chairman murray, we appreciate the opportunity today to address the access to quality of mental health care services to our nation's veterans. and we appreciate so much discussion of a topic that is integral to the well-being and full living out of a fulfilled life of our nation's veterans. mental health is integral to the overall well-being and physical health of a veteran. it's important if there is underlying depression, problem drinking, or substance abuse or other medical mental ailment that this be diagnosed in order to ensure that those who have served our country have the full treatment of something that is so core to their overall well-being and to their ability to also implement the physical health aspects of medication

management, staying employed and the rest, which is so important to the quality of life of a veteran who has served this country. it is the sacred mission of v.a. to ensure that this very integral part of our care is well delivered. and i appreciate so much your comments regarding the 20,500 providers who on the ground work so hard every day to serve our nation's veterans in this important mission. we in the written statement, i have outlined three areas of improvement and concern, but i'd like to make first mention that we appreciate so much your leadership, the committee's review and the inspector general's review. this is an important aspect of care, and we appreciate all of the assistance. and we will be working very closely with the inspector general as we go forward with

their report as it relates to the first recommendation i would like to address, and that is that we agree with the inspector general that our -- our appointment measurement system should be revised to include a combination of measures that better capture the overall efforts throughout a course of treatment for a veteran. while maintaining flexibility to accommodate a veteran's unique condition and phase of treatment. we must also continue our efforts to strengthen mental health integration into our primary care in order to ensure in the primary care settings that we are assessing mental health needs of our nation's veterans, and also be able to address the stigma that's often associated with this. it can be discussed in a primary care setting. second point we'd like to make as announced by secretary

shinseki last week. we are increasing staff to enhance both the access to and quality of mental health care by hiring 1,900 additional staff. more than 1,600 of those are mental health clinicians. as i mentioned, this will augment the current complement of 20,500 mental health employees in our system. and is designed to provide additional staff in our facilities. it's also designed to increase our staffing of our crisis line, which is so integral to the identification and treatment of people who are in crisis as ranking member brown spoke of so eloquently. and it's also an important aspect of increase in that we will be adding additional examiners for compensation and pension examinations. that's an important transition from active duty to veteran

status for those who are currently on active duty and for those who present with new conditions. we have a solemn responsibility to ensure that we increase our staff to ensure that we can handle this volume in a timely fashion, and that we can do this in a way that doesn't erode our capacity to serve our existing patients. i want to emphasize that this additional staffing will be continued to be evaluating the assessed data and refine the staffing model. we are currently piloting this in three visits, and this is a work in progress that will be continually improved as part of our comprehensive approach to ensuring that our facilities have the resources to ensure that we accomplish this mission. the third point i would like to make is that in deploying evidence-based therapies to ensure veterans have access to the most effective methods for

ptsd and other mental health ailments we are making more widespread and improving our training for those who are receiving care and delivering care of evidence-based treatments. we're shifting from a more traditional approach to one with newer treatments. and would acknowledge that we have not always communicated these changes as clearly as we might to our nation's veterans, so we're redoubling our efforts to improve communication, not only to our providers but to our veterans, to ensure that these evidence-based therapies are implemented in a way that can be supported by the veteran, and fully educated and trained personnel assuring that that is delivered. in summary, we just thank you again for your encouragement, for your support.

of this is an important part of care that is fundamental to the well-being of our nation's veterans. we look forward to answering your questions. tho and those of the committee. >> thank you, very much. ms. halladay? >> madam chairman, members of the committee, thank you for the opportunity to discuss the results of our recent report on veterans access to mental health care services in v.a. facilities. we conducted the review at the request of the committee, the v.a. secretary and the house veterans' affairs committee. today i will discuss our efforts to determine how accurately the v.a. chamber courts wait times for mental health services for both new and established patient appointments. dr. day, the assistant inspector general for health care inspections, will address whether the wait times data vha collects is an accurate depiction of the veterans' abilities to access those

services. we are accompanied today by dr. michael shepard, a senior physician in the office of health care inspections, and mr. larry rinkmeyer, director of the kansas city office audit. our review found that inaccuracies in data diminish the usability of information needed to fully assess current capacity, resource distribution and productivity across the v.a. system. in fiscal year 2011 and the perfo performance accountability report, 95% of first time patients received a full mental health evaluation within 14 days. however, we concluded that 14-day reported measure has no real value as an access to care measure, because vha measured how long it took to conduct the mental health evaluation, not how long the patient waited to

receive that evaluation. we calculated the number of days between the first time the patients contacted and we projected only 49% or approximately 184,000 of these evaluations within 14 days. of either the veteran's request or a referral from mental health care. on average, it took vha about 50 days to provide the remaining patients their full evaluation. once vha provides the patient with their evaluation, vha schedules the patient for an appointment to begin treatment. in fiscal year 2011, we determined vha completed approximately 168,000, or 64% new patient appointments for treatment within 14 days of their desired date. thus approximately 94,000 or 36% kweed exceeded 14 days.

in comparison, vha data showed that 95% received timely care. we also projected that vha completed approximately 8.8 million or 88% of the follow-up appointments for treatments within 14 days. approximately 1.2 million or 12% of the appointments nationwide exceeded 14 days. in contrast, vha reported 98% received time ly care for treatment. we based on analysis on the dates documented in vha's medical records. however, we have concerns regarding the intel writ of the date information because providers told us they used the desired date of care based on their scheduled availability. i want to point out, we've reported concerns with vha's calculated wait time data in our audits of outpatient scheduling providers in 2005 and outpatient

wait times in 2007. during both audits, we found schedulers were entering an incorrect desired date, and our current reviews show these practices continue. for new patient appointments, the schedulers frequently stated they used the next available appointment slot as the desired date of appointment for new patients. this practice greatly distorts the actual waiting time for appointments. to illustrate, vha showed 81%, or approximately 211,000 new patients, received their appointments on their desired appointment date. we found the veteran could still have waited two to three months for an appointment. and vha's data would show a zero-day wait time. based on discussions with medical center staff and our review of the data, we contended, it's not plausible to have that many appointments scheduled on the exact day the patients desired. i'll offer the rest of my time

to dr. day, who will provide the overall oig conclusion. thank you. >> dr. day. >> madam chairman, ranking member, members of the committee, it's an honor to testify before you today. i and my staff from the office of health care inspections on a daily basis deal with clinical care issues in v.a., and we know that both the employees and leadership within v.a. strive to provide the highest-quality care. and despite the subject of this meeting, i do believe v.a. provides very high-quality health care to its veterans. in fact, with respect to quality metrics, i believe v.a. leads the nation with respect to both the use of data and the publication of that data on the website. with respect to access to care metrics, i believe it's quite a different story. i believe those metrics are flawed. and i believe as our report indicates, dr. petsel has indicated that he will put together a group to try to resolve the issue and get the

access to care metrics in line, so that they do accurately reflect the business processes that are ongoing at v.a. i plan to talk about some of the access to care metrics in the private sector, but i think what i'd like to make are two different statements after hearing your opening statement. the first would be i think v.a. has a number of missions. they have a mission to provide health care. they have a mission to do research. they have a mission to train individuals who will work in the united states and elsewhere in the health care industry. they have a mission to be available in times of national disaster. and i think as individuals out there and hospitals decide how they're going to spend their time, those missions are generally accepted as being equal. there's not a waiting that says, the primary mission is the delivery of health care, and we will address those assets first

as professionals schedule their time, or allocate their time. so i think when we have a crisis like we have, that a prioritization of mission -- again, stated clearly from top to bottom, would allow individuals across the system to rethink how they're spending their time. the second issue i think is important to set a standard. i realize that health care numbers can't be driven. i realize it's a personal interaction between a patient and a provider. but at the same time, there has to be some method to determine that you're getting enough work or productivity from the people that are working for you. and so i think although v.a. has worked on these issues for a while, i think that there just has to be a clear, measurable and in my view, productivity standard that is easily

relatable to the work done in the private sector by a similar provider, so that one can decide whether the money spent is actually being effectively used. i think the other issues that -- brought forward in terms of the kind of access to care standards we could use, i think that dr. -- mr. shonehart and others well understand those, and i think we can work with them in order to improve the standards they currently have in place. with that, i'll end my comments, and be happy to answer questions. >> thank you very much. mr. torentino. >> madam chairman, senator brown, members of the committee, as an oef combat veteran, i'm honored to appear here today to share deep concerns about the administration of the va's mental health care system. my testimony is based on my experience as a v.a. administrative officer, as well as service on a v.a. network

committee. membership in several groups and background in quality management. deep concerns about the manchester new hampshire failure to provide needed care ultimately led to my resignation last december. i want to commend this committee for your vigilant oversight of v.a. health care. let me also acknowledge the announcement of plans to add to its position and address problems you have helped to uncover. but i want to emphasize that additional staff alone will not remedy the systemic problems in the v.a. management of mental health care. let me be clear. i do not wish to discredit the v.a. or its mental health staff who work diligently to help veterans. but the v.a.'s mental health system is deeply flawed. the is it system is too open to put goals ahead of veterans' health care needs. it is too susceptible to gaming practices. and too little focused on overseeing the effectiveness of

care it promises to provide. these systemic problems compromise the work of a dedicated mental health staff and fail our veterans. like many v.a. medical centers, the overriding objective at our facility fro top management on down was to meet our numbers. meaning to meet our performance measures. the goal was to see as many veterans as possible, but not necessarily to provide them the treatment they needed. performance measures are well-intended, but they are linked to executive pay and bonuses, and as a result, create incentive to find loopholes that allow the facility to meet its numbers without actually providing the services. far too often, the priority is to meet a measure rather than meet the needs of the veteran. many factors, including understaffing, make it very difficult to meet performance requirements. but administrators don't feel they can acknowledge that. instead, as soon as new performance management program manuals were published each year, network and facility leadership began planning how to

meet those measures. that led to brainstorming, even with colleagues of mine across the country to find loopholes to gain requirements that couldn't be met. while i've detailed multiple examples, i would like to share two now. several performance measures mandate that veterans and mental health treatment be seen within certain timeframes. at manchester, where demand for mental health care was great and staffing very limited, the facility director demanded a plan to get veterans seen at any cost. we got the order, focus only on the veteran's immediate problem. treat it quickly in that appointment, usually with medication and don't ask further questions about needs, because, and i quote, we don't want to know, or we'll have to treat it. another directive requires that a patient who is actually suicidal or high risk for suicide should be seen at least once per week for four weeks after an inpatient discharge. this is to ensure the veteran is

receiving the intensity of care needed to reduce the risk of readmission and increase the success of treatment. instead of providing these high-risk patients individual therapy, manchester instead created a group for them, a step that was both clinically inappropriate and contrary to the directive's intent. veterans who refused to join the group were often labeled resistant to treatment. the idea that group therapy could be us is tyutined for individual psychotherapy spread throughout the network. the executive committee actually promoted this idea as a so-called best practice. even though it was not at all good clinical practice, it was seen as a good way to meet performance measures. i believe that most v.a. facilities have an understaffed mental health service, because the v.a. lacks a methodology to determine what mental health staffing is needed at an individual facility. in a misguided attempt to justify more mental health staff at manchester, the head of our mental health service stated the

priority needed to be quantity rather than quality. she said, have contact with as many veterans as we can, even if we aren't able to help them. the outcome was the facility continued to enroll a growing number of veterans, far more than our clinicians could handle. and as a result, veterans fell through the cracks. tragically, there was no effective oversight even to detect the deep systemic problems we faced. for example, every year at the medical center, completed a office survey to assess facility compliance with the v.a.'s mandate to provide uniform mental health services. but each year our network told us we were never to answer that services were not provided. many of our answers were actually changed to say that required services were being provided when they, in fact, weren't. during my years at manchester, other members of the mental health staff and i repeatedly raised concerns with both facility and network leadership regarding practices we believed were unethical or violated v.a. policy.

those concerns largely fell on deaf ears. our staff also repeatedly brought concerns to our facility's ethics committee and to our great frustration, however, the ethics committee consistently declined to take u ethics committee consistently dedine clined to take up these issues because they felt they were clinical matters. for me the final straw was the center's failure to take action to discover a technician was intoxicated while providing care. i could not continue to work at a facility where a veteran's well-being second secondarily to making the numbers look good. i very much hope the va will make real dhings address the problems i've described. i believe there are steps va can take beyond increasing staff. the va should stop rewarding taf for measures that are not real measures of health care. extensive oversight into how

care is being provided and how program funding is deployed to ensure the funds go to the programs they are intended to supplement. finally, i would urge the committee to press the va to develop and implement a very long overdue empirically supported mental health staffing methodology so it is no longer to guess whether 19 more mental health staff will be enough. in closing, i'm honored to have had the opportunity to share both my experience and assessment of problems that i hope you can help to resolve. i'd be very pleased to answer any questions you may have thank you very much. >> major general jeans senator murray -- can you hear me now? >> move the mic up to you. thank you. >> people jones retired marine,

founder and director of outdoor odyssey, a camp for at risk youth. i don't have nel expertise in mental health but have a lot of experience in dealing with those who is have mental health issues. i have been visiting walter read and bethesda pre week since the start of the war, afghanistan in 2001. i've met thousands of folks. i have been privileged to be on the board of a fund started by wives, run by wives that deal with families of wounded, sem per phi fund. i also started you know, semp per phi odyssey as an outgrowth of outdoor odyssey. while it started as a normal transition course, i met a marine corp capital wounded, visited him many times over the next year while he was in therapy. he asked me to help him start a 501 c3 since i'd already done so

in non-profit. we orally started as a normal transition course however it was obvious after awhile that the mental health issues were such that we got into the whole issue of mental health. because of my background, i was able to bring a lot of folks in from the outside. i noted navy psychiatrist dr. bill nash, and he was so move by the experience that he had me be involved in a number of gatherings of mental health professionals. from that, i was able to because i'm an adjunct at the institute for defense analysis here in d.c., was able to start a project looking at best practices on mental health. what we have done, we've run 30 sessions now, week-long sessions at outdoor odyssey. chiefly used outdoor odyssey because i had the facilities. what we have done is build on a volunteer strategy with team leaders and almost all the people are involved are in a

voluntary category. what has transpired is this whole issue of trust, cohesion and bonding which works in the military works when you're dealing with veterans. of our cohort, 30 sessions, 35 or so on average attend each time, just had one last week so we've the problem. i agree with several of the panelists here. i don't think the numbers of additional mental health coordinators is solely going to solve the problem.

i think the coordinate has to have a better understanding of what the demands are of the individual warrior. i think it's one thing that we have learned through our experience with bringing mental health professionals to these experiences that were many of them can get a better perspective of what these individuals are facing through interaction with them. so i would encourage other folks here even my panel members if they're so inclined to be involved because i think the insights and the sight picture that the provides you is absolutely illuminating. what we've learned is i call them salient outcomes, we can see the same things you get in a normal transition course we're getting breakthroughs where people are actually coming forward and talking about demons they have never talked about before. we build a network of trust that is lasting, not just a network in a sense of a transition course but a network that will

follow them after they leave the experience. most importantly what will we've learned is the fact that a large percentage and a growing percentage of folks are having mental health issues. and i would say this is an opinion but i think it's a pretty well founded opinion that the number's going to be growing in the future. and i would think that we need experiences where folks that will done deal in the setting of a clinician have a better understanding of what the issues are that they're dealing with. i'm very honored to be here. i thank you very much. i will answer any questions and i would certainly encourage any staff members of your staff to visit and we've got plenty of and place to put you down. thank you very much. >> thank you very much. mr. shown hard, first let me do say that i'm very happy to hear that the va is finally acknowledging there's a problem. he had the department is saying

there is near perfect compliance but every other indication is there are major problems i think it is an incredible failure of leadership that no one was looking into this. in fact, when you sit at that table before this committee, we expect you to take seriously the issues that are raised here. it should not table multiple hearings and surveys and letters and ultimately an ig investigation to get you to act. i also would like to suggest that if the reality on the ground could be so far off from what central office thought was happening, as it relates to mental health, then you better take a very hard look at some of the other areas of care for similar disconnects. now what we heard from the ig is very, very troubling. for months now, we have been questioning whether central office had a full understanding of the situation out in the field and i believe the ig report has very clearly shown you do not. so i want to start by asking you

today, after hearing from this committee from veterans, from providers, and from outside experts, why you were not proactive about this problem months ago. >> chairman murray, we will have been looking at mental health for many years, as you know, with the support of the congress, we increased our capacity and hired about 8,000 new providers between 2007 and 2011. we rely the primarily on a uniform mental health handbook. that would be the source of the way in which we would deliver care to our nation's veterans. that has been the fooskts department to ensure that we're getting evidence-based therapies and a staffing model that was largely based on the handbook put out enough 2009. i think what we have learned in

this journey and we have been wanting to work very closely with our providers is a number of things. as i mentioned in my opening statement, the way in which weep measure these performance measures is not a good measure of wait time. we want to work very closely with the ig and with any other resources that are available to assist us in ensuring that we provide veteran-centered performance measures going forward. >> mr. shown hard, with all due respect, i think back in 2005, the ig said this information was there. so that's a long time with a lot of veterans in between. so my question is, how are you going to address that growing ghap we've seen between what central office believes and what's actually happening in the field. >> as dr. d aig ht described in our response to the ig report, we have a number o