and in those instances, should we then be making sure that we don't do that again? if there is a problem, we refer them to the appropriate open agencies that can help right away, is that a fair statement? >> yes, but -- >> we're only doing 2%. only 2% of those folks are referred out, it's clear in may be some sectors, some va sectors where there is a problem, not hev. these aren't for the people who are working their tails off every day, they're overloaded, they're overworked. if that's the case, let's refer them out and get care and coverage. >> well, dr. scohn -- >> i'll get to them. if you can comment on the testimony you heard, and comment on the fact based on your experiences in manchester, what do you think of the testimony from the secretary first of all, number one, and number two, am i missing something? is there an appropriate way to refer people out like that?

if it's not being done, should it be done? >> listening to the testimony so far, there's a couple things i'd like to comment on, one is the hiring practices, saying it's hard to recruit and fill these positions. there's barriers on the front lines that aren't being heard at this level up here, such as, when these special purpose funds come in, they're for x number of years, 1, 2 years, whatever it may be. and a lot of facilities, many facilities, not just manchester, those positions were then being listed as not to exceed two years, or not to exceed one year. to be able to go along with the special funding, so they didn't have to worry about their budget in the future. instead, gave them the option to opt out. if i'm a psychiatrist or mental health clinician, why especially in this economy am i going to leave a full-time position to go to work for the va if it's not guaranteed that i'm going to be there in two years or that position is going to be there in two years, that's the reality.

that's just one of many examples that the front lines are encountering in trying to get people in there. secondly, when you talk about the fee service. it felt, where i was at -- i mean -- it felt where i was at, that the fee service was saying that our system was not adequate. we're not going to send people out if we can't deliver this care that we're so proud of. and when they were feed out, the problem it says in the uniform mental health handbook, it says that the va is then responsible for ensuring the care management of the people in the community. and that wasn't even -- we had no personnel do that. >> thanks for that insight. i also want to -- i'll stay all

day, madam chair, this is an important issue. i want to talk about the barness program too. you have people getting salary and bonuses on performance. i'd like to talk about that in the next round of questioning. if somebody's getting a salary to do their job and they're just hitting numbers to get a bonus, i find that a little bit surprising. so i'd like to talk about that, and i'll refer to the next round. >> we'll have as many rounds as we need, i assure you. >> thank you, madam chair. >> i want to thank everybody who's testified today. i will tell you that one of the reasons the va can't contract out in a reural state of montan is because the public sector doesn't have any more mental health professionals than the va has. whether it's in the private sector or the va, getting these folks is a big problem, i appreciate mr. -- no one's going

to go to work for a year or two years. we need to take that into consideration when we start allocating dollars for the va, to make sure they have the advantage to be able to compete. i appreciate that perspective. i want to ask, senator brown was right in the area of 1500 positions open, and an additional 1900, there is about 3400 positions. they may not all be psychiatrists or clinicians. but how you're going to fill those in an area where the private sector is sucking folks up because this is a big issue there. the va is interesting to me. do you have an allocation by visn of these 1600 folks -- if you do -- could we get a list of those, how they're going to be

allocated? i know you talked about metrics, number of veterans and that kind of stuff. could you list the metrics on why the number are there? how many are going to be psychiatrists, nurses, clinicians? are any of them going to be psychiatri psychiatrists? >> we are leading to the visn, it could be psychologists -- >> when it comes to contracting out, do you guys use psychiatrists or can you use psychologists too? >> no, we can contract with others. >> that's good, there are some accessibility for those folks. i like montana, i want to put two things that mr. tolentino said along with major jones. i want to thank you for what you're doing, i appreciate it. mr. tolentino said when he was

there, if someone came in with a problem, don't ask if there's another issue. there's all sorts of correlations here that are wrong. okay, if that's done, and i believe he's probably right, because then we have a problem. the major stressor is unknown with the folks you're working with. we have a problem in our system. the only way you're going to find out the root of the problem when it comes to mental health is you have to find out what that stressor is, you have to find out what created that problem. does that kind of -- let me just ask it, if you had a va professional in one of the hospitals, tell their people that -- don't ask any questions, because we don't want to know, i'm hoping that doesn't come

from your end. and why would they do that? >> if that is being done, that is unacceptable. we will review the situation we have going on in manchester and continue to follow up any time that occurs. >> i think you ought to do it in every visn you've got, that's just my opinion. it's totally unacceptable. we're not going to get our arms around this. you guys have been dealt this with multiple deployments. it's an issue that we don't get our arms around it, there are going to be more and more people slip through the cracks, whether we want it to or not, that's the way it is. and i just -- our use of the

public sector is important. no one wants to dismantle the va. it's all hands on deck. lastly, and i have a bunch of questions written out by -- the metrics that are use d, it may have been you, dr. dave about those being flawed. i don't know if this is the same thing or not, but the report i read means they were kind of jimmying the numbers to make it look like people were getting treatment in a timely manner when they weren't? >> i think that the problem is, that the schedulers were inconsistently operating by business resume that said you should schedule the appointment

according to the date that was desired. and the desired date. what is the desired date, the date the patient wants, the doctor wants? in the to and fro of scheduling, i think va created a metric, the rules for which are not supportable in a systematic way. you look at the data set, it's not usable from my point of view. so i think that is in large measure part of the problem with the access measures across the system. we also hear reports of gaming, and people trying to game the system. i don't have evidence that i can give to you of gaming, but i can certainly say the data set, we don't think accurately reflects access as it is in the va. >> well, one last thing, and this will be the last one. there's a stigma in this country and probably in the world. definitely in america, the united states attached to mental health issues.

i have multiple stories about folks who won't go get treatment because they're afraid it will be on their record, perception by family, friends, colleagues. does the va have an active education program to try to reach out to those folks to let them know that this is part of -- as major general jones says it's increasing, it's present it's growing, and it's not uncommon, and it's okay. is there -- is there some kind of education or outreach going on? >> yes, senator, there's a connection initiative that has just been undertaken. i think it gets back to the primary care integration of mental health, where we're able to screen for ptsd, and the other aspect of care that we haven't mentioned today is the

vet centers who are also ways in which veterans can approach for health if they have for whatever reason to be reluctant to access the traditional system. >> i agree, and before i go on, i want to thank the chairman for the length. i just want to say, thank you for all you do. look, i put myself on the line for the va every day. because you guys have a big job to do, but have you to make sure that what's going on up here, what things that the chairman says and other people in this committee, that it actually gets to the ground because we're hearing that things aren't going so well, in some areas. we're hearing things are going fine in others, and mental health is a huge challenge, and it's not easy, and please do make sure that it gets to the ground and if there's stuff like mr. torentino said about temporary dollars, i wouldn't take a job like that if i was in

demand. let's figure out how to fix that. let's figure out what we can dove tail on to things like what major jones is doing, that can be an incredible -- it's -- you know, whether you're fishing or riding a horse or whatever, those can be incredible programs to get people back on their feet. thank you very much. >> thank you, chairman, chair woman. secretary schoenhart, i was pleased to hear the va announce they planned to hire 19 mental health workers. my discouragement is how long it took for the va to pass -- in 2006 an act was passed that was a piece of legislation i

introduced to encourage, authorize and insist that you hire those two professionals within the va, and now five and a half years later i'm discouraged how long it took to see that you move in that direction. i encourage you to hire those people and put them to work as rapidly as possible. part of our state is as rural as kansas, in which mental health professionals are more limited than urban and suburban states. we need to take advantage of the wide array of professional services that are available at every opportunity. and so i'm here to encourage you to -- now that you've made this announcement, let's bring it to fruition, and thank you for reaping the conclusion and getting us to this point.

i want to address my questions to major jones. i have candidates with me that have organized a program with the same kind of focus and effort with what you're doing. it's somewhat related to the conversation or questions of senator tester of the stigma or lack of willingness to admit that one needs help, lack of knowledge about what programs are available. how to connect the veteran with what's there. i wanted to give you the opportunity to educate me and others on what it is you've been able to do to bring that slet ran who is not likely to know of the existence of your program or programs like yours, and secondly what can you -- what can be done to overcome the

reluctance of military men and women and veterans to access what is available. >> thank you, sir. 23i6r9 off, i think that the semper fi fund i've been a board member of provides the abilities for these veterans to come. most of the veterans that come back to the caseworkers have some problems or they wouldn't be there, they've had a difficult time making the transition. so when they arrive in western pennsylvania for a week long session, they arrive with a major degree of skepticism and very tentative, and we try to restore them to what was really the strength of their experience in the marine corps. the team, the cohesion, team building. they basically restore the trust. i would say -- i don't want --

trust in the system, trust in other others. i think my work through the semper fi odyssey because of the mental health officials that have come in and allowed me to speak to other groups, led to a project i'm doing that looks at best practices, so i was a marine for a long time, we never talked much about mental health issues until recently. as a vietnam platoon commander we never talked about it, but now there's programs in the marine corps and army too, operational stress control and readiness, it's a great program, but it's not easy to overcome the stigma. and the program really rests on the strength of the nco. no major general is going to

ride into a marine corps squad or platoon or company and build immediate trust, it's got to come from the nco. what we have to do so overcome the skepticism is difficult but it's happening. especially the units deployed four and five times. they're seeing the power of what a squad leader can do to identify problems when they're still in the category of combat stress injuries. i think that's the strength of the marine corps's program. i think the problem with the army program is that it's very well built. the application is not focused on the young nco as is the marine corps program. i don't say it because i'm a marine, i just sense that the nco identifying in iraq or afghanistan that there's a problem. you can start the dialogue right there, and you can start the

reconciliation process right there, and you don't have to wait six months after he returns and he has a problem -- we try to restore and very successfully restore, because all these veterans come in and volunteer their services. we had a marine whose brother was killed in vietnam. we had an orthopedic surgeon come in as a team leader from wyoming, it doesn't take a fi beta cappa to tell, these people are giving themselves for me. i would say by wednesday of a seven-day program these people start realizing, these people care about me. then you're on the road to

identification. that's when you find the demons. the company commander was killed, he feels guilty, irrationally but true, he's never shared that with a clinici clinician. he's never divulged to his clinician that he killed a marine accidentally because their sectors aligned with each other. so i think that we have no foolproof system, but the power of the corps, the power of the army, clearly as a team, cohesion. if you can restore that to what degree you can restore that, then you're on the road to a good program. there's no shortage of people that come and chronicle their experience with a clinician. and they're not damning the clinician at all, but the clinician simply does not understand the individual

adamantly enough to build that bond of trust. >> thank you for your service to our country. and thank you all for your interest and well being of our nation's servicemen and women. thank you. >> thank you very much. dr. dave, let me turn to you. as you well know, it's hard enough to get veterans into the va system to receive mental health care, once a veteran does take a step to reach out for health, we need to knock down every potential barrier to care. clearly the report your team produced shows a huge gap between the time that the va says it takes to get mental health care and the reality of how long it takes them to get seen at facilities across their country. va has concurred with all of your recommendations, but i think it's clear we all have some real concerns. some of these issues have been problems for years. so can you address a question of what you think it would take to get the va to get this right

this time. >> i think to begin with, the veteran population is zurlsed across the country and the va is not evenly dispersed across the country. those veterans that go to fixed facilities to receive their care, the va is probably trying to address the current plan for 1600 people, i haven't seen the details of the plan, so i don't know. i think the first issue is to realize that you have a problem where you have facilities and where you don't have facilities. i think the second problem is, as has been stated here, there simply are not enough mental health providers to hire off the

street. there's like 1200 members of psychiatric from our medical school. there's a limited pool and a great deal of demand for mental health providers. they said because of the downturn in the economy and other factors that the nonva, nonmilitary demand had gone up in their experience 10%, 20% in the last couple years. when i looked at mental health access in montana, it was an interesting review for me, the va had linked up with the community mental health centers. i may be out of date since we did it a couple years ago, there was an organization of community mental health centers, allowing them to go to the mental health centers, usually staffed by

psychologists and not psychiatrists. they were able to improve the access time to get folks to talk to people in their neighborhood in their city to get some care. i think in order to make that care cohesive as mr. tolentino said, you have to be able to get medical records back and forth, so there's a coordination of care, and so i think the all hands on deck idea is one that i wholly endorse, and one where if i look at some of the cases we've looked at in the past, it was not infrequent for veterans to show up at a community mental health center in their town. and because they were veterans, they were then sent to the va, and there was not a link. they were not accepted, there was no payment mechanism or authority. soy think that would be a useful

step. secondly, i think you really do have to sit down. and as bad as metrics are, i think you just have to sit down and model what you're going to do and figure out what demand is, try to lay out a business case for what you're doing. >> is that in place at the va today? >>. >> i don't believe they have for the level of mental health they should have. >> do you want to comment on that? >> no, i would like to say, though, the original question where you said, what's needed to fix this? i really believe va needs to focus on the data integrity of the information they are collecting along with the new set of metrics. i think they need to hold the medical facility directors accountable to ensure that data,

integrity. if we've seen scheduling practices that resulted in gaming the system to make performance metrics look better at the end of the day over the past seven years, they need a culture change. to get that culture change, i think they really need to hold the facility directors accountable for how well the data is actually being captured. the auditors that did the work in the field at the sites for this review, had general observations that the focus was always on the outliers, who was not getting care outside of the 14-day window. but there really was very limited focus on how well the schedulers were capturing that information. that is the information that starts to identify demand. it starts to tell you what type of services you're going to need. and whether you need to address emergent care or strategically

address care over the long term. you have to have reliable information, coupled with, i think a positive step to increasing the staffing, that is clearly very important. >> thank you very much. senator brown? >> thank you very much. i want to get back to the bonus issue. this year, budget $12.9 million. next year $16.2 billion an increase, obviously. and the va gave out in $2011194 million to senior executive service employees. do you think that's appropriate? >> well, sir, we have -- at va, under the secretary's leadership, we have done an extensive review of performance

bonuses, and have reduced those in the number of ratings and the dollar amount that's been imt plimted. >> so the number was higher at one point? >> it was. we had taken this very much to heart. and let me offer, that the integrity of our performance measures and the integritity of our scheduling system. the fidelity with which we implement these and adhere to them that are veteran centric is extremely important to the department. we take very seriously the comments that have been made by the i.g. and we will be rigorously following up. we have been emphasizing the integrity of the system, it's obvious some of what we put in in my opinion, in performance measures, particularly as it relates to the desire date, may get us into a discussion where it leads to this kind of

confusion, what sometimes happens is that a scheduler will say, i want to schedule you for when you next want to come in. the veteran might say, when are you next available? i'll be happy to take whatever's there, that's a trick bag we need to get out of by going back in our view -- >> sir, i understand that, but my question is focusing on bonuses now, i understand there are holes and we need to fix them. the chair woman brought up it has been an issue since the mid-2000s. i get it's not perfect, you're going to work on it. what's the average salary for these people that are getting these bonuses? >> sir, can we take that for -- >> what is the salary, how do you justify 194 million tax dollars to go to pay bonuses of

people that this should be part of their job? i want to make sure i understand it. if not, i'll stand corrected. what do you think about the opinion that tieing these bonuses to quality rather than quantity? what do you think about that possibility? >> senator, my opinion with the bonuses is that i think you already mentioned it, it's bonuses for doing your job. you're doing your job up to par, you're rewarded for that. from what i was always taught from my 14 years in the military, your bonuses, your rewards for going above and beyond. and clearly i'm not seeing that. in the treatment of evidence and the care that they need. so my opinion is -- >> do you think that money could be used somewhere better? >> beg pardon? >> do you think that $194 million could be used som