even tougher for you guys. the comment about the parents not knowing, i'm not surprised. a lot of people, the worst thing in the world, after my second purple heart, i didn't want my parents to know what was going on. this is going to be the problem that i think all of you are sharing, that common denominator. you know, everybody that goes through these experiences will have huge psychological problems, but who are they going to share it with? are they going to share with a psychiatrist or a psychologist that doesn't understand the military culture, the veteran culture? they are not going to open up. you need that connection. i think the sergeant made a great point. your comments about the wounded

warrior program where they have that, the actual battalion where when somebody's got a problem, they go into that system there. i just want to get your feelings. maybe i'm going down the wrong road because i think they need somebody that has a problem, they need an ombudsman, somebody that's going to look out for their interests. that if they have a particular hospital, that they can go to the administrator. they can go to anybody and say, hey, wait a minute. this is an immediate situation. this is general quarters and we need to have a meeting right now or somebody is going to die on your watch. can you comment a little bit more on that? it's pretty much what you were talking about, buddy-to-buddy, the same things over and over

and over again, but to cut through the red tape right then and there with individuals that understand severity of the problem. >> yes, sir. this is a crucial element is to have somebody to come alongside of these severely injured, cut through that red tape and get treatment now. this is something we experienced first hand. i've experienced. i shared with some of the folks from wounded warrior project recently. we did a crisis intervention on attempted suicide. we got him in a position of stability and i found out he never accessed care at the va facility. he went down and he was denied treatment and told he would be able to be seen in three months after telling somebody he had attempted suicide the night before. i went down there and met with that veteran and we walked in and i said this is an unacceptable answer. we got the department head to

come out and say i will take him today. we have a program we can start him in next week. that saved that veteran's life that day, but there are thousands more a day that are getting the no and not getting the extra answer because they don't have somebody to advocate for them. i'm not saying that to toot my own horn. ifa >> >> i spent a lot of time even with my platoon sergeant and we would talk about how you would never forget 1967, horrible. you never forget it. what you have to do is try to make the system better.

but in terms of not capturing those individuals individuals, it is just the point of something bad. it's our fault. comment? >> it's a systems issue within the va. and our feeling is everybody who works in the va should have only one purpose in mind and that's to advocate for the veteran. it's the person who sits in the corporate office to the person who cleans and empties the waste baskets at night. that's the only, only thought they should ever have. >> doctor, that concept of the ombudsman or for lack of a better term, somebody that is ultimately responsible or somebody that is that advocate for that person in trouble. >> we agree there needs to be an ombudsman. we know about the navigator program.

that's a great program. we know that they are doing a much better job of that out in san diego. it's not only the ombudsman. it's not only the navigator. it's every single person. >> it should be an sop. >> standard operating procedure for every hospital. i yield back. >> thank you, colonel. ms. brown for five minutes. >> thank you, mr. chairman. let me thank each and every one of you. i recently did work with marines and they would be very proud of you, your sons. thank you very much for your service. you know, i have to say we are talking about the va, but this is not just the va. it's dod. this hearing should be va/dod because it's dod that send people over and over and over again to combat.

it's not transitional as far as when they come back, so it's a bigger problem. to sit here and say it's the va, that's just not true. it's just not true. we need to deal with the problem. the fact is we've been fighting a wall with reservists. and we've sent them over and over again. and they didn't have the support that they need. i've gone out when they're deployed. they don't have all of the other, that the other military branches have. we're not doing the wars the way we need to. and the system is fragmented. so as we develop a comprehensive system, let's get everybody in the room. let's deal with the system the way we need to deal with it. now, you mentioned the

formulary. we insist they negotiate the prices of the drugs to keep the costs down. what is wrong with the way we're doing that? because in the regular market, it is illegal for the secretary to negotiate the price of the drugs. which i think is dumb. >> there is no problem negotiating the price of the drugs. the problem is the drugs aren't the same so that, for example, lexopro, you would want the dod formulary as opposed to the va formulary, no doubt about it. i know first hand you can basically get anything you need with relatively little hassle. >> but i thought the va was the one that was doing a lot of the research, not the dod. >> research has nothing to do

with anything. the only thing that has to do with it is the actual drug you are being prescribed by your provider. you can do research. that was one of daniel's issues. there is a problem doing research because of the fear of the fda and dea and schedule one medications and things like that. that's a totally different issue. the problem is the formularies aren't the same. i've got patients, not only veterans being discharged, but retired military who are being seen at a dod hospital and at a va medical center and they are eligible to be seen in both, and they are under medication restrictions because the formularies are different. we need to make it a single formulary. bottom line. >> okay. >> excuse me. in addition to that, it's like if a person is doing really well on a drug, they should be able to stay on that drug.

>> the doctor can override that. >> just because you can get it for 10 cents cheaper, it can have major effects on their body. >> absolutely, but the doctor can override that. >> what gina is saying is different. it's still a generic, but as i said before, it's a different formulation of the generic. >> right. >> especially as was said. that's what's so important to have these groups of the multispeciality groups, the interdisciplinary committees that are going to communicate among themselves. >> i think that is something we can work on. miss portwine, i think you made a very important point. your son, you realized was having serious problems, yet he was redeployed. >> yes. >> he wasn't given the medication. it should have been a time-out at that point. >> well, even on the form you

can see it said "no go." that was crossed through and somebody stamped, the coordinator that sends the people put "go." >> but that's dod. >> that tells me they had hesitation sending him to begin with. >> that's dod. >> yes, ma'am. >> thank you very much. i'm saying it's a lot of work that needs to go on. it's not just va. thank you again for your service. >> thank you very much. >> thank you, mr. chairman. thank you to the panel for being here. i can assure you that this is how things change in this country is when brave men and women step forward and say to a concerned body like this of republicans and democrats sitting here listening to your story, i can't even imagine, i can't pretend to imagine how tough it is to sit here and relive this. i think i can safely say we are

committed to bringing right to all of this wrong. every one of you have hit the nail on the head by saying, every one of you have said the story is about the individual veteran. i've only been on this committee 18 months, but the last three months, the chairman and ranking member led an intensive investigation into what the heck happened to the va. from the day it started to the mission today. and every layer of this onion we peel back comes down to the same core issue. nobody is advocating for the veteran. the culture itself, when we talk about systemic problem and the culture itself, and secretaries removed and a bunch of people removed and we are trying to help america reset a button. because americans believe in our veterans. they send us here to fight for our veterans. i want to applaud your effort. you made such a huge difference

here today. this is how laws change. this is how policy becomes correct, and this is how we move forward in this country. we do it together. unfortunately, sometimes it takes the disaster that we had in a bureaucratic system of the va. the frustrating thing for me is, i have 54,000 veterans in my district. every time i describe my veterans, i talk about, i have 54,000 veterans and their families in my district. i want to applaud your effort on two huge issues we can address in this congress and help move forward on this issue of mental health. one is the support network. i can't even tell you, and i know you know how much constituents called our office in indiana. the wife or husband is in tears and begging and advocating for the spouse that the va says hipa prohibits me from allowing you to get involved in this. i've gotten personally involved, calling the directors trying to advocate for my constituent on

behalf of a spouse. the answer is still no, hipa overrides. do you have a different law? do you describe to a different definition than we do? the answer was no. hipa overrides. just having a support network to be able to come in and be that bridge between somebody who is dying and the system. i applaud that effort. i'm going to make sure we do everything we can to get that part of the law changed because we can bring advocates into the lives of these struggling men and women. for the spouses that are trying to hold families together, we can do that, too. i want to thank you for your commitment, as well, on the issue of keeping this focus where it belongs. i think some day, i don't think this is a quick turnaround, but i think you brought light, transparency and accountability to another layer america need to hear. while you are talking to us and we are trying to relate and share your grief and find solutions to move forward, you

had an opportunity to talk to the american people today. i guarantee you that every single person you are an influence to that followed your story, i'm going to hear from my constituents today and say, i relate to that mom and that father and i relate to my fellow servicemen. i think it's a tribute today. this is how government works. we have a commitment to make sure we restore, not your sons, but certainly the america that they have been fighting for. certainly our trust and their trust in us as a government who asks them to go, fight for freedom and fight for liberty. our finest heros in that nation. reinstitute by continuing to root out the bad actors and bad policy in the va and together set a reset button. i want to applaud your efforts and thank you for helping us reset an organization that started out as a great effort and has become a bureaucracy run

amuck. you have my commitment none of what you experienced will be in vain. thank you. i yield back my time. >> i would like to yield the first minute to my colleague mr. peters who represents the somers. >> thank you. i want to thank the chairman and the committee for allowing me to be a guest. we are not members of this committee. i don't think there is any place we would rather be this morning. it takes a lot of courage to do what you are doing. thank you for that. also to let you know beyond the power of your stories, it's the education you provide that only you can provide. these are insights that only you have. it's been very valuable to us. while we are new here, i can tell you that from time to time you see testimony that's going to make a difference. that is certainly what's happened today. you can feel very confident that those brothers you talked about and sisters will be heavily affected and helped by the time you put in and effort you put in today. i also just want to thank in

particular howard and jean somers for your leadership, the time you put in on behalf of daniel and the education you've given me. i look forward to continue working with you to make these issues, to resolve these issues and make things right with the veterans that the va sees. thank you. >> thank you, chairman. thank you all for being here. i'm sorry i never got the chance to know daniel or brian. i did have the privilege and honor to know clay. not only know him but work with him on veterans' issues. the profound loss is felt by everyone who came in contact with him. it shook me to the core because of someone so strong and your point on we don't, you are not going to notice it. these are very special individuals. you and i have become friends over the years. we were in st. paul a few weeks ago working on wounded warrior projects.

you hear it from the colleagues. this is a committee of heartfelt folks that want to get this right. i would mention, and i think all of you get this. at this point and the frustration we all feel, solutions and results are all that matter. i'm done with it as you all are. i'm done with the talk. i'm done with the pilot programs. there are suggestions that are concrete. i want to read you something. i came here on the 3rd of january '07, the 9th of january i worked on a bill. one of our colleagues of vietnam veteran pilot leonard boswell. here is a couple of things it said. secretary of veterans affairs should develop a comprehensive program to reduce the incident of suicide among veterans. staff education for compassion amongst them. recognizing respect. proper protocol, screening of veterans receiving medical care. tracking of veterans in a timely

manner. on and on and on. they did not do it. it was in law. we passed it. we gave the speeches. we had the signing ceremonies and went back home and said, gee, we made a difference. it's the very same thing just like you said. i guess the thing i would ask of all you, this is the second, va is the second largest governmental agency behind the dod. yet we have one of the smallest committees. we have committees i don't know what they do and they have 80 staff on them. we can give lip service or get serious how we are going to do it. we can have this or allow if this crisis passes and the american public's attention focuses elsewhere. there are veterans behind you from vietnam and others. they've seen this before. here is what i think is different. there is no doubt the american public wants to get this right. they are entrusting us as their representatives to get this right.

the commitment i've seen from this chairman and ranking members, members of this committee, this is different than the seven years i've been here. it's different how we are fo focusing. we can't let this pass. what i would tell you. you mentioned a thank you for this. chairman miller and representative duckworth and myself along with iva paul and vfw. we are going to introduce 2182. here is what i would say is different. this is a well-intentioned bill. we are going out. this is the silver lining. there is no silver lining when your son is not coming home. you've asked for a solution. i would ask each of you as 2182 starts to move and senator walz does it in the senate, let's together make sure it doesn't

end up as this act. the secretary had the authority. the american people through us said do this and they did not do it. i would only state to each of you as my colleague mr. o'rourke said, this is how democracy can work best. this idea of wringing our hands of who could have anticipated this. really? this bill was started in 2007. here we sit in 2014. keep the faith. we have to. again, i would say this. the cameras, tv, stuff that's there, whatever, none of it means a damn thing. if we don't get results this time, shame on us because here's the thing. i'm not going to get to meet daniel or brian. you've got the right guys up,

the right commitment from the public. now it's going to be, can we do it. with that i yield back. >> thank you. >> i, too, would like to thank you for your courage being here today. please know that your efforts today will make a difference at the va. i want to thank you. mr. and mrs. somers, i want to thank you for that 15-page primer there. i appreciate you all taking the effort to put together a document like that. mr. and mrs. selke, i was disturbed by the comments you found that the environment of the houston va was stressful. could you elaborate on that? what specifically led to that

conclusion? have you been there since? has it changed? tell me more about that. >> i went by myself that day and have not been back there since. for whatever reason, i just felt compelled to go and quickly get his medical records. i wanted to see them. it was again be, for ten weeks' worth of care there so there were not a lot. you drive up to the facility. it's huge, as they all are huge. there were so many people milling around out front. big crowds. lots of people that i don't know if they were there waiting for appointments or if they just don't have anywhere else to go >> to go and and it was just a hub of very busy lots of people milling around with those lines in the airport.

it was very stressful for me and i was in grief mode of the posttraumatic stress. i could not imagine. i could not imagine klay going in and i could understand when he left that day he. he said i cannot go back there. then add the information desk. but then nobody was there. i looked around they direct me to a medical records. but then i left but i remember sitting there for a few minutes thinking if i were a veteran. >> you mention another thing that your son had voiced concern of the care he was receiving.

were there specific concerns? >> i am not sure i remember what you refer to. >> okay. let me ask the sergeant. you wrote that combat veterans often approach health care as hesitantly? how is that dynamic? with of mental health care? >> even at our facility, a seattle is so large building not laid out very user friendly and myself i have a dramatic brain injury i have overcome of fairly well. i get lost and confused in that plays pretty bad and

not a lot of people to direct me. i get better service at best buy frankly. some trading would go along way. but the senator closest to me is from many buildings the numbers do not even make sense. i am told to go next door but 61 is across the campus and the numbers make no sense and there is not a lot of people to help guide or navigates of confusing situation. so to recognize who the audience of the veteran is to make an environment conducive to healing would be a start. as i discussed earlier. i keep bringing back. it takes to get him to go

beyond surface level issues. i go to a tree eyes myself on active duty in the infantry and if you went to the sec hall you were a was saying got crap for its. so we don't go to six hall of messages debilitating in nature in the sticks with me as i go through pain my wife will say when we you see a chiropractor? it is just that mentality. that is what they do with mental health issues. so when they get there it is a crisis and needs to be treated as such. number one you need to recognize to come back in

another 14 days. but to have the teams they will come. this is your team this is the people caring for you. this is the customer service with that trust and reports icahn confided these people to provide the quality care that they should. >> a good answer. thank you very much. >> 84 being here. your stories are tragic and heart wrenching but i hope you can take some comfort in what powerful advocates you are. you have told your story so

eloquently and thoroughly that it will help us. just to note some things to address we really can make a difference. i may need some help on this we needed to figure out a way to address the problem for those veterans has well as those like your children. the second saying is those that are there to provide

services to veterans and when the vso don't have the ability to bond the vso cannot be there 24/7 but they are there and maybe we need to look at some ways we can help them to do more outreach and better fill the gap. also have heard some horror stories about medicine and all the different drugs. and medical marijuana is the way to address ptsd and don't leave that off the table. even the notion of companion dogs is something that you hear that many veterans a pet helps them to get through troubled times. keeps data on the agenda. you mention a firefighter. also remember when veterans

come back they don't just need health care but the able to transition into civilian life with easy access to education so trading kaunas to college credits or employe in mint or retraining to have jobs to have something to look forward to. those things and i thank you very much to continue to go down this path with us. so even though what it might be. i dunno if you want to comment. >> i know the emergency crisis line, i work for an insurance company, we call

the nurse line you can call 365 days a year why do we have to wait until its of crisis for anyone to talk? if you start to feel a crisis that would be great for a nurse to see what they need. so what do they need? so waiting until a crisis line we are down that slippery slope. >> if i might add we are fairly new at the whole political thing but i came across the independent budget that the vso put together for congress. i would ask next time it comes to you look at that really closely because these are your veterans talking to you.

>> i would like to add quickly one of the things that klay said over the years that sticks with me that is wrong, he would say over and over i have to grovel for my benefits. i would say we need to wake up as the country. we should not have to grovel for anything. it should not be so difficult to get the care they need. >> i cannot think q enough for being here today with the sacrifices you have made a and i pray that those sacrifices make this a better nation at the end of the day.

those that sign up to serve have that intention. i am a physician and a reservist and i served in iraq one year. that has led me over here today. one of the things i know as a doctor that you can relate is when you have patients regardless of the problems there is so well loved anxiety whether musculoskeletal or something is wrong and there is anxiety. it makes it more difficult when you have these administrative problems. i know you started to deal with that in private practice may be when you first started with the prescription anything is best they are not allowed to have that increases the

problem. so we are here trying to come up with solutions to your input is very valuable so if it is credential that one veterans administration in to go to all if your prescription is good at one issue began at another. you to call another state to get the prescription filled and if not think of the anxiety that comes with that. these are things that we have to fix. in is of big difference being a lot of uniform as a reservist icahn remember being with that family 15 months then i am the last one left at the airport going home.

when i get home they say you have 90 days to go back to work. i said i am going back into weeks i will get my house in order but you have to have something to go to. so what do you do when you go home? we have to blend the two systems together to engage in post employment activity. while in uniform i have the opportunity of preventive medicine and suicide prevention we've learned a lot in what to look for to have that data with the symptoms of the year looking for in and win a decision was made but there was a calmness for someone to give away their stamp collection or there coin collection because they have made this

decision. but we don't get them after words but you just go home and i have seen families engaged in programs with that doesn't happen that way and it is said different animal but what i want you do to look for symptoms or signs but preventing to take one's life? twitter we doing that creates a situation that this is the best way to go? and that to me is really preventative medicine and i hope we find our way because our suicide rate is going up as well. so we have a problem not

just a military. but i applied your input it is extremely helpful and as you have seen it is the determined group to make a difference in the history of our nation moving forward. your input is always will come. i yield back. >> check your microphone. >> thank you for allowing me to stay today and my colleagues from arizona. all of today's panelists joining us today thank you for being here. and learning again of

suicide is a privilege to be with you today unfortunately this story is all too familiar and 22 veterans a day are still committing suicide even after we have heard the tragedy of young men who lost their life here all over the country. congress has addressed this issue before in said they would fix it before and pass legislation before but the problem has even gotten worse. i heard a lot of testimony today of ideas to make it better and i think hipaa is one that needs to be addressed but i am particularly interested in the program that the surgeon participated in. and my question is about daniel.

like many veterans with the lack of concern in the discombobulated system to allow veterans to get the care they needed and in particular individual who was unable to participate because he cannot share the experiences he experienced while in service but get he was unceremoniously put into group therapy even when requested private therapy could not get that care now he took his own life as a result of not being able to do get the care. and as a private community allows civilians to get the care they need easily.

well that a private program was ended i don't know why they said they did not have enough money but that was a horrible reason horrible. but my question is with the belief that would work or could be helpful. reno of the eggs -- disorders like anxiety it could have worked for daniel and what he faced. >> absolutely. and with his irritable bowel syndrome were sent he could not leave the house and i

cannot imagine that embarrassment. and as howard mentioned at the time be knicks had speed traps set up so he had to find a way to get off the highway so the flashing lights would not affect him. i can see that it would have been very helpful to him to have that privacy capability. >> i a agree but not the medical model but what we talk about the ability within the facility of the ids and ptsd -- ptsd is here the term is what you have to

do is have combined resources and knowledge. where people can have problems to have the ophthalmologist to say something you might not have thought of. ciller to create these panels of care anything would be overwhelmingly positive spin mecca do want to take a moment to address the issue of service members and classified settings and i want to think that subcommittee to be a part of the solution.

>> i want to ask and asking the entire panel that the d.a. could consider addressing a realize you have to have some in most cases i am familiar to participate in the field hearing the equine therapy in making quantum leaps. but from talking to veterans just to name a few. and then turning to the

medication from the ptsd. >> he had ptsd been doing some gardening. and then they decided to make it bigger then let's take the vegetables to market and sell them. and i have also heard of veterans of letting a loud noises and flashing lights as he has with ptsd. >> that using to cope the

side of medications with service animals but the list could go on and on. to stress the importance of the fact until the of veterans administration can implement best practices systemwide to tater fit each individual veterans' needs and using these space best practices that exists out there and to provide access with these treatments but to be implementation of that think you very much.

>> awad of the excuses that we have heard has to be evidence based treatment. have to get their feet if everything is evidence based? life think they need to open up their mind a little bit to think outside the box. not every therapy works for every person it does have to be individualized. in to be very therapeutic. so we have these blinders on >>. >>. >> it is the lifestyle type of approach.

but they cannot do everything. so they put together a therapy program he was involved that helped him with storming the hill and the community with the disaster relief programs and that was great for him but also for him to be there to help his brothers and sisters. the problem for whatever reason when a person decides to take their life have given up hope. what do you do about that? klay could do everything everything, golan the missions and the bike rides but therein is questions of

faith but it is a community approach, people need to come to government and sponsor organizations no one organization can do it all. they need to come together and take care of these folks >> i yield back. >> you are recognized for five minutes. >> and i appreciate your comment about evidence based i am not a doctor but non drug therapies work it should be good enough for the v.a.. but the acknowledgement of non drug therapies and your

experience every case will be different but recently we had 100 people come through and won have backpack that he dumped upside down with dozens and dozens of bottles and sgt he referred your cocktail as you have expressed some concerns about the use of generics. but just on the face you lack confidence the way it did ministers pharmaceuticals? but in the experience of pharmaceutical use by the v.a.? >> i spoke earlier about the difficulty of getting the prescription refilled but in the private world if the

doctor determines i need medication for my low thyroid i a get it and i stayed on at that is shown to be effective. i don't understand why then dod and v.a. have two different pharmaceutical programs and to do separate from the service especially on mental health. you cannot just swap them out. it makes no sense to me i don't know why one system would not work for both why not what works with dod with pharmaceutical medications why does the v.a. have to be

different? it sounds like the cost factor of a cheaper route but we have people dying every day. >> realized very much this is a personal impression that my concern after hearing each of your stories with the volume of patients of the 21,000 employees you raise concern of personalized care and it would seem and alternative therapies and wit to get alternative therapy as the intake day i had a man who said equine therapy works. that was good enough for me but not good enough for that v.a..

so within the discussion of your opinions? >> within the v.a. medical center of those who's suffered from conditions we could access recreational therapy and i was put on the six month waitlist when that came up they lost their recreational therapist. so i never had the chance to a engage in that because then i was downgraded. and then probably would not get better. that is probably a completely separate hearing. >> but the availability it

is private community where you have to go. he got a piano and guitar line know there are pottery class's soul in a psychological treatments and the other thing we have mentioned and because of our national thoughts against these chemicals did do

trials with the potential benefits. >> faq very much. >> we think the witnesses for participating whether or not you know, what you have been at that table for three hours and we are very thankful you are willing to share your stories with us so with that thank you very much and you may be excused. [applause] [inaudible conversations] [applause]

[inaudible conversations] >> joining us set the table froe chief patient care service officer she will have dr. carol the acting deputy chief consulting for mental health with her at her table. our third panel includes the legislative director for the iraq and afghanistan veterans of america in

general martin steel the vice president for veterans research executive director of military partnerships and the co-chair anti-director for the american and legions for rehabilitation commission and the chief executive officer and vice president for military communities thank you for being here. and dr. mccarthy you are recognized for your opening statement. >> thank you. >> good morning chairman and members of the committee i appreciate the opportunity to discuss the department of

veteran affairs mental health services i am accompanied today by dr. carol acting deputy chief consultant and are acting chief consultant for mental health from the readjustment counseling services joining us as well. let me express by expressing my regrets to the families of daniel, klay, and brian. think you for coming forward to tell your story and their stories in death by suicide is one too many. thank you joshua for sharing your experiences as well. veterans to reach out to a veteran in emotional distress deserves to find there are no wrong doors wins seeking help. that v.a. must insure that those stores are opened and messages are responded

properly. service members and members have called the crisis line to resupply dash receive help. but those to have a mental health diagnosis. the rate of suicide have decrease. and to provide the care they need for someone else that they can. but tragically of those 22 veterans are veterans who have been in our care. we acknowledge that we have more work to do, and we are fully committed to fixing the problems we face in order to better serve veterans. our actions include the deployment of mobile vet centers

to locations with the greatest challenges in providing timely mental health care. examples include el paso and phoenix. we have begun a program to insure veterans waiting more than 30 days for care may receive mental health care in the community from providers who are not v.a. employees. we have removed access measures but not expectations about access and are focusing on veteran satisfaction with the timeliness of care they received. we have initiated operation save, a training program for suicide prevention delivered by our suicide prevention coordinatored to vha and vba staff. we have provided suicide risk management training for clinicians. this is a v.a. mandated training for all v.a. clinical staff which teaches about assessment, warning signs, risks, means restriction, and safety plans. and we've developed a web-based

training for clinicians specifically focusing on women veterans who are struggling with suicidal thoughts about how to recognize their disstrtress and bring them into treatment. our actions take into meeting the increasing demand for mental health care include the addition of 2400 mental health professions and 915 peer support providers since march of 2012. we have expanded the veteran crisis services, renamed it as a suicide line to a crisis line to reach out specifically to those in crisis or not quite yet in crisis. in order to offer both text messaging and an online chat service in addition to receiving phone calls. we've partners with the vet center combat call center to respond to veterans in distress. we have greatly expanded opportunities to access mental health, including in rural areas by telemedicine.

we have created mobile apps to assist veterans with their symptoms. we have had focus on improving care in the community for those who might not seek our health. we have trained community providers on military culture and partnered in community engagement. we've partnered with the department of defense in depping clinical practice guidelines for suicide risk assessments and intervention and for the care of ptsd, depression, and substance abuse. we also reach out to guard and reserves at the mobilization events to bridge the gaps and understanding about benefits and services. we've greatly expanded the provision of evidence based treatments, including psychotherapies for mental health conditions. v.a. is committed to working with families and friends of veterans. we know mental health outcomes improve when families are involved in care. we now have a family services continuum that includes family education, consultation,

psychooeducation, and marriage and family counseling, and research remains under way to address improvement of mental health care and prevention of suicide. to maximize what we can provide, we have developed measures of provider productivity. integrated mental health care into primary care settings, and initiated several campaigns to break down any barriers or stigmas that may be associated with seeking health. we have developed a program on college campuses where student veterans may receive needed mental health care without leaving the campus. mr. chairman, we're fully committed to insuring accessible mental health care of the highest quality for our service members and veterans who have sacrificed so much on our behalf. we are committed in our efforts to decrease suicide by decreasing risks we can identify and focusing meanwhile on improving the quality of life for these veterans.

v.a. will continue to provide care in a veteran centered manner, expanding access and breaking down barriers associated with seeking help. we are compassionately committed to serve those who served, making it easier for them to ask for and receive the help they need. mr. chairman, this concludes my testimony. my colleagues and i are prepared to answer your questions as the panel proceeds. >> mr. nicholson, you're recognized. >> thank you, mr. chairman, ranking member misead and members of the committee. we really appreciate the opportunity to share with you our views and recommendations regarding mental health access at the v.a. and suicide prevention efforts. combatting veteran suicide is v.a.'s top priority for 2014. and it's a critically important issue that affects the lives of tens of thousands of service members and veterans, especially of the wars in iraq and

afghanistan. in the 2014 member survey, our members listed suicide prevention and mental health care as the number one issue facing our generation of veterans. in that same survey that was just conducted in february and march of this year, 47% of respondents reported that they knew an iraq or afghanistan veteran who had attempted suicide. and over 40% knew an iraq and afghanistan veteran who had died by suicide. we have over 270,000 members. 40% of them know someone who was a fellow veteran of iraq and afghanistan who has died already by suicide. in response to the overwhelming need for action, iava launched a campaign to combat suicide which includes a call for comprehensive legislation that can serve as a cornerstone across the government and across

the country. in addition to legislation, iava is calling on president obama to issue an executive order to address additional aspects of suicide prevention efforts. and iava is working to connect more than 1 million veterans this year with mental health services across the country. the need to examine mental health services and suicide prevention efforts provided to veterans is more critical in light of the v.a. scheduling crisis. in addition to the general delayed access to care veterans are experiencing as i'm sure all of you know, veshinvestigationse also uncovered significantly delayed access specifically to mental health care. while no veteran should have to wait months for a medical appointment of any time, veterans utilizing mental health services and especially those in crisis should never have to wait an unreasonable time to be seen by a medical health care provider. providing timely and efficient mental health care must be a much greater priority for the

v.a. moving forward. increasing the accessibility of mental health services must also be combined with access to care for vulnerable populations of veterans currently excluded from v.a. car. between 2001 and 2011, an estimated 30,000 service members may have received a downgraded discharge characterization due to a misdiagnosis of personality disorder. even more troubling, an unknown number of service members were punitively discharged for disciplinary actions that may have been related to an undiagnosed mental health injury. it's imperative that those individuals are identified and their records are properly re-evaluated and rectified in order to provide access to earned v.a. mental health services and benefits. examining access to care should also include a review of the current five-year special combat

eligibility for v.a. health care provided to recently transitioned veterans. the five-year time period may not be enough time for veterans who present with mental health symptoms later or who might delay care due to concerns of stigma of seeking care. extending special combat eligibility, though it may be costly, will provide access to care for veterans when they are ready to seek it. it is important to recognize the efforts that the v.a. has put into mental health care services and suicide prevention programs in recent years and especially as has been mentioned already in the veterans crisis line has been an enormous resource for our community, and the v.a. has done a terrific job with promoting that, and we have been happy to partner with them in helping to promote that, and we refer veterans in crisis to the veterans crisis line through our rapid response program every single day. it's been a fantastic resource. but more, of course, needs to be

done. increasing access to care, meeting the demand of that care, and providing high quality care with continuity and responding to veterans in crisis requires a comprehensive approach. and while there is no illusion that veteran suicide will be completely eradicated, implementing better approaches to mental health care and suicide prevention can and does save lives. again, we appreciate the opportunity to share our views on this topic and we look forward to continuing to work with each of you and your staff on the committee to improve the lives of veterans and their families, thank you. >> thank you, mr. nicholson. general steele, who is the co-chair of the veterans reintegration committee. >> thank you, chairman miller, ranking member michaud, distinguished members of the committee, on behalf of the university of south florida, thank you for holding today's oversight hearing. by way of a brief background, the university of south florida

is a global research university with over 47,000 students, including over 2200 veterans and their families. military times edge magazine recently ranked usf the fifth best college for being veteran friendly in the united states out of 4,000 colleges and universities. under the leadership of our president and our senior vice president for research and innovation, numerous usf researchers are currently involved in funded studies related to such topics as suicide prevention, traumatic brain injury, post traumatic stress, robotics and prosthetics, speech pathology and audiologist, and age-related disorders. we have numerous research and health care partnerships through aff affiliation agreements to include the james a. haley hospital along with the cw bill

young v.a. hospital located in st. petersburg. we have memorandum of understand with united states central command, u.s. special operations command, and work closely with mcbill air force base and the pentagon. our veterans research reintegration steering committee consists of scientists throughout usf's faculty, staff, and students who work with veterans along with representatives from the veterans administration, the care coalition of special operations command, and draper laboratories. we do have a holistic approach in regards to education to provide services to our veterans and their families. in order to address the mental health needs of our veterans and our diverse population of at-risk students, we have embarked on a collaborative suicide prevention project. this is a three-year initiative funded by a $306 million grant provided by the substance abuse and mental health administration. some of the goals and measurable

objectives of the project are to increase the number of persons involved in suicide prevention efforts, reduce the stigma associated with it, and the barriers, and increase family involvement in suicide prevention. as you are aware, the blue ribbon panel of the v.a. medical school affiliation was established in 2006 to look at, quote, a comprehensive fi philosophical approach with medical schools and affil yalted institutions. unquote. the panel believes the crisis in the u.s. health care system offered a unique opportunity to explore fundamentally new and better models of patient care, enl kashz, and research. as the panel revealed, currently available mechanisms for meaningful dialogue between v.a. and the academic community were inadequate. some of the major challenges include credentialing as was mentioned earlier, which required considerable time along with the research approval process, which is cumbersome,

very time consuming for both parties. the process takes months, and in some cases, can take over a year just for approval. there are also many barriers to innovation. one of our professors has an innovative approach for treatment of post traumatic stress and is highly unlikely, we believe, to receive approval from the v.a. health care facility. a.r.t. for post traumatic stress has proven to be successful, yet the v.a. has not accepted invitations to collaborate on a pilot study for patients diagnosed with pts. we do work with the department of defense. i have been there in virginia and ft. benning in georgia and also to work with the protocol which has been proven very success flg. we recommend streamlining the credential process and creating fasttrack approvals for collaborative pilot studies between the v.a. and research

universities that involve minimal risk to the patients but could provide benefits to treatment of mental disorders. we also recommend developing agreements between v.a. at the national level and academic communities throughout the country. we also believe the definition of academic affiliates need to be re-examined to move beyond the limited focus on health care to a much more encompassing venue that would include employment, education, business deployment, and increased research funding. in 2012, a v.a. research scientist from usf along with a research scientist from the medical research service at james haley conducted a preclinical animal research linking post traumatic stress, mild tbi, and the potential for suicide in the military. we believe their research needs to be extended to learn more about how the brain is affected by physical and emotional

trauma. more importantly, we believe this type of animal research will lead to more effective treatments for post traumatic stress and tbi, which will potentially reduce the risk of suicide in the military and veteran population and could be influential in alternative drug protocols. the 2006 blue ribbon panel also noted with concern the aging v.a.'s research infrastructure. the panel recommended that v.a. enhance its research facilities by fully exploiting opportunities to share core resources with its academic affiliates. to that end, the university of south florida recommends strong consideration of the development of a singular unique one of a kind research clinical and outpatient treatment facility. this initiative is intended to be a collaborative venture between the department of defense, the veterans administration and usf in order to meet the health and welfare needs of our veterans and their families. usf remains committed to providing the nexus to foster

research collaborations in pursuit of excellence and the rehabilitation adjustment, resilience, and reintegration of wounded warriors and their families into civilian life. our nation's dedicated heroes from all wars deserve to have the benefit of the best research and services available in order to return to productive lives as members of our society with jobs and homes for the sacrifices they and their families have made for our country. thank you again for holding this hearing and the opportunity i have to submit this testimony. >> thank you, general. mr. goldstein, you're recognized five minutes. >> thank you, mr. chairman. every day in america, 82 people take their own life. that's one every 17 and a half minutes. since this hearing began over three hours ago, statistically approximately 12 people have chosen to end their live with suicide. 1 in 4 suicides is a veteran. 26% of suicides are veterans. and veterans only make up 7% of

the population. the stakes could not be higher. we must find a solution to this problem. chairman miller, ranking member michaud and members of the committee, on behalf of our national commander dan dillinger and the 2.4 million members of the american legion, i thank you for taking on one of the most serious challenges facing america's veterans. finding solutions for this mental health crisis. the mental health of veterans is something the american legion takes very seriously. the american legion established a committee on tbi and ptsd in 2010 because of growing concerns about the unprecedented numbers of veterans returning home with what is come to be called the signature wounds of the war on terror. since then, legion staff along with senior leadership has met regularly with academia, medical consultants, experts in mental health and science, and we published the finding of a three-year study to treatments and therapies in a report called

the war within, which is also available on our american legion website. following up on that report, we recently conducted an online survey to evaluate the efficacy and availability of treatments and what we found was somewhat disturbing. the result of the survey culted in coordination with the data recognition coordination showed a third of veterans had turninated treatment plans before completion and almost 60% of veterans reported no improvement or feeling worse after having undergone treatment. clearly, there are problems with the current practices in place. the american legion convened a symposium last month to discuss these findings and highlight over areas where complementary and alternati tative treatmentsd prove helpful. we listened and saw first hand the encouraging results of veterans who benefits from animal therapy with service dogs, art therapies, acupuncture

and a pohost of other nontraditional treatments. the american legion believes by exploring options like these, we can work together to help the veterans get the treatment they need. it's devastating when a veteran can't get timely appointments. 50% of veterans reporting no changes or worsening symptoms says that what care they're getting is just as important as whether or not they can access the care in the first place. this is not to say access doesn't matter. indeed, over the past several months, the difficulties veterans face accessing care have been front-page news and have been a major focus for this committee. for the american legion, it wasn't enough to sit and watchidally as veterans struggled to get help. we had to go do something about it. that's why the american legion developed veterans crisis command centers that have been deployed across the country. as specifically where it had been reported that veterans were being stonewalled while trying

to seek care. by utilizing american legion posts already located in every community in america, the american legion has combined town hall meetings and coordination of care for veterans so they can get the immediate counseling and medical help they have earned and desperately need without getting in the way of v.a.'s ongoing efforts. we're there to augment their efforts and be a force multiplier. so far in phoenix, arizona, el paso, texas, and fayetteville, north carolina, we have been able to reach 2,000 veterans and next week, we'll expand operations to two new locations in st. louis, missouri, and ft. collins, colorado. with more locations to follow as we try to get help to veterans. yes, there are things v.a. should be doing to make sure veterans in crisis get the help they need, but we now see that veterans can't just depend on v.a. to fix the problem. that's why the american legion has full-time staff and a leadership community dedicated to studying the challenges of mental health treatments, to

insure the way america treats veterans is a way that will bring real improvements to their lives. that's why veterans, v.a., and local business across the country are supporting our veterans crisis command centers and donating their time and efforts to link veterans with the resources they need. by the time the panel finishes ouronaling remarks, america will have lost another person to suicide. that is a terrible tragedy. we all have to work together to insure that this rate cannot and will not continue. thank you. >> thank you. >> thank you, chairman miller, thank you mr. michaud and committee for convening and asking me to testify. i currently serve as executive vice president for veterans communities. while i'm not a veteran, my life's calling has been to serve veterans. having works for a decade at

vampt as a psychiatrist and chief of mental health, i have been able to observe the v.a. from both the inside and out. this experience has given me a unique perspective as to the nature of access problems facing veterans and possible solutions. in general, i contend that the most immediate solutions reside in growing capacity through more robust partnerships between v.a. and local communities. working alongside v.a. last year, voa supported in-house more than 10,000 homeless veterans, a number that will increase this year. though significant, the opportunity for impact in partnership with v.a. is much larger and can include helping veterans at risk of watching their unmet needs become urgent problems that evolve into mental health crises. due to inadequate access. the v.a. has a golden opportunity to lead this effort right now by leveraging organizations like voa to grow

capacity and improve access. in contemplating partnership strategies, it is important to recognize that access barriers go way beyond wait times. red flags in isolation, and inadequate knowledge of available resources, an unwillingness to engage in the health seeking process. difficulty navigating complex systems and lack of care coordination all impact access. recognizing this array of access barriers, voa has developed the battle buddy bridge program. a program rooted in trust and designed to mitigate access barriers through real time peer-to-peer engagement and local resource navigation. peer approaches which are used by other organizations including the augusta warrior project, team red, white, and blue. iava, the mission continues, team rubicon, and others transform the access dynamic in many cases.

as such, it is my first recommendation that community-based peer engagement and navigation programs be brought to scale with federal support as part of an all-out assault on access barriers at the v.a. and beyond. leveraging this model further, my second recommendation is for the v.a. and the private sector to set up rally points in communities as well as on v.a. campuses that are endowed with trained peers, vehicles, resource maps, and tightly linked to v.a.'s suicide prevention program, the national crisis hotline, 211 exchanges, tech based veteran community portals and any other referral sources of relevance. rally point networks could have a profound impact on access in any geography. as a final point, i want to highlight a major partnership -- a major partnership success

story that supported services for veteran families program of the v.a. this program administered by v.a.'s national center for homelessness among veterans has fostered relationships between v.a. and communities that are unprecedented. in the opinion of many experts in both the community and the v.a., the streamlined structure of ssvf offers the best means for managing partnerships going forward. as such, my third and final recommendation for resolving mental health access issues and improving suicide prevention going forward is to -- for the v.a. to adopt an ssfv like mechanism as the basic template for v.a. to use in developing more robust partnerships. by using this mechanism, v.a. can most effectively leverage partners to create programs that improve access to the vast array of resources which address

mental health conditions. to close, more robust partnerships between the v.a. and community will not only help veterans enrolled in v.a. to get better access. it may also help veterans -- it may also help provide access to veterans who refuse to enroll in the v.a. as well as veterans who are located in remote areas. let's all take advantage of recent untoward findings at v.a. and recognize that while inadequate access to care in the veteran population reflects the shortcomings of a federal agency, it also reflects a fundamental failure of the american community and process. it is time to roll out a new era of public/private partnership that grows capacity and insures veterans have access to the resources they need for successful community reintegration.

>> thank you very much, doctor. dr. mccarthy, on tuesday evening, this committee heard from a whistleblower, the former chief of psychiatry at the st. louis v.a. medical center. are you aware of his testimony? >> i'm aware of it, yes, sir. >> he stated he could not identify within his clinic the average number of veterans that are seen by a provider per day or the time a provider spends on direct patient care per day. when he asked other psychiatry chiefs to estimate similar data at their facilities, he received answers that ranged from 8 to 16 veterans per psychiatrist per day. we worked with the v.a. database administrator and psychiatry director, he said he was shocked to find that outpatient psychiatrists at the st. louis v.a. were only seeing six vettens on eight hours for 30-minute appointments with a rare 60-minute appointment, only three of those each week, and he

could only account for three and a half hours of work in an eight-hour day. as we have already heard people talk about a nationwide shortage of mental health providers, do you feel the utilization of staff at v.a. is appropriate? >> sir, that's why we have what we call the spark tool. this is something we have developed as part of our productivity model. >> my question, i'm sorry, my question is, do you think that utilization of staff at this level is appropriate? >> i do not believe that what you said is an appropriate way to use staff. however, i have data that may not be the full story. >> do you know what the mental health staffing is and productivity requirements throughout the system? >> i know the model which is in terms of the number of psychiatrists in a given population. >> whose model? >> it's our model, sir. >> v.a.'s model? >> yes, sir. >> okay. should we be using what v.a. wants now or should we be

looking outside of v.a.? >> it seems like it may not be a right answer to your question, but i can tell you why the model developed. it's a team-based model of care. >> from v.a.? >> yes, sir. >> okay. do you know what the health staffing and productivity requirements are throughout the system? >> we have a quadrant type model which looks at productivity and other measures to determine if we are staffing appropriately. >> do you know what the standard is? >> okay, help me understand, are you asking how many are used per physician per day? >> i guess that's good enough. do you? >> i don't have the exact expectations -- >> the other question is, is v.a. meeting the standards? >> sir, i can't answer that question. if we look at our work value units compared to the national average for physicians who are

psychiatrists as well as for psychologists, we are meeting the national average for productivity. >> according to whose numbers? are those numbers that v.a. establishes or -- >> no, they're external -- >> no, no, i'm talking about internal numbers. >> okay. >> are your folks reporting a truthful number? >> what that model is based on is the actual encounters that occur. >> no, no, are your folks telling the truth? >> yes, sir. >> everywhere? >> i can't answer a question like that, sir, but about the model, i can tell you that the numbers are duriven from a cystine that can't be manipulated. >> based on what we have seen the last three or four months, do you trust the numbers people are given? >> if you ask me about access nebs, i don't. there has been affidavits before the committee that shows that access numbers are not reliable. >> but you think the other

numbers are reliable? >> there are some numbers that are reliable, yes, sir. i have been looking for numbers that we can try and understand measures of our access and timeliness of care. and we have, for instance, numbers of -- >> let me ask you a better question. would you bet your life that the numbers that people give you are truthful? >> i'm sorry, sir. are you talking about numbers related to productivity? >> i don't care what the number is. would you bet your life on any number that somebody gives you as a truthful number because we just had a panel of witnesses who have lost their children. they lost their lives. now, i'm asking you, would you bet your life that the information that people are telling you is truthful? >> sir, i would not. i would not bet my life. >> that's all i need to hear. thank you very much. mr. michaud. >> thank you very much,

mr. chairman. dr. mccarthy, we heard an earlier panel issue dealing with hipaa. my question as it relates to hipaa is actually in the department. and i actually did find the oig report, and i heard that the veterans health administration and the veterans benefit administration could not exchange information because of hipaa problems. they both work for the same department. i'm not sure why there would be any hipaa problems with vha talking to vba. my question is, is the recommendation from the oig back in 2011 was that the v.a. medical center directors and vba directors will meet monthly. they meet monthly and discuss this issue. has that issue about any hipaa problems been resolved between vha and vba? do you know what the outcome of that is? if not, could you get back to

the committee? >> i could give you an example. if i do an exam on a patient, that's not considered a vha document. it's considered owned by the veteran or by the vba, and so that's not something that vha releases. there are some separations that are aimed at protecting veterans. >> but both vba and vha works for the department of veteran uz fairs. so i'm not sure why there would be hipaa problems between vba and vha. so yeah, if you could get back on that, i would appreciate it. doctor, i agree with you that v.a. can't do it alone. what has been your experience with trying to partner with the v.a., provide the service to, you know, in the communities, and has it been different, you know, outcomes depending on what region the doa has been in

around the country involved in? >> that's a great question. i do believe there is variability in getting back to my final point. i think it's important that we look to the v.a. to develop a consistent mechanism that's responsive. and that program that i described which i'm sure you're familiar with, ssvf, is one that is very responsive and very effective. the bigger question, as i see it, what is vha's mission? vha's mission to deal with all reintegration problems? and i would say probably not. and because so much is trying to stream through vha to deal with reintegration issues outside of health care, it's created a strain on the system and has diluted its primary mission of providing outstanding health care, including mental health services. >> thank you. getting back to the v.a., i

noted in your opening remarks, v.a. spending on mental health is approaching $7 billion, double the amount in 2007. what is the v.a.'s -- what is v.a. using as a measure of success of this investment in mental health services? >> thank you, congressman. there is no single measure that we can point to that is going to satisfactorily answer that question. what we have heard today, over the last few weeks, points to the fact that v.a. has a lot more to do. at the end of the day, what matters most is whether or not we have met the needs day, what matters most is whether or not we have met the needs for individual veteran to presented himself or herself for v.a.

mental health care, whether we have addressed those needs at the time they came in, or whether they left with a better plan to move forward. that's the ultimate outcome of our care. it has to be addressed and assessed for each individual at the time of care. i think we can point to some things in our system. we know over the last years, there have been 37 rescues or saves that have been facilitated through the veterans crisis line. on the one hand that's a remarkable number. on the other hand it's not enough and we know that. we can look to veterans with mental illness, case management program, we know they are able to live in the community of their choice to find employment and to stay out of the hospital. we know that when veterans drop out of care with serious mental illness, we can successfully rein gauge them in care.

there are multiple other examples. i think at the end of the day, it's the individual veteran and whether or not we have addressed their needs to do is the ultimate test. >> thank you. >> thank you, mr. chairman. thank the panel for being here. i want to go ahead and continue along the line for just a moment the chairman did, dr. matthews. in st. louis v.a., 60% of the veterans did not return for care. then we hear in other testimony a third of veterans dropped out of care and 60% showed no improvement. this is difficult to treat. i understand that. it's a very difficult issue and very individualized with each patient that you see. but how can you explain that kind of dropout when these people are lost and you don't know what happened to them. those are the folks that may be needing a hot line, the ones committing a suicide, this

astounding rate. you have more veterans committing suicide than dying in combat, then we have a true crisis. we've added several thousand providers to the v.a. during the last, i guess, couple three years. so how in the metric he's talking about, productivity, i don't agree with that it's meeting the same metric. what we found out with oversight investigation hearings is time after time after time, the v.a. self-analysis is not true. this turns out when investigated by an outside party, what we've been hearing -- let me tell you how frustrating it is for me to sit up here. i expect people when they come to that diocese, whether they are sworn in or not to tell the truth, not to make themselves look better. let me tell you what the v.a. has done. as a surgeon you have to have a lot of trust to let a patient lie down and let you open them up and operate on them. the v.a. has lost a tremendous

amount of credibility and trust. it's going to be very difficult to put that humpty dumpty back together again. what can we do now moving -- that's ault all in the rearview mirror. how can we move forward? that's what i'm asking. >> we do have a lot of work to rebuild that trust. we absolutely do. our department is working on that, our secretary laid out expectations about ways to restore that trust. what we can tell you are things like for the veterans who seek our care and entrusted mental health care to us, for those veterans receiving our services, the suicide rate is actually going down for all veterans to seek v.a. care and are involved in our care for all of them, not just mental health veterans. their rate of suicide is going down. we do have some successes. i guess what i want to do is not discourage the veterans reaching

out who -- >> i don't want to do that at all. my time is limited. dr. sharon, a couple things that interested me is dollar lot of programs around, outside, others you've heard of, what you do, how does the v.a. help coordinate? you're right. some veterans don't want to go through this big maze of things v.a. walk, this big building, wind their way around and follow a dotted line to someplace. how do you coordinate all that? >> it's a great question. there are a number of efforts around the country, won in l.a., los angeles veterans collaborative which brings together 250 organizations a month, including the v.a. with the aim of developing coordinated systems. the idea i shared with you, recommendation number two, to create rally points is to get

proactive by creating navigation networks that is operated by veterans who can function as surrogate family. we heard them talk about the need for a support system, special relationship between brothers and sisters in the community. we need to leverage that. that's a way to get information from people suffering. it's a way to introduce a process and content expertise into communities with navigators who engage and then advocate. >> one of the things in my local community my wife is involved in, humane society, we find out veterans sometimes won't go to the hospital because they leave their animal, dog at home. they don't have anyone to take care of them because they are alone. humane society are taking care of those animals so veterans can go to something i never thought of. i had no idea that was going on,

that people would not get care because their companion, their animal, didn't have anyone to care for them if they wept in to seek care. i think one of the great challenges, i applaud you trying to do that, a lot of people trying to help. you'll see a renewed effort here. how do we coordinate that. with that, mr. chairman, i yield back. >> mrs. brownly, you're recognized for five minutes. >> dr. mccarthy i want to follow up on doctor's line of questioning. talking about the issue of trust. one of the issues, what data -- when you state the successes, what data are you looking at? is it we've heard a lot about bad information and people not

telling the truth. so it's hard to believe there are successes if there are. i'm not feeling good about the data which you would make those conclusions. >> thank you for asking that. we have in the last few years been able to obtain data from the states, some with the help of members of this committee. we now have suicide data from 48 states, not v.a. data, that we are using to analyze rates of suicide for veterans, including veterans who may not be seeking our care. the data we're using include the data we're getting from the states about actual suicides. we often did not hear about veterans in our care who completed suicides. now we have data about them but also other veterans. that data doesn't go back to 2001 but if you start counting in 2001 after 9/11, that's the

data we're following the trends for now. >> so do you believe that there's a crisis going on in the v.a. and certainly in terms of academic to mental health care. >> absolutely. >> what are some of your -- what are your top three things you are planning on doing to resolve this crisis. >> among them are extending hou hours. they have expanded services and hours to also provide for care. some are with the american legion and we're grateful for that. >> so with partnerships, public-private partnerships, i hear over and over and over again that it's very difficult to work with v.a., expand to

veterans in our communities. what are you doing to alleviate some of those barriers. >> they are in the various medical centers. we've reached out to all kinds of people of goodwill in the community, people that would like to partner with us, site specific. >> reaching out. we've done that in my district. that's a good first step. because quite frankly in my area the v.a. didn't know about all the services that the communities are providing for veterans. i think now they do. how are we going to --

>> as far as access to fee basis care, we are using models of payment for fee basis care traditional models but expanding contracting services that would be available. el paso, for example, has reached out and formed a partnership with the practice that provides in-patient mental health care to provide more outpatient. >> what about alternative therapies. are you looking at partnerships equine therapy. i have a great program in my district, a successful program. >> they could partner with programs like that.

>> community partnerships, engaged as part of community helping them. are you asking if every v.a. should have equine therapy? >> i want to know how we can increase these partnerships. >> i'll use my own example, i'm really watching the clock here. my time has run out. i'll follow up with my question. >> thank you. a question for dr. mccarthy following up closely on a few others. what are the waiting times for access to mental health care. >> it's hard to give an tut number given that both members of this committee and i have said i'm not sure we trust the actual numbers. what we now have, though,

transparently are information about access. i printed and brought some of that information. what's posted is for every v.a. medical center what the new patient mental health wait time is, the established mental health wait time and then running average over the last month for what that wait time has been. when we look over the last month, certainly for those there are significant improvements over what there had been before. >> ma'am, are those reliable data. >> i believe reliable. i would not state my life on it. have they been audited by independentities outside the v.a. >> i do not know.

we've heard testimony clearly manipulated, falsified. on the 23rd they said the data was not reliable. they talked about what we could draw from that. i agree with colleagues we don't know what the data is. t what do we know? it's clear investigations going on after saying falsified. in particular one whistleblower in one hospital. i asked the v.a., what is the range of the workload for doctors across the nation. the total range, bottom range, according to one whistleblower in one hospital was lower than the national range. so one independent source

verified, what the v.a. is doing to actually assess, verify and authenticate the data so folks on this committee and 341,000 employees at the v.a. can actually say this is where we're heading, this is where we've been, this is how we improve the system. give me a sense of how the v.a. is going to answer the basic question of how we're going to independently assess data. >> our acting secretary talked about not looking at the same kinds of access measures but looking at satisfaction with the timeliness of care, measure of access and timeliness. >> all done, internally handled by the v.a.? who is coming independently and saying, i don't trust the data? you apparently don't trust your own data unless it serves the purpose. i'm looking at ig report for 2012, the average of 50 days -- average is 50 days to receive full mental health evaluation.

i would say today office of the inspector general says we don't know. we use the data from the v.a. now they are telling us today it's made up, could be falsified. unlike many hearing from constituents, called my office yesterday, what you're being told by the v.a. is whitewashing the situation in this particular vision because they are falsifying the data and punishing those that make that point. again, quickly, if you can tell me how you're going to prove to me and members of the committee and american public this is our data and this is how we can improve, improving our performance to meet the needs of our veterans. >> sir, i believe there are audits planned, not familiar with audits. i do invite you to go to the website and look at the data because you can see it. it's part of our effort at increased transparency. i think looking at how long it took people in the last month to get -- >> i can't believe the data,

because it is not independently verified, not authenticated. there's no one on the outside. in my districts, some reports have come out in the last couple of days of how they have double-checked, everything going fine. i don't think they talked to a single veteran. it's not matching up with what the whistleblowers are saying. every time someone comes to our committee and says we have data, might not be good data we've got data. garbage in, garbage out. that's what's happening here. we can't trust that. i would suggest independent, outside assessment, chairman pushing that. that's what needs to happen. reestablish trust and more importantly reestablish and make certain we're getting the care we claim we're getting to veterans. i yield back. >> thank you, mr. kirkpatrick. >> thank you, mr. chairman. i recently attended a veterans standown in phoenix, a one-stop shot, services our veterans need.

they have all kinds of things going on, thousands of people there. off to the side was a room. i looked in, there were veterans sitting there with needles in their ears, the back of their neck. they were receiving acupuncture. i was curious. person delivering acupuncture is volunteering time to be there. to a person, every veteran i talked to said they benefit freddie acupuncture, helped relieve stress, anxiety, asked me to advocate it be an approved treatment in the v.a. system. i'm doing that. but my question -- i didn't ask whether it was a pts diagnosis. clearly some in the room did, every one benefiting from the treatment. my first question to every panel was this, do you think acupuncture should be an option within the v.a. for medical

treatment for every veteran starting with dr. sherin. >> i believe strongly in alternative approaches for mental health issues and pain. substance abuse, i think acupuncture is a powerful technique, so is meditation, so are many other well established treatments. the question, though, that i go back to is that something you build into the v.a. or is it something that the v.a. supports in the community where there are already functioning systems. >> my question simply, did the v.a. cover it, over it as a treatment. i need to hear quickly. should it be regular treatment regardless where it's provided. >> i would say absolutely.

>> all treatments available helping veterans. yes, made available for treatment. thank you. >> lieutenant general. >> i'll fully support also. treatments need to be investigated. part of the cultural shift we're talking about, what this panel is all about. it's the same thing. not evidence-based, not approved. >> take care of this population. i want to make one amplifying comment. i'm a vietnam era vet."

we don't have the same thing happening to vietnam era population. i'm saying one other thing. my father is a prisoner of war, world war ii. suffered entire life from posttraumatic stress. never recovered. he was an alcoholic. all part of what are we doing for all these opportunities we have to bring it together to make it better, take care of the patient, take care of the veteran. >> a big proponent and advocate for alternative medicines. >> need someone doing it. a lot doing it, covering costs out of pocket. having help with that would definitely be a big deal to them. especially younger vets are transitioning. they have lower incomes as they are earlier in their career

trajecto trajectories. >> dr. mccarthy, it is part of clinical guideline, joint guideline for ptsd. >> does the v.a. pay for it? >> some medical centers but not across the board. >> my follow-up question is what would it take for the v.a. to have this be part of the standard treatment offered to our veterans? >> we need to ensure credentialed providers available on staff or v.a. in the community we could partner with. >> thank you. i'd like to skpor this at some point in more detail. thank you, mr. chairman. >> thank you. >> thank you, mr. chairman.

dr. mccarthy, when you talk about rbus relative value units as a measure of productivity, would it be correct that rbus are based predominantly on time spent with a patient, mental health? >> primarily. >> do you feel that's a good measure of productivity? >> we use rbu and take out the part that covers malpractice and overhead cost. it's a part of the rbu, wrbu. not ideal but the best we have. >> a measure of the productivity you're using. do you go and check to see if those rbus match up with the number of patients seen. in other words, if someone has rbus what would add up to eight hours of patient care, are you checking to see if they have matched that. if they have seen three patients

but have rbus that match an eight air our day, eight hours of interaction, are you checking that? >> i can't say that i personally am. i can say that i would hope that folks are matching that up. >> formally that's not being done. >> a relatively new model, rolled off. >> mental health added. make sure it's validated. >> that would authenticate now which isn't being done. the other thing we found not being done is what is cost for rbu what are we spending for rbu put out in care. that's a key number as far as productivity and efficiency and think we have to go that way. our next question is do our doctors and mental health claim responsibility for their

patients? in other words, do you look back and say dr. x had ten patients that attempted suicide and six that actually committed suicide. do you look at those numbers, have patient their responsibility. >> absolutely. we have a very active peer review program where patients are reviewed and reviewed in that format. in addition we go through what we call when those events occur. a very thoughtful approach to each one. >> what happens if one provider has an abnormally high number? how much -- the documentation and all the other factors around the

patient projecting on the screen. the committee reviews actually all the components of the care, looks at the follow-up, looks at when appointments were scheduled and so forth, and then an assessment of did the doctor do the right thing? people are rated on a peer review scale of 1, 2 or 3. 3 is if the case should have been handled differently, 2 if it might have been handled differently, 1 if people felt it was meeting the general standard of care. if the provider has a level 3, they are counseled about that, and if there is more than one level 3, there is an intervention program followed and a program put in place. >> any firings taking place? i can say that there are situations in which you would have. >> thank you very much. dr. sherin when i was deployed i was concerned that those who receive ai