new at this whole political thing, but i came across something called the independent budget, which if i'm interpreting correctly the vso put together for congress. i would ask that next time that comes to you, you really look at that really, really closely. these are your veterans talking to you. >> i'd like to just add quickly. one of the things that clay said over the years that sticks with me and it just is wrong. he would say over and over, i have to grovel for my benefits. i just think we need to wake up as a country. our veterans should not have to grovel for anything. it just should not be so difficult to get the care they need at all.

>> thank you very much. >> thank you, mr. chairman. i can't thank you enough for being here today, the sacrifices that you have made. i pray that the sacrifices that you and your entire family made will make us a better nation at the end of the day. i think most that sign up to serve have that intention, that they will make this a better nation at the end of the day. i am a physician and also a reservist and i served in iraq for a year. that has led me to want to be here today. one of the things i know as a doctor and i'm sure dr. somers you can relate, that when you have patients, regardless of their problems, there is a level of anxiety that, because they have something wrong, whether it's muscular, skeletal or mental, it doesn't matter.

something is wrong and there is anxiety. it makes it more difficult and heightens the anxiety when you have all these administrative problems. i know you started to deal with that in private practice. more so maybe than when you first started. the prescription you think is best, they're not allowed to have. those types of things increase the patient problem in actually trying to take care of the patient. we really are here, i will say on this committee beings not just to complain but to come up with solutions. so your input today is extremely valuable. one of the things i see is if a doctor's credentialed with one va, he should be credentialed with every va that allows him to go from one to another if there is a deficit. if your prescription is good at one va it should be good at another va. you can do that if your patient is out of town, you can call another state and get the prescription filled. when you can't, think of the anxiety that comes with that.

these are things we can fix. these are things we've got to fix. i'll also contend it's a big difference, too, being in uniform and out of uniform as far as care. as a reservist, i can just remember being with that family for 15 months. then all of a sudden, i'm 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, that ain't going to work. i'm going back in two weeks. i'm getting my house in order and go back to have something t. and so when you're just wallowing out there, and i think we need to engage. this is dod side, engage in what you're doing when you go home. and have the v.a. be part of that as well. and we've got to blend these two systems together. we have to engage in the post-deployment activity. when i have been in uniform, i had an opportunity to serve in preventive medicine.

we learn a lot. we get a lot of training in uniform of what to look for and have the battle buddy and the types of symptoms you're looking for. sometimes when the decision is made that you're going to take your life, there's a calmness. you look for someone giving away their stamp collection, their coin collection, because they have made up their mind, and they spend more time with family because they made the decision their problems are going away. those are the types of things we get. you get them in uniform, but you don't get them after. for guard and reserve in particular, you just go home. i did see -- i have seen at ft. lewis, for example, families engaged with programs, but it doesn't happen the same way with guard and reserve, and it's a different animal. i guess more than anything else, what i want to do, when you talk about solutions, we can all be trained to look for solutions and signs, but how do we go about preventing the very ideation of taking one's life? what are we doing that creates a

situation where someone comes up with that ideation that this is the best way to go? and that's the type of input we need. and that to me is really preventive medicine more than anything else. and i hope that through this, we find our way, because our suicide rate is going up in our civilian population as well. so we have a national problem here, not just a military problem. again, i applaud all your input. it's extremely helpful to us. and as you have seen, this is a determined group here that wants to make a difference in the history of our nation as we move forward. and we're glad to have you as a part of it. so your input is always welcome, and thank you for commitment. i yield back. >> thank you, doctor. check your mike. >> thank you, mr. miller and mr. michaud for allowing me to

participate in today's hearing and special thanks to my colleague from arizona who represents our community so well. i want to thank all of the panelists, in particular, thank you to daniel's parents, howard and jean, for being here. we worked together quite closely, and learning of daniel's suicide, and it is an honor and a privilege to be here with you again today. unfortunately, daniel's story and the story of the other young men who committed suicide is all too familiar in our country. and 22 veterans a day are still committing suicide. even after we have heard the tragedies of the young men who lost their lives here. and their brothers all across this country. and as we heard from mr. walz, congress has addressed this issue before, passed legislation before, said they were going to fix it before. yet, the problem has not only gotten better, it's gotten worse.

i have heard a lot of testimony today about ideas to actually reform the system and make it better. the hipaa issue i think is one that the committee would agree needs to be addressed. i'm particularly interested in the pilot program that sergeant renschler participated in. my question would be about daniel. daniel's experience with the phoenix v.a., like many, many veterans' experience at the v.a. was one of lack of concern, lack of care, lack of follow through, and a discombobulated system that didn't allow veterans to get the care they needed. in particular, one of the struggles daniel faced was as a individual who served in classified service, he was unable to participate in group therapy. because he was not able to share the experiences he experienced while in service. and yet, at the phoenix v.a., he was unceremoniously put into group therapy, and when requested private therapy, was

not able to get that care. and of course, as we know, he took his own life as a result of being unable to get that care. the medical home model, i believe, in the private community has provided an opportunity to create patient center care. and allow civilians to get the care they need in one home, easily, that's centered directly on their needs. while the private program in washington was ended because of -- well, i don't understand why. they said they didn't have enough money for it, which i think is outrageous and a horrible, horrible reason to stop providing care we know is effective and appropriate. my question for dr. jean somers is whether you believe a medical home model would work or could be helpful to veterans like daniel? we know many of our post-9/11 ved rns face ptsd, physical

problems. would it have been a model that may have worked better for daniel than what he faced? >> absolutely. as daniel's irritable bowel syndrome worsened, he didn't feel he could physically leave the house. i can't imagine that embarrassment. and then as howard mentioned, at the time, phoenix had the speed traps set up on the major highway to get from his home to the phoenix v.a., so he actually had to find a way to get off of the highway so that the flashing lights would not affect him. so absolutely. i can see that it would have been very helpful to him just to have the privacy capability. >> i completely agree. i think not only the medical

home model, but what we talked about, the ability within the facility for the different people, because of his ibs and his tbi and his ptsd, you're being treated as we learned here, the term being in silos. and what you have to do is you have to get out of the silos and you have to combine resources, combine knowledge. and we have heard of programs such as was mentioned that have very successful, where people can have problems and for whatever reason, you have an optometrist or opththalmologist in there and they say it sounds like it's not this but this, and something you might not have thought of. the medical home ability, the ability to create these panels of care would be overwhelmingly positive. >> i want to take a moment to thank mr. benishek for

cosponsoring legislation we drafted with the somers to address the issue of the service members who served in classified settings and who need appropriate care when they return to the v.a. i want to thank the subcommittee and the committee for supporting just a part of the solution to this issue. thank you. i yield back my time. >> thank you very much. >> i really appreciate it. and i appreciate the panel testifying and appreciate your courage. i want to ask about the alternatives to medication. and i want to ask the entire panel, which alternatives do you believe the v.a. could consider in addressing the mental health issue? i realize you have to have some medication in most cases prescribed, but i'm familiar with the recreational therapy that the chairman and i participated in a field hearing not too long ago on recreational therapy, the equine therapy, in my district, we have a quantum

leap farms. they're all over. they travel from all over the country to go to quantum leap. the service dogs do wonders, i understand, from talking to veterans. just to name a few. but can you maybe elaborate a little bit with regard to the al turnatives to the medication for mental health therapy, ptsd, tbi, what have you? >> yes, brian had a brother who came back and he had ptsd, and he had a friend that was doing some gardening, so he started just working in gardening with him. pretty soon, they realized they really liked it, and their garden was pretty good, so they decided to make it bigger. then they thought, let's take these vegetables and take it to market and see if we can sell them. so now they have this huge area, and they do this. i have also heard of veterans going on farms because there's not a lot of loud noises and

flashing lights and, you know, the sound issues they have with ptsd. so those are two others. >> thank you. anyone else, please? >> we could just put together an extensive list of what veterans use to cope with these things outside of medications. motorcycle riding, bike riding, equine therapy, service animals. i mean, the list could go on and on. and i would rather stress the importance of the fact that there's no one solution, and until the v.a. can get to implementing best practices system wide and tailor fitting to each individual veteran's needs and using these known best practices that exist out there until they can do that, we're not going to be able to fix anything. we can put policy in place

saying you have to provide access to these individual treatments that exist, but it's the implementation of that policy that's the major issue here. and yeah, i mean, the list is extensive. >> thank you very much. definitely one size does not fit all. anyone else? >> i would like to weigh in on that. we hear a lot of the excuses that we heard in phoenix was, it has to be evidence-based treatment. and how do you get innovative therapy if everything has to be evidence-based before they'll use it? i think they need to open up their minds a little bit and think outside the box, as you have heard, not every therapy works for every person. everything does have to be individualized, and i have heard of gardening before, too. as being very therapeutic for

people. i think they need to get out of the mentality that this is all we can do. we have these blinders on. >> thank you very much. bottom line is we need to listen to the vets, just like you said. anyone else, please? >> i think it's, again too, use the word holistic. it's a community, it's a lifestyle sort of approach. i mean, the v.a. needs to do what the v.a. needs to do the best way the v.a. can do it. but the v.a. can't do everything, so there are a lot of -- clay kind of put together his own kind of therapy program. he got involved in service. that was helping him. he got involved with iva, storm in the hill, and their community. he got involved with team rubicon, doing disaster relief programs. he got involved with ride and recover, riding bikes. that was great for him to be able to heal, but it was also great for him to be there to help his brothers and sisters heal. the problem, you know, for whatever reason, when a person

decides to take their life, they have given up hope. so what do you do about that? and clay could do everything. he could go on these, you know, on these missions and he could do one-week bike rides, but what got him was being alone. in his apartment by himself, helpless. and there's questions of matters of faith there. but it is a community approach. people need to come to government and volunteer organizations, partner, no one organization, not even the government, can do it all. and everybody needs to realize that and come together and take care of these folks. >> thank you so very much. i yield back, mr. chairman. >> mr. jolly is recognized for five minutes. >> thank you, mr. chairman. i want to associate myself with the comments of mr. bilirakis

about alternative therapies. we know they work. and mrs. somers, i appreciate your comments about evidence-based. i'm not a doctor, but i have seen evidence that non-drug therapies work. that should be good enough for the veteran, it should be good enough for the v.a. i want to talk a little bit about the v.a. acknowledgment of non-drug therapies and your experience with that, understanding every case is going to be different. i hosted a v.a. intake day recently. we had about 300 people come through the congressional office in the district. one man brought a backpack he brought to my desk and dumped out surplus medications. dozens and dozens of bottles of them. sergeant you referred fractuyou cocktail going from 11 to 14. you have expressed concerns about ambien and the use of generics and otherwise. just on its face, do you lack confidence in the way the v.a.

administers pharmaceuticals, not on the merits of pharmaceuticals, but in the experience of pharmaceutical use administers and directed by the v.a.? >> i'll speak to that. i spoke earlier about the difficulty of clay getting a prescription refilled. but what has been said before in the private world, if i go to a doctor and they determine i need sin tloid for my low thyroid issue, i go and i get it and i stay on it as long as i'm retested and that's shown to be effective. i don't understand why the dod and the v.a. have two different pharmaceutical programs and the veteran has to suffer the consequences when you separate from the service and move to v.a., especially on mental health drugs. you just, you can't swap them

out and stop cold and all of that. or even on anything physical. it makes no sense to me. i don't understand why one system wouldn't work for both. why not whatever works for dod as far as pharmaceutical medications or anything, why does the v.a. have to be different? it sounds to me like it's cost factor. they have to shift to the cheaper route. well, we have people dying every day because we have switched to the cheaper road. >> i realize very much so this is just a matter of personal impression and not clinical, but my concern having heard each of your stories is that simply because of the volume of patients, million plus volume of mental health patients, 21,000 employees. you raised the concern about personalized care. it would seem to me it's clearly lacking. i don't know what your impressions would be if you could speak to that, and also, simply whether or not alternative therapies have ever,

your sons had that discussed perhaps, or sergeant, in your counseling, the ability to get alternative therapy? i say that based on a personal experience as well, at v.a. intake day, i had a man in my office who said equine therapy works. well, that was good enough for me. but it wasn't good enough for the v.a., so can you speak to any discussions about alternative therapies, availability of, your opinions to that. >> yes, sir. so again within the v.a. medical center, they had at one point in time available the poly trauma patients, those who suffered for conditions, we were able to access recreational therapy. i was put on a six-month waiting list, and when the six months came up, they lost the recreational therapist, so that was my only experience there. never had a chance to engage in that because i was downgraded from poly trauma care when the v.a. determined my traumatic

brain injury reached the plateau of recovery and probably wouldn't get better. that's a completely separate hearing day. as far as the efficacy of alternative therapies, we could, again, it really helps. and the v.a. currently -- >> the availability. >> the availability is not there through v.a. channels. it's private community is where you have to go. >> dr. and ms. somers -- >> i would agree. daniel himself was a musician, so he was easy for him. he got a piano and a guitar, and that was his therapy, but i would totally agree with that. at the san diego v.a., i know they have pottery classes. which we were thrilled to hear about, and a guitar program. >> and when you talk about evidence-based, it's certainly not just medications. there are the psychological treatments that are out there, but they're only using two of them at this time when there are so many other potentials out

there. the other thing we mentioned is the mdma, ecstasy, and lsd for pain. the mdma for ptsd and lsd for pain. because of our national phobia against these particular chemicals, we're making it very difficult to do trials with these potential, potential benefits. >> thank you very much. thank you to each of you. mr. chairman, i yield back. >> thank you very much, members. we thank the witnesses for participating, whether or not you know it, you have been at that table for three hours. and we are very thankful that you have been willing to share your stories with us. so with that, thank you very much. and you may be excused. [ applause ]

>> i would like to invite the witnesses to please come forward. joining us at the table will be from v.a., dr. maureen mccarthy, deputy chief patient care service officer. she will have dr. david carroll, the acting deputy chief consultant for special mental health with her at the table.

our third panel includes alex nicholson, the legislative director for the iraq and afghanistan veterans of america. lieutenant general martin steele, associate vice president for the veterans research, the executive director of military partnerships and the co-chair of the veterans reintegration steering commit for the university of south florida. also warren goldstein, the assistant director for tbi and ptsd program for the american legions national veterans affairs and rehabilitation commission, and dr. sharon, chief executive officer and executive vice president for military communities for volunteers of america. thank you all for being here. and dr. mccarthy, you are recognized for your opening statement. >> thank you.

>> good morning chairman miller, ranking member michaud, and members of the committee. i appreciate the opportunity to discuss the health care for our nation's veterans. i'm accompanied today by dr. david carroll, acting deputy chief consultant, as you mentioned, and our acting chief consultant for mental health and dr. michael fischer has joined us as well. let me begin by expressing my sorrow and regret to the families of daniel, clay, and brian. i want to thank you for coming forward and telling your story and their stories. we truly believe that when death by suicide is one too many. thank you, joshua, as well, for sharing your experiences. veterans who reach out for help deserve to receive that help. a veteran in emotional distress deserves to find there are no

wrong doors when seeking help. at v.a., we must insure those doors are swiftly opened. calls are returned, messages are responded promptly, efficiently and compassionately. over1 million veterans, service members and their family members have called our crisis line and received help. suicide rates among those who are v.a. users, who have a mental health diagnosis have dereed decreased. the rates of suicide following a suicide attempt have likewise decreased. we invite veterans to entrust their care to us, and we want to insure them that we can provide the care they need or connect them with someone else who can. tragically, it is true that about 22 veterans per day die of suicide. but another tragedy is 5 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? have you ever let a provider go?

>> i can't say i've let a provider that had mental suicide issues go, but just a performance review. >> when i was employed, i was always very careful about those who received no mail during an entire year. and i always tried to encourage people at home to send this soldier something, and i wondered what happened to them when they went home. which leads me to -- i just want your opinion real quick on the idea of when you're getting a garden reserve go home. active duty, go back to a base or post, an opportunity for a consultation for the guard and reserve of what are you doing when you go home? what activity are you engaging in? because to me the worst week was the first week home when i did nothing. then i went back and saw patients again. so do you think that that would be beneficial? because you're not coming home to parades and there's not a lot of jobs. >> i think i may have missed the

question. what we try to do in the community is actually to generate lots of opportunities, and one of the key features of opportunities is -- involves kinship, support relationships, community. we look at individuals in terms of their well-being. and in order to have well-being, yeah, you need emotional health, you need physical health, you need intellectual health, you need a family, you need a community, and you need spiritual health. those are the targets we look t at at the volunteers of america, and one thing we're trying to push out is a lot more recreational type activities that bring people together and help knit the fabric you're pointing out. >> you see the great value in that and i appreciate it. i yield back. >> thank you very much. mr. o'rourke, five minutes. >> thank you, mr. chairman.

i also would like to thank the panelists for their testimony today and their service to our veterans throughout the country, and as i represent the veterans in el paso, i would also like to thank before plbrit aain who se a command center there, and most importantly in talking with veterans, it was very successful. so i want to thank you. i want to thank dr. mccarthy. she mentioned the mobile vet center and other resources that are being directed to el paso, all of which i think should tell us that we had a problem in el paso that we're now be lalatedl trying to correct and fix. and during that time when especially access to mental health care was so problematic, i had the opportunity to meet a young veteran named nick damico and his mom bonnie who came to a town hall meeting of mine.

and nick was having a hard time accessing mental health care services at the el paso va and shared that with me and my team, but also was there to hear veterans who served as far back as korea and vietnam and the gulf war share their frustration with not being able to get into the va. as he was driving home with his mom bonnie from our town hall that night in september, he said, you know, i'm having a hard time getting in and i'm a young, new veteran. some of these guys have been trying for years and can't get in. and four or five days later, nick damico killed himself. and i've got to connect the lack of access, the delay in care which turns into denial of care to nick damico's death. it is at least partially responsible. and yet in that time, the el

paso vha and the national vha was telling me that things were under control, and as recently as may 9 of this year, the director of vha told me that there was zero days wait time on average for a veteran seeking mental health care access in el paso. what i take that to mean is no veteran waited more than 14 days to do that. the discrepancies between what we were hearing from people like mr. damico and the va were so great that as i told this committee before, we initiated our own survey of mental health care wait times. found the average wait time was 71 days. found that, as dr. matthews told us earlier this week, more than 14% of veterans stopped trying to seek mental health care because it was too frustrating, and 36%, one-third, couldn't get an appointment at all. is to i want to ask y so i want to ask you, if you had known the average wait time was 70 days, or as the va found last

month, 60 days, but certainly more than 14, we have the worst wait times for access to mental health care for new veterans, the worst as of june. what would you have done differently? you said in your opening testimony, we are fully committed to providing accessible care. you obviously did not have that in el paso. if you had known this, what would you have done differently? >> congressman o'rourke, i had the opportunity to visit el paso. i had a visit there in june, the 16th and 17th, and i know at some point we're going to talk to you about that visit. what has happened in el paso is tragic. there were five psychiatrists that left all at once. that left a huge hole in the ability for them to be able to continue to provide mental health care. >> here's what i'm trying to ask because i have limited time. what the va was telling me and perhaps you and the veterans in el paso was one thing.

which turned out to be untrue and was very different from what reality was, which was that there was terrible, terrible access to care for veterans who could get it, and one-third couldn't get into mental health care at all. so if you had known that in september of 2013, what would you have done differently? >> i would have assisted you with huge infiltration of resources but also telemental health services. i continue to provide care, even while i work at the va office, by telemedicine, and that's the kind of help we can provide for those who have a hard time recruiting. >> you would vexpanded capacity people like nick could get in to see somebody. so given the fact we were not told what the real conditions were, and certainly the va in el paso and the va in washington, d.c., the director reported different numbers to me, to the

veterans in our community, who is accountable for that? what are the consequences? who is responsible? >> i'm not prepared to answer that question; i'm sorry. i'll be happy to take that one for the record. i don't have a name. >> that is my case in point. you can't tell me who is accountable. there are no consequences for veterans dying. nothing is going to change as long as we still have the same mentality and culture at the va, which you exemplify today in your testimony. the fact that you cannot tell me who is accountable for this, that there are no consequences, that if you agree if you had known the truth, you would have done something different and arguably people would have survived who are now dead, and yet there are no consequences. i appreciate the surge in resources, the additional provider, your flight to el paso in mid-june, but unless we change the culture at va, this is going to be a temporary fix that will not last. mr. chairman, i yield back. >> thank you very much.

mr. jolley, you're recognized for five minutes. >> thank you, mr. chairman, general steele, thank you for being here today. why are you pessimistic about the va embracing art as a -- >> great question. >> it was your statement, not mine, by the way. >> no, it's a great question that you ask me. i just think from the experiences, sir, that we've had in regards to trying to bring it in as an alternative therapy, along with these other issues that we're talking about alternative therapies, i believe, because i'm an eternal optimist, that the pessimism i have about the va, they will be pulled into it because of what's happening here and what we're able to be successful with in the department of defense in the military right now, because they are clamoring for art therapy because it works, particularly in the early stages of the special operations command, those lawyers that are having multiple deployments that are going back, they've come, they

sought art therapy. it's been very successful, returns them to the fight for admiral craven and the special operators. i believe that whole mechanism within d.o.d. will result it into eventually being mainstreamed into va, if we pool all these together in alternative therapy. >> dr. mccarthy, is there something that stands in the way? you have a major research university partner ready to collaborate with the peer review alternative therapy. what stands in the way from the va embracing that, generally? is it bureaucracy, is it procedure, is it regulation, is it funding, is it institutional bias, is it not invented here? >> i'm sorry, i don't have an exact answer to that. i would really be happy to review the program and understand it and then understand what the barriers might be in order to make the

implementation. i personally don't know. >> sure. and i guess i'm just asking a general conceptual. we hear all about these alternative therapies that are available, these non-pharmaceutical therapies that are available that work. in my previous profession, i tried to work with the va research department on a regenerative medicine proposal that was discovered at a non-va center, and i came up against a bias of extra research, not wanting to be too tied to extra research and therapies. just asking an assessment, why not art, but is there an institutional bias against extramural research and solutions? >> i would not say there is an institutional bias. what i can say is that va funds in particular, intramural research are sometimes funded internally, but to fund that is to partner with someone in the

va and then it would become intramural and that would provide funding. >> is there any protocol on how the va counsels a patient on pharmaceutical therapies or non-pharmaceutical therapies. are there va regulations that address that? >> congressman, that's an important question. i think the standard within mental health care for va treatment is to provide care that makes sense for the veteran. we offer a recovery model which would include evidence-based range of psychotherapies, psychologies certainly supported by alternative medicine approaches, but it's to be an

integrative package of care that makes sense for that particular veteran in their life. it's not bias toward any one of tho those. >> when it does come to some of the pharmaceuticals, the first 30 to 60 days, and again, i'm not a doctor but i know it's kind of critical when you begin a regimen, or when you switch medications because of d.o.d. to va. is there more oversight or care provided to the patient? is there a different follow-up to patients in the first 30 days or 60 days that they begin a pharmaceutical regimen? >> i can speak as a psychiatrist. it's clearly the expectation that people are monitored more carefully as you're making changes, either initiating a therapy or making increases in doses, yes. >> thank you. one last question, dr. steele, quickly. u a distinguished d.o.d. career now working within va. are there areas where d.o.d., va, the transition, all of this

together given your career of experience and now with a research university, one or two things quickly that you would say could be game changers? >> accountability and acceptability are the game changers. the separation from active duty to the va system is such that it needs to have all this cohesiveness to make sure everything is transferred over. if we can get legislation that does that and ensure there is transparency in openness, i think we have a great chance to have a major game change in all of this. >> thank you very much, mr. chairman. i yield back. >> thank you, mr. walsh. you're recognized. >> thank you, mr. chairman, for holding the hearing again, to each of you. i was going to say, dr. mccarthy, i was going to say

it's not personal, but then i got to thinking, there is nothing more personal in this. we had daniel and brian and clay, and this is pretty personal stuff. i guess the thing i'm most amazed at is i'm amazed at the lack of anticipating what you're going to be asked when you come here. it's a lack of reflection on this. i could have anticipated what he was going to ask, you can probably anticipate what i'm going to ask because i ask of it every one of you who sits here, but it might be symptomatic of why would we go to that trouble, why would we look, and my answer is if this maplace is working correctly, we should be mirroring and channelling that. i guess it's disillusion again. i'm with you, i'm an eternal optimist. nothing matters but results. nothing matters but we get this fixed right. the american public is fully behind getting this right, and we just have to figure out how

to do that. again, what i caution you all of is people have sat there and offered up good suggestions. we even got so far as to getting things in place. dr. carroll, you get to answer a few questions now. here's what the law said for you. the research shall be conducted under the suggestion and consultation with the department of health and human services. what have you done with them? >> sir, we are in partnership with the department of health and human services and d.o.d. and through the national action alliance on suicide prevention. >> what's come out of that in concrete results and implementation that went forward. >> we have -- education that the suicide prevention coordinators provide at every va medical center, they provide it to veteran service organizations, to veterans groups, to veteran providers as well as all va and vha and vba. >> how do you measure that?

you're responsible for doing this. in carrying out the plan, the secretary should provide outreach to veterans and veterans families and providing information to veterans of iraqi freedom and endurg freedom. they shall include the following, help families with veterans understanding issues arising, identifying signs and encouraging veterans. you just saw a family who said they didn't hear a damn thing for you. would that not be the measure? >> we have failed these families, sir. there's no question about that. our suicide prevention campaign last year was called stand by them. it was specifically aimed toward veterans and people in the community to stand by veterans and to reach out and to support them, to look for the signs of suicide and to encourage to get them into care. our suicide prevention coordinators at every va medical center do at least five outreach events to community organizations, veteran service organizations every month. >> what does the peer support

counseling program look like? how much training are you doing and how much are you encouraging outside people to come in and do peer support? >> peer support is one of the most important things we've done in va mental health care. we've hired 914 peer support counselors since last year. they are veterans recovering from a situation in their own lives. we are there either trained or certified as peer support providers or we will pay for that training. they are employed across va medical centers. we need more of them. we want them to be in primary care as well as mental health programs. they are a transformative source in our mental health care program, sir. >> i fall under this camp and i think dr. sherin made the case. we certainly aren't going to do it all alone. there are 30,000 non-profits to help veterans. they simply aren't very well

coordinated. doctor, i would ask you that at what level of confidence are you that this time we'll get there? i have a provider in the community that was fees-based. he mostly treats vietnam veterans. this guy is beloved in that group there. he canceled his contract in the milgd middle of that after 30 years. so i have veterans who say, why did you cancel this? this one was working, now i have to start all over again. so this new model that you're odd advocating, which i think many of us intuitively know the way to go. >> there is. the va hasn't led the way in the effort, but the va is doing this internally. this is happening within the walls of the va. the concepts we're pushing is to go beyond the walls. if we want to promote integration, we need veterans working with each other in the community. >> some of the things i read

that the va is doing, those could be applied the same way and already are? >> that's right. >> i yield back. thank you, chairman. >> thank you, mr. waltz. very quickly, and thank you, members, for being here. under threat of subpoena we finally got from va that the 2013 mental health employee survey, and if i can, i want to read just a few excerpts and ask if you will comment. leadership is disrespectful, autocratic and uncaring. they are clear that they are getting bonuses is the type priority if we want to keep our jobs. this is the worst leadership from director on down that i've ever heard of. next one, poor leadership and administrative skills causing more confusion and disorganization at times when my superior does not fully find out all aspects of the issues before issuing a decree, and the third one, no effective leadership in mental health for psych nurses,

abusive management, practices such as control, choosing staff, performance roles, note transparency. comments? it took a long time for this committee, number one, to get this information. >> and i apologize for that delay. i don't know what held it up. >> oh, i do. continue. >> i have had a chance to review some of the aggregated data from that -- >> you have not had a chance to review it. >> i have. that survey consisted of items that could be rated as well as the free text comments, and some of what you shared is the free text comments, but there are some aggregated results that are significant from 2012 to 2013 as we hired more individuals to be part of the team. people did focus on a real sense of teamwork to be able to provide for the veterans. could i also add that i would just like to respond to mr. o'rourke that i would like to restate my answer to your

question about accountability and who is responsible. i think we at va are all responsible, and that includes me. and i apologize for not saying that beforehand. but when you reframed that question to me, it became clear that i answered that wrong, and i'm sorry. >> dr. carroll, you made this comment skrjust a second ago talking about peer support is one of the greatest things that you did. did va support that? >> support it financially, sir? >> no. the concept. >> yes. >> they did. you fought it every step of the way. you fought it every step of the way. this committee and other people said, you need to bring these folks who have experienced this in their own lives forward, and va fought tooth and nail against it. >> i regret that, sir, since i

have been part of the central office team since 2007, we've been looking for ways to move this forward. >> i don't believe if you ask my member who has been sitting here for an extended period of time, they will tell you that va has, in fact, fought bringing them in because they claim they didn't have the right credentials, they were not specific, you know, to the treatment, and, in fact, you just highlighted it as one of your best successes. >> thank you for your partnership in that. >> with that, if there's no further comments or questions, i thank everybody. we thank the witnesses for being here today. i ask unanimous consent that all members will have five legislative days in which to revise and extend and add extraneous material. once again, thanks for the witnesses. this hearing is adjourned.