound and become chronic and lifelong. The costs 
mount in personal, family, emotional, medical, financial and social 
damage to those who have honorably served their Nation, and to society 
in general. Delays or failures in addressing these problems can result 
in self-destructive acts, including suicide, job and family loss, 
incarceration and homelessness. Currently, we see the pressing need for 
mental health services for many of our returning war veterans, 
particularly early intervention services for substance-use disorder and 
evidence-based care for those with PTSD, depression and other 
consequences of combat exposure. As we have learned from experience, 
when failures occur, the consequences can be catastrophic. We have an 
opportunity to save a generation of veterans, and help them heal from 
war, but decisive action is essential.
    Mr. Chairman, in mental health, VA is now at a crossroads, and its 
next steps are critical ones. This issue is extremely serious--and 
everyone wants to ensure that VA gets it right. We observe that 
Congress is frustrated, as are we. Billions of new dollars and 
personnel for improving VA mental health services have been pumped into 
the system over the past five years--and despite the significant number 
of new hires, a 46 percent increase in staff between 2005-2010, \6\ VA 
recently reported it still needs to hire 1,600 additional mental health 
clinical and 300 support staff. \7\ Many have pointed out \8\ this 
increment alone will not fix the problem. So, the question is what can 
and should be done at this critical juncture? What are the best 
solutions to solve the existing problems? Within the next couple of 
years, more combat veterans will be returning home and many will need 
VA's services. We concur with remarks made by Deputy Under Secretary 
for Health for Operations and Management, William Schoenhard, at the 
April, 25, 2012, Senate Veterans' Affairs Committee Hearing that 
sending these veterans out of the system en masse is not the answer--
this group particularly can benefit from VA's expertise in treating 
post-traumatic stress, PTSD, substance-use disorders, traumatic brain 
injury and other post deployment transition issues. To that end, it is 
essential that VHA address and resolve the issues that tolerate 
variable provision of mental health and substance abuse care and 
prevent consistent, timely access to care at VA facilities nationwide.
---------------------------------------------------------------------------
    \6\ VA Office of the Inspector General, Offices of Audits and 
Evaluations and Healthcare Inspections, ``Veterans Health 
Administration, Review of Veterans' Access to Mental Health Care.'' 
April 23, 2012 http://www.va.gov/oig/pubs/VAOIG--12-00900-168.pdf
    \7\ United States Department of Veterans Affairs, Official Press 
Release, ``VA to Increase Mental Health Staff by 1,900,'' April 19, 
2012. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2302
    \8\ The New York Times, Editorial, ``Does the V.A. Get It?'' April 
24, 2012. http://www.nytimes.com/2012/04/25/opinion/does-the-va-get-
it.html
---------------------------------------------------------------------------
    Unfortunately, the problems in VA's mental health programs are 
complex, and cannot be resolved within any single dimension. The VHA is 
facing systemic challenges that are similar in nature to the 
organizational problems that the Veterans Benefits Administration (VBA) 
is facing with respect to its seemingly intractable backlog of 
disability claims. The root causes are multiple, systems-based, 
longstanding, and complex. DAV has been a staunch advocate for 
correcting the root problems in VBA--not just managing a symptom of the 
problem by reducing the backlog on a crash basis. We believe the same 
holds true for VA's mental health clinical programs.
    One of the most troubling barriers that prevents VA from being more 
effective in many of its programs is VA's own human resources (HR) 
policies and the practices surrounding them. Practitioners and clinical 
program leaders across the VA system have told DAV for years that 
recruitment of new professionals is a vexing and frustrating challenge 
that contributes to VA's failings and deficits. Even when new 
candidates are plentiful, well-qualified, and eager to join VA 
employment, the process that leads to offers of VA employment can 
linger for months, and in rare cases, years, before an employment 
commitment can be made. Many excellent candidates wait for months 
without feedback from VHA and simply move on to other opportunities. 
Delays of such magnitude are due to a variety of factors, but one 
principal reason for them is that human resources personnel are 
accountable only to their program officials in HR, but not to clinical 
selecting officials. In our opinion, they do not treat recruitment as 
an urgent process requiring the highest level of customer service to 
both the internal and external customers. This is especially ironic, 
given that about 100,000 health professionals train in VA facilities 
annually. Many of these young professionals may want to stay in VA but 
their personal and financial circumstances prevent them from waiting 
months or years for a VA job offer.
    As a part of the Independent Budget (IB), DAV has been calling for 
reform in VA's human resources policies. \9\ Recent hearings on VA 
mental health in the Senate confirm that the lack of responsiveness of 
human resources offices and management policies are contributing to 
deficits in VA's mental health programs. Sadly, unresponsive HR 
practices are also affecting all of VA's key missions. We urge the 
Committee to carefully examine VA and Office of Personnel Management 
appointment authorities in statute and how they are being applied 
within VA to determine whether additional legislation would offer any 
helpful resolution. VA should develop and track measures of performance 
in HR recruitment, on-boarding and retention of clinical staff. Almost 
as important, the Committee should provide targeted oversight in 
examining why VA human resources programs are so weak and unaccountable 
at a time when they should be acting forcefully and supportively to 
ensure VA programs in VHA, VBA and Memorial Affairs are properly 
staffed to meet their missions. With help from Congress, we believe 
this aspect of VA's challenges can be solved with better leadership and 
more responsiveness, beginning at the local level and extending 
throughout the system.
---------------------------------------------------------------------------
    \9\ The FY 2013 Independent Budget, ``The Department of Veterans 
Affairs Must Strengthen Its Human Resources Program,'' pp 178-182. 
http://www.independentbudget.org/2013/05-47-220-MC-C.pdf
---------------------------------------------------------------------------
    I must also report that many VA facility executives seem to tacitly 
support current bureaucratic practices in HR as a means to conserve 
facility funding and stretching healthcare budgets. Almost every VA 
facility operates a ``resources committee'' or similar function to 
examine every vacancy occurring and then to require selecting officials 
to justify in writing (and sometimes by making personal appearances and 
appeals before the Committee) why vacancies should be filled at all. 
This grueling process that constitutes a ``soft freeze,'' can consume 
months, all the while allowing the facility to ``save'' the personal 
services funds that would have been paid in salary and benefits 
associated with those unencumbered positions. It is common practice for 
resource committees to deny authorization to fill mental health and 
substance positions, creating ``ghost'' positions that are listed in 
the Service FTEE allocations but can never be recruited. We understand 
that in many locations, the 1,600 newly allocated FTEE will not even be 
sufficient to fill these vacancies. We believe, certainly now in the 
face of inadequate mental health access, that such practices should be 
halted. With the massive and rising unmet needs being reported today, 
VA must become very sensitized and make every effort to quickly fill 
all mental health provider vacancies and their support staff positions 
as a high priority in HR offices. VHA Central Office and VA Medical 
Center leadership should be accountable to ensure that this occurs.
    Despite all these staffing challenges, the transformation of the 
VHA's mental health program over the past decade has been 
revolutionary. As the wars in Afghanistan and Iraq were raging, VA 
inaugurated its internal reforms in the beginning of 2004 and developed 
a Mental Health Strategic Plan rooted in the principles of recovery-
oriented care. In 2008, VA instituted a national Uniform Mental Health 
Services Handbook to ensure consistency of available services 
throughout the healthcare system's 1,400 sites of care. Full 
implementation of the Handbook is still ongoing, and now a patient-
centered care model has been added to the mix for all of VA healthcare. 
Likewise, state-of-the-art approaches to care, evidenced-based 
treatments and new technologies have been validated by research for 
some mental health challenges, including PTSD. All of these activities 
have occurred during a time of steadily increasing patient care 
workloads and rising demand for services. Despite the addition of 
thousands of new mental health staff, demand for these services by tens 
of thousands of new veterans has obviously overwhelmed the system and 
made it difficult for VA mental health providers to translate 
transformational mental health policies and cutting edge clinical 
services into consistently delivered clinical practices.
    Today's wars are truly different, and accompanied by multiple and 
longer deployments than any previous experience of military 
servicemembers, National Guard or reserve personnel. Additionally, the 
VA must not only contend with a new generation of war veterans but 
continue longer term treatment of a significant number of veterans from 
prior eras of military service with mental health challenges and a 
large, older population with debilitating chronic and serious mental 
illnesses. We believe the clinical policy changes VA has made over the 
past eight years are positive and will ultimately equate to better 
patient care and improved mental health outcomes--but significant 
challenges have arisen now on a daily basis, and these will need 
continued attention, intensity, resources and oversight--and the 
development of sound and workable solutions to ease the pressure while 
meeting veterans' needs. The VHA must develop a number of short and 
long range goals to resolve existing problems identified by the OIG, 
Congress and the veterans service organization (VSO) community. 
However, even those gains will not be enough unless VA conquers the 
challenge of making its own transformational cultural change across the 
healthcare system and at every service delivery point nationally. The 
HR function discussed is but one significant challenge that cries out 
for immediate reform.
    VHA must develop reliable data systems; fix the flaws in its 
appointment and scheduling system with effective policies and IT 
systems that fill the current gaps, and is responsive to mental health 
needs; develop an accurate mental health staffing model that accounts 
for both primary and a multitude of complex specialty mental health 
capacity demands; revolutionize its hiring practices and eliminate the 
barriers that obstruct timely hiring of mental health providers and 
support staff; adjust its practices to address the complexities of co-
occurring general health, mental health and psychosocial problems of 
veterans in a truly patient-centered manner, and re-establish 
credibility and trust with the veterans that VA is charged to serve.
    In addition to these general principles we have recommended to 
guide VA reforms, DAV also makes the following specific recommendations 
for additional oversight or legislation, as warranted:

      There is an immediate need for VHA to implement a 
National Tele-mental Health Program, modeled on the National Tele-
radiology Program, that provides the infrastructure, professional 
expertise and staff support needed to deliver consistent, evidence-
based mental health services at all VA healthcare facilities. 
Facilities could access the program to address surge demand for 
services and meet the challenges of staffing shortages. If sites were 
established on the East Coast, West Coast and in Hawaii, extended 
evening clinic hours could be offered that would ease the burden on 
veterans for time off work and child care. An effective tele-mental 
health program could also help ease the recruitment challenges being 
reported by smaller and more rural VA facilities that have difficulties 
recruiting and retaining mental health professionals.
      With Congressional oversight, VA should institute a 
Secretary's Task Force or Commission on Mental Health and Substance-Use 
Services, composed of VA and non-VA mental health and policy leaders 
and with participation by VSOs. This body should be given a broad 
directive, the staff, resources and mandate to provide comprehensive 
analysis and advice on the organization and delivery of VA mental 
health, substance abuse, and suicide prevention programs.
      The VHA should institute an external Mental Health 
Assessment and Site Visit Program to evaluate local fidelity and 
adherence to national mental health and substance-use disorder policy 
in the Uniform Services Handbook, as well as become a monitor for 
access, satisfaction, and quality of care issues. An external 
assessment will increase the objectivity and visibility of the site 
visit process. The current internal, VA staff review should serve as a 
pilot for this external comprehensive program evaluation and reporting 
process.
      The recent VHA reorganization divided the mental health 
program management responsibility and organized them under two 
different Deputy Under Secretaries--the the Deputy Under Secretary for 
Operations and Management and the Deputy Under Secretary for Policy and 
Services. This management change was implemented to ostensibly increase 
``integration'' but, in our opinion, instead has increased VA Central 
Office staff redundancy, reduced responsibility and accountability, and 
removed valuable professional staff resources from coordinated care 
delivery. Given the deteriorating performance of mental health programs 
and the difficulties now being highlighted, the wisdom of this 
reorganization should be reexamined and full authority returned to the 
Patient Care Services and the Office of Mental Health.
      As a high priority, VHA should address the co-morbidity 
of mental health and chronic pain syndromes in Operation Iraqi Freedom/
Operation Enduring Freedom veterans in order to provide better 
treatment guidance and reduce the epidemic of prescription drug misuse 
and the use of high risk opioid prescriptions.
      The VHA should revise the Veterans Equitable Resource 
Allocation (VERA) funding model to account for, and fund, the rising 
cost and complexity of comprehensive mental health and substance-use 
care in VHA.
      The Committee on Care of Veterans with Serious Mental 
Illness, which was authorized by law as a monitor on the quality of 
mental healthcare in VHA, and has been staffed by VHA, does not meet 
the original congressional intent, functions, and responsibilities. 
Congress should re-charter this Committee to ensure that it provides 
input from expert advisors in the mental health, substance abuse, and 
veterans communities, receives staff support and access to data in 
order to assess the performance of the program and healthcare 
facilities, present its findings to VHA and VA leaders, and advocate 
for all veterans who need outreach and anti-stigma, mental health, 
substance use, and especially suicide prevention programs. The VSOs 
should be active, full members of the Committee, rather than be part of 
its external consumer liaison group.
    Mr. Chairman and Members of the Committee, in closing we applaud 
VHA for its focus on providing veteran-centered care and changing to a 
recovery-based model of care with the goal of not only symptom control 
and reduction but a goal of helping veterans achieve improvement in 
their overall wellness and functionality in society. Likewise, we 
appreciate the Committee's continued oversight efforts in VA mental 
health and for continuing to insist that VA dedicate sufficient 
resources in pursuit of comprehensive mental health services to meet 
the needs of veterans VA serves--particularly the post-deployment 
mental and transition readjustment needs of returning war veterans. DAV 
recognizes this strong support and progress, but it is eclipsed and 
obscured by the problems we are discussing here today, and happening at 
the worst possible moment when expectations are highest. VA should 
expeditiously work toward real reforms to make the system stronger, 
while properly prioritizing and addressing the urgency of the current 
findings. We believe the recommendations provided by the OIG and the 
VSO community, along with VA's measures, can collectively be used to 
solve these challenges.
    Chairman Miller, this concludes my prepared statement. I am pleased 
to address any questions you or other Members of the Committee may wish 
to ask.

                                 
                 Prepared Statement of Alethea Predeoux
    Chairman Miller, Ranking Member Filner, and members of the 
Committee, thank you for allowing Paralyzed Veterans of America (PVA) 
to testify today on one of the most important healthcare issues facing 
America's veterans and the healthcare system of the Department of 
Veterans Affairs (VA). PVA believes that when veterans have timely 
access to quality mental healthcare services they in turn have the 
opportunity to establish productive personal and professional lives. 
PVA thanks this Committee for their continued oversight and hard work 
on this important healthcare issue.
    In recent years, the VA has made tremendous strides in the quality 
of care and variety of services provided to veterans in the area of 
mental health. These improvements include incorporating mental health 
into VA's primary care delivery model, increasing the number of Vet 
Centers, launching mental health public awareness campaigns, and 
creating call centers that are available to veterans 24 hours a day, 7 
days a week. While these improvements were much needed and have helped 
many veterans, PVA believes that issues of access to mental healthcare 
within the VA continue to exist and more must be done to make certain 
that all veterans receive mental healthcare that is timely and 
effective.
    The VA's Office of Inspector General (OIG) report, entitled, 
``Veterans Health Administration: Review of Veterans' Access to Mental 
Health Care,'' identified many weaknesses within VA's Department of 
Mental Health that if improved upon will allow VA to continue in its 
progression of providing high quality mental health services to 
veterans. Overall, the report concluded that the Veterans Health 
Administration (VHA) mental health performance data is not ``accurate 
or reliable, and VHA measures do not fully reflect critical dimensions 
of mental healthcare access.'' More specifically, the report stated 
that ``VHA's measurement of a first time patient's access to a full 
mental health evaluation was not a meaningful measure of wait time; VHA 
was not providing all first time patients a full mental health 
evaluation within 14 days as required by VA policy; VHA schedulers did 
not consistently follow procedures; and VHA overstated its success in 
providing veterans new and follow-up appointments for treatment within 
14 days as required by VA policy.'' \1\
---------------------------------------------------------------------------
    \1\ The Department of Veteran Affairs, Office of Inspector General, 
Offices of Audits and Evaluations and healthcare Inspections; 
``Veterans Health Administration, Review of Veterans Access to Mental 
Health Care.'' April 23, 2102, 12-00900-168; http://www.va.gov/oig/
pubs/VAOIG-12-00900-168.pdf
---------------------------------------------------------------------------
    While PVA is deeply concerned by these findings, such conclusions 
were not completely surprising. In fact, this year's Independent Budget 
states, ``One overreaching concern of the IBVSOs is the lack of clear 
and unambiguous data to document the rate of change occurring in VA's 
mental health programs, as noted in the May 2010 GAO report . . . VA 
needs more effective measures to record and validate progress.'' \2\ 
Four main recommendations were made by the VA OIG: 1) Revise the 
current full mental health evaluation measurement to ensure the 
measurement is calculated to reflect the veteran's wait time experience 
upon contact with the mental health clinic; 2) Reevaluate alternative 
measures or combinations of measures that could effectively and 
accurately reflect the patient experience of access to mental health 
appointments; 3) Conduct staffing analysis to determine if mental 
health staff vacancies represent a systemic issue that impedes VA's 
ability to meet mental health timeliness goals; and 4) Align data 
collection efforts related to mental health access with the operational 
needs throughout the organization. \3\
---------------------------------------------------------------------------
    \2\ The Independent Budget, FY 2013, pg. 71; 
www.independentbudget.org
    \3\ United States Government Accountability Office, Report to the 
Ranking Member, Committee on Veteran Affairs, House of Representatives, 
``VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, 
and Efforts to Increase Access.'' GAO-12-12; October 2011; http://
www.gao.gov/assets/590/585743.pdf
---------------------------------------------------------------------------
    PVA supports these recommendations and believes that the 
recommended actions will allow for VA to better identify and address 
the issue of access to VA mental healthcare services. In addition to 
these recommendations, PVA believes that increased attention to 
staffing, productivity and performance of providers, and patient demand 
will further assist VA in providing care that makes a difference in the 
lives of veterans.
    The analysis and results from the VA OIG report on mental health 
access data shines light on the inconsistencies of policy 
implementation within VHA, and how such inconsistencies can negatively 
impact veterans' access to quality care. For instance, VA requires that 
all first-time patients receive a treatment planning evaluation no more 
than 14 days from the initial request or referral for services. As the 
VA OIG reports states, various mental health offices within VA have 
been interpreting this policy to have multiple meanings, and the end 
result is not having reliable data to accurately assess veterans' 
access to care or the performance of providers. The VA must not have 
policies just for the sake of having policies. The VA must ensure that 
staff adheres to all policies that are put in place to guarantee a high 
caliber of services for veterans, and must further develop safeguards 
that ensure such policies are carried out correctly from day to day.
    On April 25, 2011, the Senate Veterans Affairs' Committee held a 
hearing entitled, ``VA Mental Health Care: Evaluating Access and 
Assessing Care.'' During this hearing a veteran and former VA mental 
health professional testified that too often the VA mental health 
system places a burdensome emphasis on having staff meet numerical 
performance goals at the expense of providing veterans with the best 
care possible. \4\ PVA believes that VA leadership must make certain 
that policies and regulations are developed to provide safe, quality 
health services for veterans, without compromising the professional 
integrity of the qualified providers who deliver the care. VA policies 
must be pragmatic and attainable, and improve the delivery of care by 
creating benchmarks and measures that help assess strengths and 
weaknesses of healthcare services and delivery.
---------------------------------------------------------------------------
    \4\ 4 Senate Veterans Affairs Committee, ``VA Mental Health Care: 
Evaluating Access and Assessing Care.'' April 25, 2012. http://
www.veterans.senate.gov/hearings.cfm?action=release.display&release--
id=f485cb0d-3ad4-407f-99a8-9f517d9c3af6
---------------------------------------------------------------------------
    PVA's Medical Services and Health Policy Department conducts 
regular site visits to VA Spinal Cord Injury Centers on a monthly 
basis. PVA's medical professionals that facilitate these visits, along 
with VA leadership from the various medical centers, compile staffing 
and bed capacity data for a monthly report. Included in these reports 
is the required number of staff that is needed to care for patients 
within a medical center as determined by VA policy. The reports also 
include the actual number of staff available for duty during the month 
of the visit. Staff members counted in the report include nurses, 
physicians, social workers, psychologists, and therapists.
    For the past year there have been consistent deficits in one or 
more of the mental health positions included in the report. Such 
deficiencies in mental health staffing directly impact veterans' access 
to mental health services. For example, within VA's Spinal Cord Injury 
System of Care, veterans receive annual examinations that encompass a 
mental health screening. This annual mental health screening is 
extremely important for veterans who have sustained a catastrophic 
injury as they have a high propensity to face challenges involving 
self-esteem, independence, and quality of life. The aforementioned 
mental health staffing shortages have the potential to compromise 
quality mental health screenings and treatment for veterans within the 
SCI system of care who are dealing with symptoms of mental health 
conditions.
    Without sufficient staffing, providing care when it is needed is 
difficult. Timely care is critical to preventing and treating mental 
health conditions. If VA is going to provide mental healthcare services 
in a timely manner, it must be equipped with adequate staffing in the 
various types of mental healthcare that it provides. For instance, 
within VA SCI primary care, our site visit reports indicate that 
psychologist positions in VA medical centers have extremely high 
turnover rates due to low compensation scales and high patient panels. 
This is a systemic issue within VA that involves various departments--
human resources, primary care, and mental health. Ultimately, staffing 
issues such as this impede veterans' access to mental healthcare and 
overall patient wellness.
    The VA recently announced increasing the mental health workforce by 
an additional 1,900 mental health professionals. To ensure that these 
staff increases are effective, PVA recommends that the VA conduct a 
comprehensive analysis of the mental healthcare needs of veterans and 
hire additional staff based on those needs. The VA cannot accurately 
assess the performance and productivity of providers if they do not 
have an understanding of the needs that the providers are expected to 
meet. As the VA OIG report emphasizes, accurate data on access, as well 
as trends in demand and provider productivity will help provide care 
that is timely and meets the healthcare needs of veterans. PVA also 
encourages the VA to develop a mental health staffing model that 
focuses on adequate staffing of mental health professionals throughout 
the numerous systems of care within the VA. Again, this model should be 
based on a patient needs assessment of veterans.
    Another systemic issue that impedes patient wellness involving VA 
mental healthcare is the lack of inpatient mental health services 
readily available to veterans with catastrophic disabilities. PVA's 
Medical Services team has found that inpatient care is not always 
available to veterans with a spinal cord injury or disorder due to a 
lack of accessible space, or the VA not being able to provide the 
necessary physical and medical assistance that is often needed when a 
veteran has a catastrophic injury or illness. When this is the case, 
these veterans are referred to alternative methods of treatment that 
may not always adequately meet their needs. The VA must work to provide 
all veterans with access to mental health services when they seek help. 
A physical disability or multiple complex health conditions should not 
prevent veterans from receiving quality, effective mental healthcare.
    PVA thanks Congress and VA for investing a great deal of resources 
into improving mental health services in recent years. However, we 
believe that more must be done to improve access. While PVA does not 
believe that there is one definite solution to improving veterans' 
access to VA mental health services, we do believe that a comprehensive 
assessment of veterans needs and mental health staffing is a starting 
point for identifying both strengths and weaknesses within the delivery 
of mental healthcare, and improving the delivery of services to 
veterans. All veterans regardless of generation should have access to 
timely, quality mental health services.
    PVA appreciates the continued oversight from this Committee on this 
extremely important issue.
    PVA would like to once again thank this Committee for the 
opportunity to testify today, and we look forward to working with you 
to improve VA mental health services for our veterans. I would be happy 
to answer any questions that you might have. Thank you.
Information Required by Rule XI 2(g)(4) of the House of Representatives
    Pursuant to Rule XI 2(g)(4) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.
Fiscal Year 2012
    No federal grants or contracts received.
Fiscal Year 2011
    Court of Appeals for Veterans Claims, administered by the Legal 
Services Corporation--National Veterans Legal Services Program-- 
$262,787.
Fiscal Year 2010
    Court of Appeals for Veterans Claims, administered by the Legal 
Services Corporation--National Veterans Legal Services Program-- 
$287,992.

                                 
                   Prepared Statement of Ralph Ibson,
    Chairman Miller, Ranking Member Filner, and Members of the 
Committee:
    Thank you for conducting this important hearing and inviting 
Wounded Warrior Project (WWP) to offer our perspective.
    Mr. Chairman, you posed a critical question last June at a full 
Committee hearing on mental health that asked, in essence, whether VA 
is able to provide timely, effective, and accessible care to veterans 
struggling with mental health conditions. In testifying at that 
hearing, we observed that VA has instituted policies designed to 
achieve those goals, but that the gap between VA mental-health policy 
and practice can be wide. We have since learned much from both our 
warriors and VA mental health staff as to how wide that gap is. Thank 
you for your ongoing efforts to close that gap.
IG Findings: Symptoms of Deeper Problems
    Late last month, VA's Inspector General released a hard-hitting 
report that highlighted systemic flaws in both VA's scheduling of 
patients for mental evaluations and appointments, and in the 
reliability of its scheduling data. In our view, VA's scheduling 
failures and inaccurate reporting on performance data are symptoms of 
far deeper problems. In short, despite heroic efforts of dedicated 
clinicians across the system, VA is not consistently meeting its 
fundamental obligation to provide timely, effective mental healthcare 
to OEF/OIF veterans who are struggling with combat-related mental 
health conditions.
    It has been our observation that the Department of Veterans Affairs 
is quick to characterize many of the challenges it attempts to confront 
as ``priorities.'' But we can think of few higher priorities for VA 
than healing the psychic wounds of war.
    Multiple surveys, including a survey last year of our own warriors, 
\1\ have made it clear that many VA facilities lack sufficient mental 
health and support staff, and many lack sufficient space to accommodate 
the numbers who seek treatment. These and related problems have taken a 
troubling toll. We've all seen the results: veterans facing long waits 
for evaluation and treatment; veterans who need intense treatment being 
seen too infrequently; and far too often, veterans getting treatment 
that is simply inappropriate clinically, or dropping out of treatment 
altogether.
---------------------------------------------------------------------------
    \1\ WWP asked Wounded Warriors to participate in a survey in 
November 2011 that asked about their experiences with VA mental 
healthcare. Of more than 935 respondents, 62% had tried to get mental 
health treatment or counseling from a VA medical facility; some 2 in 5 
of those indicated that they had difficulty getting that treatment. And 
of those reporting that they had experienced difficulty, more than 40% 
indicated that they did not receive treatment as a result. Getting 
timely appointments was a frequent problem.
---------------------------------------------------------------------------
    For too long and as recently as during budget hearings earlier this 
year, Department leaders assured the Veterans Affairs Committees--
despite strong evidence to the contrary--that VHA has all the mental 
health staff it needs. In hearing after hearing, VHA officials have 
testified to the large numbers of returning veterans with PTSD who had 
been ``seen'' in VA facilities, as though being ``seen'' is the same as 
receiving timely, effective treatment. VA testimony has described 
multiple initiatives that have been mounted over a period of years, but 
``new initiatives'' haven't necessarily translated into veterans 
getting the help they needed. Late last year, the Department for the 
first time acknowledged that real problems exist, and described 
``action plans'' which in essence, promised further study rather than 
specific action.
    Squarely facing irrefutable documentation of deep problems and 
unanswered questions regarding its plan to recruit 1900 additional 
mental health staff and fill longstanding vacancies, VHA testified 
recently to efforts currently underway. Appearing before the Senate 
Veterans Affairs Committee last month, VHA representatives testified 
that in addition to its plan to add staff, it (1) has convened a ``work 
group'' related to scheduling, (2) is planning to implement an as yet 
undefined mental health staffing model next fiscal year, (3) is 
reviewing its data regarding patient access, and (4) is continuing a 
process of facility site reviews. While we don't seek to denigrate 
these efforts, the lack of specificity fails to constitute a real plan, 
and certainly don't address what we see as underlying systemic 
problems. Yet with no real remedy in place and mounting evidence that 
veterans are falling through the cracks, VA's Under Secretary for 
Health continues to urge veterans with mental health concerns to enroll 
for VA care. \2\
---------------------------------------------------------------------------
    \2\ Department of Veterans Affairs press release, ``VA to Increase 
Mental Health Staff by 1,900,'' (April 19, 2012), accessed on May 1, 
2012 at http://www.va.gov/healthbenefits/
---------------------------------------------------------------------------
    We ask this Committee to press VA to make mental health a real, 
ongoing top priority, and to ensure that it goes well beyond addressing 
the broken scheduling system the IG identified. As one VA mental health 
clinician described it to us--
    ``Getting someone in quickly for an initial appointment is 
worthless if there is no treatment available following that 
appointment.''
    Our warriors certainly echo that view. But to understand even more 
keenly the gravity and extent of those problems, WWP is currently 
surveying VA mental health staff across the country to learn what 
they're seeing at close hand. The survey \3\ is still underway and the 
data we're sharing is only preliminary. We did not have an avenue to 
distribute this survey to every VA mental health provider, but we 
believe the data provide a helpful snapshot of the problems clinicians 
are encountering daily. For example, with responses from VA staff in 17 
of VA's 22 VISNs, 87% reported that their clinic or program lacks 
adequate staffing to meet current demand. Two providers capsulized it 
as follows:

    \3\ Wounded Warrior Project, Survey of VA Mental Health Staff, 
accessible at www.woundedwarriorproject.org/vasurvey
---------------------------------------------------------------------------
    ``Understaffing is a huge problem . . . The mental health service 
line has grown over the past several years in terms of veterans 
enrolled, but has shrunk in terms of staff.'' ``VA in this area is 
entirely overwhelmed and booked to capacity. The families and the 
combat veterans are both suffering. Access to therapy on a timely basis 
is non-existent.''
    Among the most common reasons for understaffing, respondents (who 
were invited to identify all applicable reasons) cited the following 
problems at their facilities:

    u  administration policy against adding or filling positions (67%);
    u  increase in volume of veterans seen for mental healthcare (67%);
    u  funding constraints (63%);
    u  Human Resources' delays in recruiting/hiring (56%);
    u  greater intensity in patients' need for services (44%); and
    u  clinicians being detailed to other duties (43%).

    To its credit, VA has at last acknowledged a staffing deficit. But 
the lack of an operational staffing model raises real questions as to 
how new staff positions will be allocated. And it's not clear that VA 
clinicians themselves have any role in identifying staffing needs. As 
one clinician described it,
    ``Staff at my facility have repeatedly been told that we are viewed 
by the VISN as `overstaffed;' . . . I do not understand how we can be 
viewed as overstaffed, given the clinical realities of caseload sizes, 
waiting times for first appointments, and time between subsequent 
appointments.''
    We understand that VA Central Office is at last focused on mental 
health staffing, but the reality on the ground certainly does not 
inspire confidence in recent hiring practices. Citing the fact that it 
has taken many months for the hiring process to be completed, one 
clinician working in a VA mental health crisis program reported that 
``my program was without a nurse practitioner for 11 months and we have 
now been again without a nurse practitioner for 16 months.'' He 
described these as ``ridiculous amounts of time for any clinic or team 
to go without needed help,'' and observed that ``other staff burn out 
and start looking elsewhere in the interim, and so the cycle seems to 
go on and on.''
    The implications of VA's staffing problems are stark. Some 80% of 
survey respondents cited insufficient numbers of staff as the principal 
factor in delaying veterans' access to needed mental healthcare. 
Facility leadership appear to deal with staffing shortages in different 
ways, but these shortages are clearly compromising quality of care, as 
widely reflected in our survey responses. For example, 55% of 
respondents reported that at their facility OEF/OIF patients were 
either frequently or very frequently assigned to group therapy even 
though individual therapy may have been more appropriate. And nearly 
59% of respondents either disagreed or strongly disagreed with the 
statement that they had leadership support to choose the most 
appropriate treatment for their patients, including longer-term 
psychotherapy.
    Were VA able to hire 1900 additional staff and fill its 1500 
existing vacancies, it would apparently confront other critical 
shortages--from a basic need for space and privacy in which to provide 
this sensitive kind of treatment, to having any support staff. As 
survey-respondents put it,
    ``Let us not forget that space issues are significant as well. It's 
hard for management to feel very compelled to hire additional staff 
when they already have no idea where to put the staff they have. We 
have had psychologists and social workers at this facility go literally 
months without an office, relying on the daily absences of other staff 
members to free up an office in which to see patients.''
    ``I have no waiting room, no on-site clerk, no one to schedule/
cancel appointments. I do it all and it takes a lot of time from direct 
patient care.''
Impact on Veterans
    Ultimately, it is critical to understand the impact these systemic 
problems are having on veterans. Responding to our survey, VA mental 
health staff shared the following observations:

    ``I have a patient who came very close to attempting suicide in 
between appointments. I strongly believe that if I could meet with him 
weekly, or even more on occasion, his suicidal ideation would have 
decreased and he would be less likely to act on his thoughts.''
    ``One veteran whose appointment was cancelled several times at one 
of our CBOC clinics ended up committing suicide.''
    ``Veterans who are ambivalent or anxious about therapy for problems 
like PTSD need a fair amount of encouragement and contact in the 
beginning if they are to engage optimally in treatment. I have seen 
many veterans drop out of treatment, or relapse, or end up hospitalized 
due to a crisis, due to time between contacts being too long.''
    ``Veterans have opted to utilize vet centers or private providers. 
Those that continue to wait until their next appointment which could be 
months, suffer in silence. Some veterans are afraid to speak up fearing 
retaliation.''
    ``Effectively we have no mental health at our clinic. We are told 
to tell Vets they need to go to the VA hospital for mental health. 
However it is difficult for some because of travel distance . . . I 
think there are a lot of vets who call or inquire about mental health 
at our clinic, are told of lack of room, and then give up.''
    ``I am aware of several veterans who have attempted suicide, or who 
have died by overdose . . . and believe that more time with clinicians 
and easier access to programming may have changed things.''
    ``Even with two community based outpatient clinics, the catchment 
area is so large that it is still very difficult for some patients to 
access care AND in cases where a patient may be at high risk for 
suicide, the outpatient clinics often cannot or will not accommodate 
care due to it being a ``complicated case'' requiring care by the 
`mother ship' [the VA medical center], so vets get NO care because they 
are too debilitated to expend extra energy to get to the `mother ship.' 
''
Improving the Culture of Caregiving
    Finally, in setting out the array of systemic issues that 
compromise the effort to provide veterans timely, effective mental 
healthcare, it is important to consider the ``culture'' within which 
care is provided. As one clinician described it succinctly,
    ``The reality is that the VA is a top-down organization that wants 
strict obedience and does not want to hear about problems . . . 
Consequently, I have little hope that there will be real improvement. 
You will only see band-aids and more useless performance measures 
designed to make management look good.''
    This is not an isolated view. VA faces a real challenge as it 
relates to the culture at many facilities, given at least the 
perception that leadership employs a kind of command and control 
model--issuing policy directives and setting performance standards--
without regard to whether facilities' clinical staff actually have the 
means to carry them out, or whether they are really measures of--or 
even reasonable proxies for--good care.
    A clinician at a major VA tertiary-care facility put it even more 
starkly:

    ``There is an environment of fear instigated by mental health 
leadership. Staff are scared to bring patient care concerns to 
leadership because of retaliation that happens frequently. Turnover is 
high and mental health leadership explicitly tells clinicians that we 
are replaceable.''
    We commend VHA for conducting medical center site visits, and 
including time in those visits to meet with mental health providers (as 
schedules permit). It is not clear, though, how safe VA staff might 
feel to share the honestly critical concerns that an anonymous survey 
can elicit. VHA officials have been vague at best as to what those site 
visits have revealed. But while our own survey is still ongoing, the 
preliminary data suggest reason for real concern as it relates to an 
often unhealthy work climate. Asked, for example, about factors staff 
had experienced recently related to challenges in providing clinical 
services, respondents (asked to identify all applicable challenges), 
identified the following as among the greatest:

    u  experiencing high level of stress themselves (56%);
    u  feeling ethically compromised (50%); and
    u  considering leaving VA employment (44%).

    Just as some staff perceive that they are not heard, one should 
question the extent to which the veteran is heard. For example, VA has 
been strongly promoting the use of particular modes of therapy for 
treating PTSD that involve repeated intense exposures to their wartime 
trauma. But, just as any patient would expect their doctor to respect a 
decision to reject a recommended surgical intervention--even if that 
surgery represents optimal, evidence-based treatment for the problem--a 
veteran with PTSD should be afforded options. But that's not 
necessarily the case, as some have reported. To illustrate----
    ``Even telling patients that the only therapy we can offer them 
involves prolonged exposure [to the trauma they've experienced] sends 
them elsewhere. These patients should not just be offered short term 
treatment that may be too intense for them.''
    ``I know many unhappy clinical staff . . . related to requiring 
them to provide [exposure-based therapies] whether appropriate or not, 
and then having that be the end of the therapy.''
    In that regard, VHA leaders seem so insistently focused on 
evidence-based treatments that veterans' preferences can get lost. Last 
year, for example, the Richmond VA Medical Center last year terminated 
a group-therapy program over the strong objections of its participants 
and defended the decision, asserting that the group-therapy didn't 
constitute an evidence-based practice. VA Central Office officials' 
rigid rejection of the veterans' position remains inexplicable. The 
upshot, though, is that several of the group participants turned away 
from any further VA treatment because of the broken trust they believe 
they experienced.
    Unfortunately, our warriors often perceive that VA medical 
facilities don't offer them reasonable scheduling options. To 
illustrate, numbers of our employee-survey respondents cited veterans' 
concerns regarding this problem. The observations of two of who voiced 
a similar perspective:

    ``I'm aware of a number of veterans who are trying to maintain jobs 
or stay in school, and who have essentially been forced to choose 
between treatment and those other obligations. This could be easily 
ameliorated if our managers would agree to recent requests made by a 
number of well-trained clinicians for flexible schedules. (Granting 
these requests would also, incidentally, greatly improve the morale of 
these therapists, whose personal reasons for wanting the change to a 
flexible schedule are valid and are being dismissed; I know at least 
one psychologist who will likely leave the VA because of this issue.)''
    ``Many patients have requested evening appointments because of 
work/school schedules, and we cannot always accommodate them. Many 
staff have requested alternative work schedules to accommodate patients 
who request evening hours; however, mental health leadership at my 
facility have a policy against approving alternative work schedules.''
    It should go without saying that veterans' mental healthcare must 
take account of patients' wishes. Indeed VA policy reflects that core 
principle. \4\ But our concern again is with a system in which the gap 
between policy and practice can seem like a chasm.
---------------------------------------------------------------------------
    \4\ Department of Veterans Affairs, VHA Handbook 1160.01, Uniform 
Mental Health Services in VA medical facilities and clinics, (September 
11, 2008), sec. 5.b.(2)(a).
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Needed: A New Paradigm for Transforming VA Mental Health Care
    The problems that returning veterans--and dedicated VA mental 
health clinicians--are encountering extend beyond gaining full 
implementation of VA policy. In our view, the barriers that impede too 
many OEF/OIF veterans from getting timely, effective mental healthcare 
also make it critical that VA address several broader issues.
    1. It is no longer reasonable, in our view, for the Department to 
foster the belief that ``VA can do it all.'' The prevalence of war-
related mental health conditions among OEF/OIF veterans, the high 
percentages of veterans either foregoing VA care or dropping out of 
treatment, and the risks in their NOT getting needed treatment make it 
imperative that VHA acknowledge the limitations of its own healthcare 
system and seek out other partners. Limitations in VA mental health 
staffing, space, and geography underscore that the Department cannot do 
it all, and cannot go it alone. Institutional pride must give way to 
engaging a broader community to lend support. It's time, in our view, 
for VHA to reach out--to its medical school partners, to organizations 
representing mental health professionals, to state and local 
government, to the faith community and other communities--and state 
clearly, ``We need your help in providing for the mental health needs 
of returning warriors! We can't do it alone.'' As a bare minimum, VA 
must employ community-based care options when it cannot provide wounded 
warriors timely treatment.
    2. In a very real sense, VHA operates two almost-parallel mental 
health systems--one providing treatment through medical centers and 
clinics, the other in Vet Centers. Our veterans are consistently 
positive about their experience at Vet Centers, but with isolated 
exceptions report problems in accessing treatment at VA medical centers 
and clinics. Some 36% of those VA mental health staff who responded to 
our recent survey effort reported that their facility either did not 
have a close working relationship with the local Vet Center, or that 
relationship was less than optimal. These two systems should be much 
better coordinated, and should operate as though they are integral 
parts of a single mental health system, but that is not the case today. 
\5\ Moreover, VHA's acknowledgement of a need to increase staffing at 
VA medical facilities begs the question of Vet Center staffing. Some 
Vet Centers too are overwhelmed and require additional staffing, while 
there are indications that some areas of the country need additional 
sites. And as we testified last June, VA medical facilities have much 
to learn from Vet Centers, particularly as it relates to providing 
peer-support.
---------------------------------------------------------------------------
    \5\ VA's Uniform Mental Health Services Handbook, which ``defines 
minimum clinical requirements for VHA Mental Health Services . . . that 
must be provided'' addresses only what must be provided at each VA 
medical center and clinic. It does not address Vet Centers.
---------------------------------------------------------------------------
    3. VA faces many challenges in remedying the problems we've 
discussed--to include developing a reliable mental-health staffing 
methodology, streamlining the clinician-hiring process, developing 
mental-health performance requirements that measure patient outcomes 
and cannot be ``gamed,'' and fostering a healthier work climate. The 
Department has been attempting for some time, and with a relatively 
small staff, to ``put out fires'' relating to veterans' mental health. 
Without in any way minimizing the complexity of the issues and the hard 
work dedicated staff have given these efforts, the gravity of the tasks 
argues, in our view, for bolder steps than we have seen and for an 
approach which is far less reactive. It is time, in our view, to move 
beyond reliance on ad hoc work groups (whose members are likely pulled 
from clinical care), and instead to enlist independent expertise 
(whether through the Institute of Medicine or independent-expert 
consultants) for needed help. Surely VHA can also more productively 
enlist and engage its own mental health staff in cooperative problem-
solving at the facility level, and in doing so foster the trust and 
confidence critical to a healthy workplace and to success in 
recruitment and retention.
    Thank you for your continued focus on the importance of timely 
effective VA mental health services for our warriors.
    I would be pleased to answer any questions you may have.

                                 
                        Statement For The Record
    Hon. Tim S. McClain, President, Humana Government
    Chairman Miller, Ranking Member Filner, and members of the 
Committee:
Introduction
    Thank you for the opportunity to submit a statement for the record 
on the Department of Veterans Affairs' (VA) mental health staffing, 
quality and quantity; a topic critical to the thousands of Veterans and 
their families facing serious mental health issues. As mental health 
issues among our Nation's Veterans and servicemembers continue to 
dominate the headlines, VA faces the challenge of meeting this growing 
demand for quality mental healthcare and services.
    Humana Veterans Healthcare Services, Inc. (Humana Veterans), a part 
of the Humana Government organization, has answered the call and is 
helping VA to meet the mental health needs of our Veterans when the 
Department is unable to provide the care at a VA facility. Through 
contracts with VA, Humana Veterans provides access to quality non-VA 
healthcare through two congressionally-mandated pilot programs--Project 
HERO (Healthcare Effectiveness through Resource Optimization) and 
Project ARCH (Access Received Closer to Home).
    Last month, Secretary Shinseki announced VA's intent to hire 1,600 
mental health clinicians and 300 support staff. As the Committee 
examines the proper staffing levels of mental health providers at VA, 
we urge the Committee to consider the existing contractual resources 
such as Project HERO and ARCH, which are already available to Veterans 
and can quickly be mobilized to help meet their mental health needs. An 
understanding of all resources available to VA, including underutilized 
non-VA and VA resources, will help this Committee and VA to make 
informed decisions on the proper mental health staffing levels at the 
Department.
Mental Healthcare Quality and Staffing
    The quality of mental health providers certainly has a direct 
impact on Veterans' health outcomes. The mental health providers in 
Humana's network are fully credentialed and qualified to deliver a very 
high level of care. When examining staffing quality and health 
outcomes, care coordination is a critical element that should not be 
overlooked. With Project HERO contract scheduled to end on September 
30, 2012, VA is planning a follow-on national program referred to as 
Patient Centered Community Care (PCCC). Because mental health is among 
the planned services excluded from PCCC, this program will not result 
in Veterans receiving patient-centric coordinated mental healthcare. 
Exclusion of key services such as mental health goes against the very 
concept of care coordination, and makes it impossible for Veterans to 
fully realize the benefits of care coordination. Also, VA's decision to 
exclude mental health from PCC is misguided, especially when research 
clearly shows that physical issues often accompany mental conditions. 
For example, Post Traumatic Stress Disorder (PTSD) is a mental health 
condition that often coexists with Traumatic Brain Injury (TBI), which 
is a physical condition. Last month the Substance Abuse and Mental 
Health Services Administration (SAMHSA) issued a report that stated the 
following:

    Research has found a strong relationship between physical and 
mental health. People with mental health illnesses are more likely to 
have co-occurring physical health conditions, resulting in higher 
healthcare costs and disability. Co-occurrence of mental and physical 
health problems can increase healthcare utilization and complicate 
treatment plans. \1\
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    \1\ U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration (SAMHSA), National Survey on 
Drug Use and Health. ``Physical Health Conditions Among Adults with 
Mental Illness,'' April 5, 2012.
---------------------------------------------------------------------------
    The lack of care coordination is further exacerbated by VA's 
apparent decision to remove the administrative functions from PCCC that 
are associated with non-VA care authorizations, visits and treatment. 
VA is in the process of implementing a national program called NVCC 
(Non-VA Care Coordination), which requires the Department to invest 
significant resources, both in staff and necessary tools, to build in-
house capacity to handle the ``back door'' administrative functions. 
For example, this includes helping Veterans make and keep medical 
appointments, ensuring the return of clinical information, and making 
timely payments to non-VA providers. Humana Veterans is in the business 
of providing cost-effective administrative services and has developed 
an excellent personalized service model in Project HERO, which produces 
excellent results through metrics reported every month to VA. VA 
apparently intends to attempt to duplicate a large portion of the model 
internally. VA intends to build internal functions that insurers and 
health plans have as a core capability. VA should do what it does best 
(i.e., providing excellent healthcare) and contract with commercial 
companies for required administrative services, which is what they do 
well. VA's proposed course moves them closer to becoming more like a 
payor/insurance system similar to TRICARE and Medicare. Further, VA 
must recognize that an unintended consequence of removing contractor-
provided administrative services from the proposed PCCC program 
threatens the contractor's ability to maintain a provider network that 
is responsive to VA's changing needs. It also means that VA will not be 
able to obtain advantageous pricing, since the contractor cannot 
negotiate a better price with their network providers in the absence of 
a predictable minimum workload and without the ability to guarantee a 
low no-show rate, and timely, predictable payments.
    VA cannot ensure that Veterans receive high quality care if they 
move forward with the current plans for PCCC, which excludes mental 
health and other key administrative and care coordination functions. 
Instead, Veterans will receive only fragmented care that is neither 
effective, efficient nor timely, which is in effect the current Fee 
system.
Long-Term Effects of Combat
    Combat and exposure to combat condition, especially wounded, dead 
and dying individuals, profoundly affects a servicemember's future 
mental health status. A recently released research paper by the 
Syracuse University Institute for Veterans and Military Families 
includes the following findings:

    Veterans exposed to combat experience the lingering mental health 
effects of that trauma for decades after combat exposure; for many, the 
effects are permanent. This research shows that the effects of combat 
exposure are more pronounced for those whose service includes more 
traumatic events, such as exposure to dead, dying, or wounded people. 
Knowing this, our society can better predict the outcomes that these 
veterans will experience over time and the VA can better target 
resources and predict long-term resource demand.
    Based on our Gulf War parameters, we estimate that the costs of 
mental health declines to be between $87 and $318 per year for each 
soldier with combat service and exposure to dead, dying, and wounded 
people. \2\
---------------------------------------------------------------------------
    \2\ ``Combat Exposure and Mental Health: the Long-Term Effects 
Among Vietnam and Gulf War Veterans,'' Daniel M. Gade, Ph.D. and 
Jeffrey B. Wenger, Ph.D. Institute for Veterans and Military Families, 
Research Brief, released May 4, 2012.
---------------------------------------------------------------------------
Non-VA Mental Health Services Available
    Humana serves Veterans in VISNs 8, 16, 20, and 23 through Project 
HERO, and provides care to Veterans living in four out of the five 
pilot sites for Project ARCH which includes Farmville, VA; Pratt, KS; 
Flagstaff, AZ; and Billings MT. For both of these pilot programs, 
Humana provides access to a competitively priced network of physicians, 
institutions, and ancillary providers to supplement the VA healthcare 
system while adhering to high quality and access to care standards. 
Currently, we have the authority to provide mental healthcare to 
Veterans living in any of the VISNs participating in HERO, but our 
authority to provide such care is limited to Pratt, KS under Project 
ARCH. Our robust network of mental health providers is comprised of 
4,539 for HERO and 7 for the ARCH site at Pratt, KS. The geographic 
distribution of these providers is such that Veterans can easily access 
them by traveling an average of 14 miles for their care. VA's 
utilization of these two programs for mental health referrals has been 
low. For example, since Project HERO's inception in October 2007, we 
have received a total of 1,096 mental health referrals through 30 April 
2012. We began implementing Project ARCH in Pratt, KS on 28 August 2011 
and to date, have received zero mental health referrals.
    There is abundant research that point to the mental health staffing 
shortage in our healthcare system. Thus, VA will likely face 
recruitment and retention challenges for the newly announced 1,600 
mental health providers. There is certain to be delays in identifying 
qualified providers, and even when VA is able to do so, the bureaucracy 
of the Federal personnel system will further delay the on-boarding of 
the new hires. This could mean years before all 1,600 providers are 
deployed in the VA healthcare system and available to treat Veterans. 
VA should assess existing resources that can be deployed quickly. This 
includes an assessment of the existing contracts that VA has in place 
with community partners such as Projects HERO and ARCH, and tapping 
these underutilized resources to provide timely mental healthcare for 
Veterans. VA can also re-examine the pilot program's eligibility 
criteria and the definition for the pilot sites, especially with ARCH, 
which Congress intended to be a VISN-wide program. In addition, VA 
should examine its current mental health workforce to determine ways to 
best maximize the productivity and efficiency of the staff, which 
requires proper metrics and incentives.
    An informed decision on the proper staffing levels is only possible 
if VA identifies and maximizes underutilized non-VA and VA resources. 
Humana has a proven service model and stands ready to assist VA in 
delivering to Veterans quality mental health services in a timely 
manner. Humana Veterans has existing capacity to handle additional 
mental health referrals under Projects ARCH and HERO and is committed 
to further expanding our network, if needed, to properly accommodate 
the referrals from VA.
Conclusion
    VA must not miss an opportunity to implement real care coordination 
of mental health and other services.
    Improving the mental health and well-being of our Veterans is 
certainly a daunting task; however, our society cannot and must not 
fail the men and women who bravely served this Nation. No single entity 
has the capacity to fully address the mental health needs of our 
Veterans. This is a national problem and a local community problem. VA 
cannot do this alone just as the communities across the Nation cannot 
do it alone. Instead, it will require collaborative partnerships and 
care coordination among all mental health assets. VA can begin by 
assessing the partnerships it has in place under existing contracts and 
programs such as HERO and ARCH. In addition, PCCC is an opportunity for 
the VA to mobilize networks of mental health providers in the 
communities where Veterans live. Rather than excluding mental health 
and other services inherent in a care coordination program from 
proposed PCCC model, VA should rethink their approach and infuse strong 
care coordination elements into the program design to include medical 
surgical, laboratory, mental health, and health & wellness elements. We 
look forward to continuing and enhancing our collaboration with VA to 
bring excellent mental health services to our Nation's heroes.
    Thank you, Mr. Chairman, for the opportunity to submit this 
statement for the record.

                                 

    Thomas J. Berger, Ph.D., Executive Director, Veterans Health 
Council, Vietnam Veterans of America
    Chairman Miller, Ranking Member Filner and distinguished members of 
the House Veterans' Affairs Committee, on behalf of President John 
Rowan, our Board of Directors, and our membership, Vietnam Veterans of 
America (VVA) thanks you for the opportunity to present our statement 
for the record on ``VA Mental Health Care Staffing: Ensuring Quality 
and Quantity''.
    As has been already reported by various sources, the Inspector 
General (IG) report of April 23, 2012, concluded that the VA does not 
have a reliable or accurate method of determining whether they are 
providing veterans timely access to mental healthcare services and that 
the VA is unable to make informed decisions on how to improve the 
provision of mental healthcare to veteran patients due to the lack of 
meaningful access data. VVA finds this absolutely unacceptable
    Veterans Health Administration policy requires that all first-time 
patients requesting mental health services receive an initial 
evaluation within 24 hours, and a comprehensive diagnostic appointment 
within two weeks. For years now, VHA officials have claimed that 95 
percent of its new patients were seen in that time frame. But the 
recent IG report called those calculations confused and inaccurate. By 
IG researchers' count, fewer than half of those patients were seen 
within the 14-day requirement. The average wait for a full evaluation 
among the rest was 50 days.
    The report also sharply criticized VHA staffers for not following 
proper scheduling procedures, further confusing the data collection. 
For new patients, scheduling clerks frequently stated they used the 
next available appointment slot as the desired appointment date for new 
patients, thereby showing deceptively short wait times. For established 
patients, medical providers scheduled return appointments based on 
known availability, rather than the patient's clinical need. The report 
found that the V.A.'s system for measuring waiting times for 
evaluations ``had no real value'' because it measured how long it took 
the department to conduct the evaluation, not how long the patient 
waited to receive it. As a result, the report said, even if a patient 
waited weeks for an appointment, the V.A. could say there was zero 
waiting time if it completed the evaluation on the same day it was 
conducted.
    Although IG investigators also blamed some of the long wait times 
on shortages in mental health staff throughout the department and noted 
that from 2005 to 2010 mental health services increased their staff by 
46 percent. However, according to the report ``VHA's mental healthcare 
service staff still did not believe they had enough staff to handle the 
increased workload and consistently see patients within 14 days of the 
desired dates.'' These flaws in the VA's appointment system has for 
example, led to an average wait time of 28 days for patients at the 
Milwaukee VA Medical Center and over 80 days at the Spokane VA center 
in Washington state. And in several extreme cases reported in the 
media, lack of immediate access to mental health services has resulted 
in veteran suicides.
    Although the IG recommended, among other things, that the VA revise 
its method of measuring waiting times and analyze its staffing levels 
to ensure that it is able to abide by its own policies, it remains 
unclear as to how this will be accomplished so that VA facility and 
VISN directors can no longer ``game'' the system. Under Secretary for 
Health, Dr. Robert A. Petzel, said in a letter to the IG that the VA 
generally agreed with the recommendations and that it would initiate a 
timeliness review of its entire medical system, not just the four 
regions analyzed by the inspector general. Thus VVA is forced to ask 
the questions: Precisely how will this be accomplished so as to finally 
end this and other ``gaming the system'' practices that we know are 
used in many (if not most) clinics around the country, and exactly what 
productivity and performance measures will be utilized to determine 
whether the VA's measurements and analyses are real and correct?
    Furthermore, in July 2011, the Senate Committee on Veterans' 
Affairs requested VA to conduct a survey that among other questions, 
asked mental health professionals whether their medical center had 
adequate mental health staff to meet current veteran demands for care; 
71 percent responded their medical center did not have adequate numbers 
of mental health staff. Now in May 2012 we hear of VA's plan to hire an 
additional 1,900 mental health staff. VVA asks if there is or will be a 
staffing analysis to determine if mental health staff vacancies 
represent a systemic issue impeding the VA's ability to meet mental 
health timeliness goals, and if so, will the VA develop a transparent 
but accurate action plan to correct the impediments.
    Clearly the VA mental health scheduling and staffing systems needs 
a complete major overhaul.
    VVA agrees with a statement from the Chair of the Senate Veteran 
Affairs Committee who said earlier this spring: ``Getting our veterans 
timely mental-healthcare can quite frankly often be the difference 
between life and death.'' VVA also hopes that this HVAC Committee will 
directly oversee VA's efforts to do so, and we offer our assistance.
    Again, thank you for the opportunity to offer a statement for the 
record on this important veterans' issue.

                                  

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