being done to reduce long-term opioid use and treat the underlying conditions causing chronic pain so that veterans are able to live a better quality of life. thank you, mr. chairman. and i yield back the balance of my time. >> thank you, ranking member kuster. i will introduce our witnesses in just one moment. but i ask the witnesses stand and raise their right hand. do you solemnly swear under penalty of perjury that the testimony are you about to provide is the truth, the whole truth and nothing but the truth? please be seat. i would like to recognize the honorable jeff miller, chairman of the full veterans affairs committee who is joined us. thank you, chairman miller. you have the floor. >> thank you chairman. thank you, ranking member kuster thank you for the work the subcommittee has been doing over the last several years.

fy might instead of giving a typical opening statement, i want to ask ms. clancy a couple of questions because i need to move on to another appointment. and i believe, dr. clancy, you've been made aware that i'm going to be asking a couple of questions, albeit a little out of order. and i want to talk specifically about bradley stone, that we know that he was seen by his va psychiatrist a week prior to his commission of multiple murders and subsequently dying of suicide. he was on many, many prescription drugs and had alerted va, as i understand it, to mental health and physical difficulties in the weeks leading up to the incident. but it appears that va said he

showed no signs of suicidal or homicidal ideations. and i'd like to know, how did va come to that conclusion when -- that the veteran was okay? and i say that in quotes, when he was reporting all of these feelings prior to the incident? >> in general people would come to that conclusion by asking the veteran a series of questions about were they having thoughts of harming themselves and so forth to get some assessment of suicide risk. so, my conclusion if the clinician said -- would be that the veteran answered -- gave negative responses to that. >> okay. on the 24th of april of this year, i asked the department if it would confirm whether or not they had provided the full

committee with all of the files related to bradley stone. to date, i have not received a response, so, again, i ask you, has va provided this committee with all of the files on bradley stone? >> i had been told that va provided the committee with the files with some redactions and also provided an incamera review. and the redactions were about social security numbers and some information that was about sensitive details about the living family members of bradley stone. and, again, offered to discuss that with the committee incamera. >> and again as i have stated in every single letter i have sent to the department requesting information, an incamera review is not acceptable. that may be what you want to provide us but that is not at all acceptable. so you know, the staff is

informed you and the department, that i was going to ask particular questions. so again i ask you, has all of the information -- and i would go back to -- i sent the secretary a letter on april 24th where i referred to ms. diana reubens, director of the regional office, on april 22nd saying that the philadelphia regional office had provided everything related to mr. stone's file. her response was, unequivocally yes. and so i am taking from your comment today, then, everything that she provided to the central office, the central office has now provided to this committee? >> since i'm under oath, i'm going to be very careful. i cannot speak to what diana reubens is telling you.

i have been told by our lawyers that we have provided this committee with everything, including the redactions of social security numbers and sensitive details about mr. stone's family. >> for the record mr. chairman and dr. clancy, i know for a fact the va has withheld hundreds of pages related to the bradley stone file. so, with that i would say that we have requested all the documents every way we know how. so i'll ask you one more time, can i expect the department to deliver the complete records by the end of this week? >> i will take that back and i will verify what i've been told, that we have given this committee everything except for redactions, as i noted earlier. >> okay. i can assure you, it's not redacted. it is missing. completely missing. >> i will bring that message

back. >> we also expect you to deliver the behavioral health autopsy unredacted by the end of the week. and i have told va and i will reiterate it again. an incamera review is not acceptable. and i ask, will you commit that all documents that i've requested will be provided by the end of this week? >> the behavioral health autopsy is a unique feature of what we do at va health care for veterans. rather than having a private limited to the people at facility, root cause analysis or deep dive of what happens when a veteran takes his or her own life. this is something we have centralized so we can can learn across the system what kinds of factors might have precipitated the suicide, what could we have done differently or better, and it also involves a conversation with the family members of that veteran. none of whom have been told that

we would be thoughtfully sharing their details with members of the committee. and we think that it will have a chilling effect on family members sharing sensitive details and are very, very uncomfortable with sharing the behavioral health autopsy. >> thank you very much for that educational opportunity. i refer to you again the fact that we are the legislative branch. you are the executive branch. we have complete and constitutional oversight over the department and unredacted information or anything that is done within your department that you choose to withhold we'll subpoena it, if necessary. can i expect to have this information delivered by friday? >> i will take that back, mr. chairman. >> thank you very much. and also i would -- i would also like to add on a positive note, i was in cincinnati yesterday. i was in dayton the day before. i want to thank you for the good job we see being done at the

facilities there. there's been a great change in dayton in specifics. and i enjoyed the opportunity to spend a couple hours with the people in cincinnati. we do focus on a lot of the negative and the press likes to focus on that as well, but i want to commend you on some of the great things. and i would hope some of the great things specifically at cincinnati would be shared throughout vha and the rest of the department. thank you very much. >> if i might for one second mr. chairman first, thank you very much for that. i know how hard those people work. cincinnati is actually the hub of expertise in intensive care for our system, so they actually provide remote assistance to -- >> i had a chance to view it. >> did you? it's great. it really is. >> thank you very much. >> mr. chairman, one quick point, dr. clancy. the va has turned over behavioral health autopsies to

this committee before, and so ranking member can kuster. >> yes. i just wanted to say for the record, as a health care attorney who's worked in this area for quite a long period of time, in the realm of quality assurance and what the purpose of this type of quality assurance is about, when you go back and look, it's intended for physicians and the medical team to grow and learn from these experiences. and i just want to -- i'm concerned at the impression that might be left with veterans and their families. particularly the family members that have been through the trauma of a suicide that this information would be treated confidentially. these hearings, as we know are televised. it's a very public setting. i think we should get to the bottom, but i don't want to do anything that would have a chilling affect on families that are sharing the most personal

aspects. we already have such a strong stigma around mental health and about peek seeking treatment. and i would be extremely concerned if we left the impression today that we are some way dig into private affairs. if there's information about living family members that is not relevant it could be extremely personal. and i guess i just don't understand why we couldn't do that in a -- in a private setting or in a redacted way. why this committee would be trying to determine -- and i'm not speaking to if you think there are documents that have not been provided. that's a separate matter. i know under our statutes is confidential and it's not to be shared. and the purpose of that is so that people will come forward. so, that's my only comment.

>> mr. chairman thank you very much. i appreciate the expertise you bring to this committee and to the subcommittee. and you can rest assured, and i think so you know that what we're trying to do is to hold people accountable. we are not trying to release any information that is personally identifiable. this is also a murder situation. it's a suicide, which is very difficult, but a murder/suicide. and so i believe that while the va is going through and doing this, and attempting to find out where things may have broken down, the fact is we have gotten this information before from other incidents. this one is particularly grievous because of the murders that took place. and i would remind thaw we are a federal body, not a state body. we're bound by the united states constitution.

of which we are given oversight of the executive branch and we are not bound by many of the laws -- hipa laws and other information to receive that information for us to be able to do our oversight in this and it's not political. again, we are trying to get to the bottom of a very tragic event. we're trying to partner with the va as well. and right now they are not being as open as they should be. there are documents that are clearly missing from the file. documents that i believe are damning documents and would put va in a very negative light. i understand that. but you can't remove those documents from the file just because it makes you look bad. that's what we're trying to get at at this point. again, i thank every member of

this subcommittee for the job that you have been doing. and look forward to continuing the good works. thank you, mr. kuster. >> i ask all other members wave opening remarks as per the committee custom. no objection so ordered. with that i would like to introduce our panel. on the panel we have dr. carolyn clancy interim undersecretary of health for department of veterans affairs. mr. michael valentino chief consultant pharmacy benefits management service, veterans health administration. dr. harold kudler, chief consultant, mental health services, veterans health administration. mr. randall williamson, director of gao's health care team. and dr. jacqueline maffucci

research director for the iraq and afghanistan veterans of america. dr. clancy you are now recognized for five minutes. >> good morning chairman, ranking member kuster members, thank you for the opportunity to discuss the overuse of medication for veterans particularly for those at risk of suicide. one of our most important priorities at va is to keep our veteran patients free from harm at all times. i'm deeply saddened by the tragic outcome involving a veteran, so to families here today or watching this hearing who have lost a loved one i want to express my sorrow and regret for your loss. i appreciate you sharing your experiences with us. we will honor your loved ones by learning from those experiences and improving care for veterans in the future. we acknowledge up front that we have more work to do to reduce opioid use, meet the increasing

demands for mental health care and prevent suicides and we've taken significant actions to improve these areas in order to better serve veterans. as ranking member kuster said, chronic pain is a national health problem. it affects about a third of the nation's adult population and about half of veterans from recent conflicts. as a result a number of veterans and americans rely on opioids for pain control. and they can be effective for a while, until the side effects become quite worrisome and often mixed with other drugs they can have additional adverse unintended effects. as you noted, mr. chairman, we've adopted a number of initiatives and tools to advance our goal of safe and effective pain management making data about rates and doses of opioids as well as the other medications a veteran is taking visible at

the network facility and at the clinician level. starting this july 1st we will be expanding on a very successful pilot of an approach called academic detailing which essentially consists of one-on-one coaching for every single clinician prescriber in our system. in addition to information about effective use of medications it also -- this approach also works with clinicians to have difficult conversations with veterans to help them try other alternatives for pain management and so forth. i think it's important to note that many of the veterans we serve come to us as they're transitioning from military service on opioids and other medications. and abrupt continuation is not possible or actually practical, but we have to continue to taper these doses. we've seen some successes.

as you might expect, those with the least amount of problems have tended to do better than those who are experiencing more severe pain. suicide among veterans is very complex and tragic. those of us who have lost a loved one to suicide know the deep and lasting pain. we've worked diligently with our scientific partners to understand suicides among those veterans receiving va care and among all veterans across the nation. we know the treatment works. we've identified many positive outcomes for veterans who are receiving our care. for example, the repeat taechts at suicide among veterans who have attempted to take their own lives has declined quite a bit for veterans enrolled in our system. between 1999 and 2010 the suicide rate among middle-aged male veterans who use our system fell by 31% at the same time

that the suicide rate for middle-aged men who are not veterans or veterans who don't use our system actually rose during that time period. the rate of suicide among women's veterans are higher than other women in the general public but women veterans who use our system are actually less likely to die from suicide when compared to other women veterans. as you know, our research has allowed us to estimate that about 22 veterans die by suicide every day. what's less well known is that 17 of those 22 don't receive treatment for care within the va system. and i worry that some of the 17 are actually seen in our system and are fearful about raising mental health concerns because of concerns about stigma or privacy. suicide prevention efforts have to extend to veterans who may not seek assistance and any

veteran who needs help can come to any point of entry of care in our system and will be seen that day. we've also increased targeted outreach efforts to veterans in communities throughout the country and we've made it easier for anyone to call the veterans crisis line and in response to many suggestions from stakeholders, in the very near future you'll be able to do that when you call one of our facilities directly. you won't have to hang up and call the line. you can just hit a number on the phone. and that will directly transfer you. i really want to express my appreciation to the congress for the clay hunt act in its passage, which will expand our capabilities to help veterans. so, thank you for that. the importance of mental health treatments, i don't think can be overstated. about 20 years ago in this country, we simply did not recognize how important a challenge mental health care is for all americans. at va we have embraced the problems that veterans from returning conflicts brought to

us, whether that's various mental health problems post-traumatic stress, traumatic brain injuries and so forth. and in doing so, we have had to blaze some trails. we have had to go ahead of what is going on in the rest of u.s. health care where utilization of mental health has been dramatically curtailed over the years. that's meant we had to work with public and private science partners to build the basic science, the epidemiologic data and population expertise. we've learned a lot. we've made significant gains and seen the successes of treating mental health problems, but we have so much to do to dispel the stigma linked to mental health issues. it wasn't that long ago that cancer inspired that kind of whispering. people didn't talk about it out loud. because of fears and misinformation. and, frankly, we hope with your

help and the help of many partners, that soon we'll be able to eliminate that fear and misinformation associated with seeking mental health care. in the meantime, we're focusing on creating an atmosphere of trust and privacy. i want to just close by saying we're committed to improving our existing programs taking every action to create new opportunities and, most importantly, improving the quality of life for veterans. we're compassion to help those who served. we're proud to have this honor and privilege. we're prepared to answer your questions and look forward to working with you until we get this right. thank you. >> thank you dr. clancy. mr. will yomiamson, you're recognized for five minutes. >> thank you ranking member and ms. kuster. i'm here to announce vha's report on veterans with major

sgreess ive disorder, mdd, who were prescribed one or more anti-depressants. mdd is a major risk factor for suicide among veterans. it is particularly debilitating mental illness often associated with severe depression and reduced quality of life. also i will discuss certain aspects vha's suicide prevention program. specifically, i will discuss the incidence of mdd among veterans treated by va the extent that vamc clinicians prescribe anti-depressants to veterans with mdd and monitor anti-depressant use and data vmcs are collecting and reporting on suicides for vha suicide prevention efforts. data shows 10% of veterans were diagnosed with md and 94% of those veterans with md were prescribed one or more anti-depressants. however, the estimate of veterans with mdd may be low

because in reviewing a sample of medical records from selected vmacs we found vmacs do not always correctly report and record confirmed mdd diagnosis among veterans. at six vmacs we viewed a sample of veterans with mdd prescribed anti-depressants and found they did not always receive recommended care for three important recommendations and clinical practice guideline referred to as cpg, that vha has established to guide its clinicians in treating mdd. for example, although the cpg recommends that a veteran's depressive symptoms be assessed using a standardized assessment tool at four to six weeks after initiation of anti-depressant treatment, we found that for 26 of the 30 veterans in our sample, va clinicians did not

use this is sesment tool at all or use it within a specified time frame. while not mandatory for vmac clinicians cpg recommendations are based on evidence-based data from clinical trials research and other proven and reliable sources and are meant to enhance outcomes for veterans with mdd. moreover, vha does not have a process at any level to systematically monitor the extent that vmac clinicians deviate from cpg recommendations. with little if any visibility over whether the care provided is consistent with the cpg va is unable to ensure that deviations from recommended care are identified and ee value witted and whether appropriate actions are taken to mitigate potential significant risk to veterans. finally, we found that demographic and clinical data in

va's -- vamcs collect on veteran suicide to better inform suicide prevention program were often incomplete and inaccurate. for example, as part of va's behavioral health autopsy program, which i'll refer to as vhap, vmacs collect data suicide on date of death, number of mental health visits and last mental health contact. we examined vhap reports from five vmacs and found two-thirds of them contained inaccurate and incomplete information. moreover, the situation is further exacerbated because vhap reports prepared by vmacs are generally not reviewed at any level within vha for accuracy, completeness or consistency. lack of accurate and complete vhap data limit opportunities to learn from past veteran suicides and ultimately diminish efforts to develop effective methods and approaches to enhance suicide prevention activities and reduce

veteran suicides. va has made good progress in addressing the six recommendations to improve weaknesses we noted in our report. in the six months since a report was issued one recommendation has been fully implemented and several others are very close to being fully implement pd more globally, this work illustrates once again a continuing pattern of vha's noncompliance with its own policies and established procedures unclear guidance inaccurate data and poor oversight. these are among the same factors that led gao to include vha on its high-risk list. until va instills a culture throughout the organization that holds its staff and managers truly accountable for effectively performing their responsibilities, appropriately overseen outcomes and achieving a recognized standard of excellence vha will continue to fall short of providing the highest quality and cost effective care to our nation's

veterans. this concludes my opening remarks. >> thank you, mr. williamson, for your remarks. dr. maffucci. did i say that rate? >> yes, you did. thank you. >> thank you. you're now recognized for five minutes. >> chairman coffman, ranking member kuster and distinguished members of the subcommittee on behalf of iraq and afghanistan veterans of american 400,000 members and supporters, thank you for the opportunity to share our views and recommendations on prescription management and the potential riveng of veteran suicide. in 2014 iva launched its campaign to combat suicide. in february with your help we signed the clay hunt save act into law. this was the first step on a long road to address the challenges of combating suicide among our service members and veterans. the issue we're here to talk about toes is complex because it encompasses two topics --

providing care for veterans seeking relief from chronic pain mental injuries and other conditions, and recognizing the potential for abuse and misuse of these powerful drugs. while these drugs are extremely powerful, they can be extremely effective for a veteran who has not found relief elsewhere. a 2011 report shows chronic pain affects 100 million american adults and this number is growing. given the last 14 years of conflict and the very physical daily demands on our troops, we've seen a similar trend among service mechanics members and veterans. over 60% of the iraq and afghanistan veterans seeking va medical care seek care for musculoskeletal ailments. this is the most common category for disability compensation. nearly 60% seek care for mental injury. within iava's own community two of three respondents to our member survey reported experiencing chronic pain as a result of their service. one in five reported using

prescription opioid medications. one in three using anti-anxiety or anti-depressant medications. among this newest generation of veterans, medical advancements have allowed for higher survival rates from complex injuries, but this also increases the likelihood for life-long impacts of nerve and skeletal damage. treatment of pain in these instances can be even more complex because co-occurrence with other conditions, like depression, anxiety ptsd or tbi, may limit treatment options. for clinicians assessing pain and devising a pain management strategy can be very difficult as well. particularly given that knowledge in this field is still growing. primary care physicians who see the bulk of patients with chronic pain report that they feel underprepared to treat these patients due to lack of training. this includes vha providers who were surveyed in 2013. adding to the challenge or study showing that untreated pain can

actually put an individual at higher risk for suicide. and yet we also know prescription medications can result in strong addictions and provide a means for suicide attempts. the va reports that over half of all nonfatal suicide attempts among veterans results from overdose or intentional poisoning. this highlights the challenges that clinicians face when treating patients with complex injuries and demonstrates the importance of comprehensive, integrated pain management. while the va has moved the needle forward investing in research on pain publishing an evidence-based clinical practice guideline, implementing an opioid safety initiative and introducing a stepped case pain management system more remains to be done. with approximately 22 veterans dying by suicide every day and more attempting suicide, reducing instances of overmedication and limiting access to powerful prescription medications must be included in a comprehensive approach to

addressing this issue. a recent study showed while patients receiving opioid therapy are at an increased risk for attempting suicide, following some of the va's clinical practice guidelines reduced this significantly. this shows the critical need not only for these guidelines but full implementation of those guidelines. va's 2009 directive on pain management, which outlines the stepped care management to pain expires in october of 2014. while it expired in date only and the policy remains active iva discouraged updating this important policy has not been prioritized. we urge va to prioritize this and fully implement it at all facilities. iva would like to -- minimizing the risk of overdose and overmedication through form larry takeback prabz and prescription monitoring programs. last year an important change to dea regulation expanded authorization for drug drop-off

sites. this change gave va the ability to stand up drug take-back programs in their hospitals. this is critical to limiting the possibility of yus use and abuse of powerful prescription drugs. yet no action has been taken. while the va's working to fully implement its participation in state prescription drug monitoring programs full implementation remains to be seen. we urge the va to prioritize this as well. and/or opioid with very little oversight or follow-up. we also hear stories of veterans with enormous pain and doctors who won't consider their request for stronger medication to manage this pain. these are tough challenges. iva remains committed to work with the va and congress to address them. again, thank you for the

opportunity to offer our views on this important topic. we look forward to working with each of you, your staff and this committee in this critical year ahead. thank you for your time and attention. >> thank you, doctor. i deeply appreciate your testimony. let's see, who's next? our thanks to the witnesses. dr. clancy, according to a gao report, va deviated from recommended guidelines in most all of the 30 veterans' cases reviewed by not assessing anti-depressant treatment properly. in your opinion, is policy simply ignored or is there just a lack of oversight by leadership? >> so, first i want to say that we regard the gao recommendations -- feedback is very important -- a gift if you will, to help us get better.

i'm not sure that any guideline written on planet earth should be followed 100% of the time. many doctors think of them as tools, not rules, because there will be patients with unique circumstances that don't fit perfectly. in terms of the follow-up assessment, i think that is important and we need to do a better job. we will be looking to see whether that is a feature of the fact that we had -- we're having access problems and it was hard to get people back in or if we just weren't on the ball. but that's a very important feature. >> dr. clancy, we found if our review veterans who died of drug toxicity who reported hallucinations and died of suicide and reported homicidal thoughts. are these the improved outcomes you're referring to? >> no they're not mr. chairman. >> dr. clancy in response to gao report, va noted it would conduct chart reviews and

develop a plan to determine and address the factors contributing to coding variances. this was to be completed by march 2015. has this been completed? >> it is in progress. we are not completed yet. i will also add to that that in addition to that i have been meeting -- inspired by the gao report and feedback by dr. dr. kudler and other mental health leaders in our system, to try to figure out who are the veterans we think are struggling the most with mental health disorders, that we should be targeting to make sure that they are getting the best possible care. >> thank you dr. clancy. when do you think that report's going to be done? >> i would have to double-check on when we committed to having the recommendations done. >> va stated it would examine associations between treatment practices and indicators of

recovery or adverse outcomes of veterans being treated with anti-depress anlts. the targeted date of completion was also march 2015. has this been completed? >> i believe that it has. i'd have to double-check my notes here. here we are. >> can you -- well, can you get a copy of it? >> yes, absolutely. >> roughly 63% of the behavioral health autopsies reviewed by gao, critical data was missing. is this inaccurate reporting based on incompetence or is it to intentionally keep central office in the dark? >> i have no reason to suspect it's to keep central office in the dark. as i understand it, this program was transitioned from doing root cause analyses at individual facilities to a centralized repository two years ago. as you might expect, training

reviewers and people who are doing the interviews and collecting the data, to collect that data consistently and accurately, took some time. frankly, some iteration to make sure we were getting it right. dr. kudler, do you to want add to that? >> yes. pardon me. at the time the gao was conducting this study the behavioral health autopsy study was just being launched. the forms were new. they were in need of refinement. they've been continuously refined, as have the training of suicide prevention coordinators 300 them across the country who fill them out. there were questions about what data goes there, how do you count this or where do you go with that? that's been addressed with training and upgrading of our manuals. would he rearviewing all of these centrally and national level. we've created software that crosswalks these to another suicide tracking system so we can make sure we're accurately looking at these from multiple

perspectives perspectives. so it's continuously improving and progressed a great deal since the original report. and we'll continue to work on it. >> dr. clancy, this subcommittee requested the behavioral health autopsies for numerous veterans who have died by suicide and in all cases, except one, holmes, va has stated that this information is confidential privileged, et cetera, so it cannot be released to us. if this is true why was the report for miss holmes released to the committee? >> i would have to take that question for the record. i would say in general the behavioral health autopsy reports, i think ranking member kuster described this more clearly than i could. this is quality assurance where you want the most forthright kind of input and observations. and if people think that this is

going to be disclosed, we will not get input that is that forthright. >> well i think we're very concerned about the fate of our veterans and this subcommittee and the committee as a whole has an oversight responsibility for your operation. and we cannot do that oversight operation and making policy best for our veterans if you don't fulfill your obligation and submit that information when requested to the congress. ranking member kuster? >> thank you, chair, and to all our members. especially dr. maffucci i appreciate you being here and the experience of veterans returning, as you mentioned, from 14 years of conflict. the injuries are more complex. the good news is people are surviving. the difficulty, as you say, they

have chronic life-long issues. i want to focus in on how we move impard. i shared the concerns that have been expressed about the data and making sure that we are getting at the heart of the issue here. but i'm very interested, as i mentioned, i had a meeting with the team up at white river junction facility. there's some cutting-edge research. i'll talk to the chair about perhaps bringing in witnesses to share that. in particular the opioid safety initiative. a couple different things, and whichever is the appropriate witness, one is getting at the heart of what's causing the pain. i've lived with -- my husband has chronic pain. and many, many years of back pain and various medications. and come to find out what he needed was a hip replacement. it wasn't about his back at all. and now he lives pain-free with yoga and stretching and exercise and such.

so i'd like to find out what's being done to get at the crux of what is causing the pain. secondly setting a goal of reducing opioid use and working with practitioners to bring down the opioid use. particularly emphasizing patient education, close monitoring. they talked about actual drug testing because in our area selling these opioids on the market, what happens sometimes is people will not use the medication themselves and they can determine that through frequent drug testing, which, as you can imagine, is not popular with the patients. but necessary. and then alternative medicine, acupuncture, i mentioned yoga, massage, exercise. so if you could comment on this opioid safety initiative, how far has that gone, how wide widely has it been -- is it in use? what can we do to help move that forward? >> so, thank you.

those are all terrific questions. i'm going to start and then turn to mr. valentino. like the case with depression, we do have a clinical practice guideline we developed with colleagues from the department of defense on the management of chronic pain published in 2010. as of september this year it will be updated which is about the frequency with which you'll want to update these guidelines. we'll have input from veterans and family members. the guideline does include urine drug testing periodically. we have, as i mentioned, probably too quickly in my opening statements, made in a serious of series of steps made data about prescribing patterns at the network level, the facility level, and most recently at the individual clinician level available and visible. so clinicians can actually see what has this patient been on

over time. what other drugs are they on so forth. getting to the root of the problem, i think is incredible important. i'd be happy to submit for the record to brief anyone any time, about the exciting research we have in process. because i think it's very important. i think there's a lot we need to learn in two areas. one is, what are the predict irs of veterans or anyone who is likely to use opioids for a short time and go down the path of using them on a regular basis, because if we knew then that's where we would target a lot of efforts. the second is, which veterans are most likely to respond to alternative treatments to nonnarcotic medications and so forth. as i said, we have some research going on in that area and have a lot more to learn. mike, do you want to add to that? >> yes, thank you. so, this -- the opioid safety

program is just shy of two years old. and we've had to build it from the ground up. as dr. clancy mentioned it's been very itterative. we focused on data collection to focus on outliars. we focused on those, asked for correction action plans. the next iteration was to drill down to va facilities, which we did identify outliers, asked for corrective action plans. we know this is working because 17 medical centers originally identified have now fallen off the list. we are poised right now at this moment, and we built the tools and we're validating them for accuracies, to drill down to the individual provider and patient level. this is very complex, as might guess. someone may show up in the data as an outlier, but maybe they're a pain management specialist.

maybe they treat cancer pain. maybe there are other situations where you would expect it. so, we have to make sure we get it right so there's confidence in the tool. but we've had really really good results. i'll just go through some of the metrics. since we began we have 110,000 fewer patients receiving any kind of opioid short term or long term. 34,000 fewer patients receiving opioids and benzodiazepines together, which is a known risk. 75,000 more patients have had a urine drug screen, who are on long-term opioids, as you mentioned, because that is definitely an opportunity for diversion. we to want make sure patients are taking it. we have 92,000 fewer patients on long-term opioid therapy, which we define as longer than 90 days. we also have begun to look at the totality of opioid -- the opioid burden.

so there are many opioid drugs but you have to sort of boil those down to a dmon dedominator. morphine equivalent daily uses -- >> mr. valentino, i'm sorry, my time is up. i'm very interested in what you have to say, but my colleagues need their turn as well. thank you very much. >> let's see if we cannot try and run the clock out on some of these answers. >> i would like to thank the chairman for bringing this important issue to light. unfortunately, it comes too late for one of my colorado springs families. i'd like to tell you the story of noah, a former marine, who served with honor in iraq in 2009 and afghanistan in 2011. i won't use his last name but his parents have offered the use of his picture. so if i could just show you noah's picture. after leaving the marine corps noah began working on a business

degree at university of colorado-colorado springs and started his own online business based out of colorado springs. noah comes from a military family. his dad having honorably served for 23 years. noah chose to put off college so he should serve this great nation. unfortunately, his parents are appalled by the care that their son didn't receive. from the va. they believe their son would still be alive had he received better care. noah was diagnosed with ptsd and received a 50% disability due to ptsd. on april 2nd of this year he went to the colorado springs va clinic where medical notes from his visit state that he had suicidal thoughts, or suicidal ideation specifically. noah was prescribed a psychotropic drug and sent on his way. now, we don't know at this time what this drug did or didn't do. but we do know this, he was not referred for suicide prevention.

he was not offered counseling. and there is no follow-up from the va. he went missing the evening of may 4th and was found dead from an apparent suicide may 12th of this year. a month ago. as you can imagine, his family is devastated. they are asking a lot of serious questions, so, dr. clancy, i would like to ask you several questions on their behalf. why was their son, who had -- who had been given documented -- who had been documented with having suicidal thoughts or ideation not referred to suicide prevention? why wasn't their follow-up from the va? and why wasn't he offered counseling? >> i will look into this personally, mr. congressman. that's heartbreaking. i can't even imagine -- i can't imagine, but i know it's horrendous what his family is going through.

the picture was worth many, many words. someone who did so much for this country. and i will look into that and get back to you on these and to the family. >> would one of the other witnesses have any response to my questions? to the family's questions? >> you know, as a psychiatrist someone who has treated veterans in clinics for 30 years it's hard to understand the report that we're given. and yet these seem to be the facts that are available. we have to look into it. my first thought is that i want to make sure this family has been reached out to directly and that we have a chance to collect this information. as i say, we created a system. the system can be cold and inhuman, but we need to have a real sitdown with them and understand everything that happened from their point of view, questions they have, which may torture them, and we will work with them to do that. >> okay. thank you, both.

mr. chairman, thank you for having this hearing. i yield back the balance of my time. >> mr. o'rourke texas. >> thank you. dr. clancy a question to which i'd like to receive a quick direct answer. a quick direct answer. we're touting reduced prescriptions of opioids as though perhaps that in itself is success. what i'd like to know are the consequences. i have veterans who show up to my town hall meetings saying their prescriptions were cut off without notice without transition, without ramping down. how many of those who are no longer receiving prescriptions from the v.a. are now using heroin or other street drugs? >> we can't know that with the information we have. it is something we worry about constantly. so -- >> let me tell you another problem. this is hopefully helpful feedback for you from el paso. others who have prescriptions are required to renew those prescriptions after a monthly visit with their prescriber.

they're unable to get the appointment in el paso to see the prescriber so they cannot get the prescription renewed so they go without or they go with something that they shouldn't have that perhaps they buy on the street. and at a minimum they're suffering. and in some cases i would connect that suffering to suicides we see in el paso. i'd also like to give you the following feedback. as i shared with you and met with you on monday, the may 15th access report from the v.a. shows that el paso is ranked 157th out of 158 for mental health care access. we have 115 mental health care positions approved for el paso, only 87 of those are filled leaving a 24% vacancy rate. your predecessor when we would relay anecdoteal information i was hearing from veterans we are seeing everyone within 14 days. we found more than one-third

could not get an appointment not in a month, not ever. that situation we're receiving responses back has not improved in the year that we've had new leadership there. this is -- should be for you a five-alarm fire. i have met with the widows and the mothers of suicides in el paso far too often. i'm continuing to do that and i just did the last time i was home in el paso. as you know for whatever reason the v.a. has been unable to solve this issue and treat it as a priority it should be and to turn around el paso. i'm glad to hear there are good things happening in other parts of the country but everything i do is view through the prism of the veterans i serve in el paso. you know we have a proposal to address this. i want your commitment that you're going to work with us because the community has come forward in the vacuum of v.a. leadership of action and will and resources to do the right thing. i will do whatever it takes to work with you and your team and

the secretary to get this implement implemented, but this is a crisis that has deadly repercussions for the veterans we all serve in el paso. i want to make sure because we didn't take it seriously over the last year because our statistics and our vacancy and our position relative to mental health access is actually worse than it was a year ago. i want your commitment that you're going to work with me to resolve this that it is a crisis for you, that it is urgent for you and we're going to turn this around. >> you have my full unwavering commitment. we were very impressed with your reaching out and bringing in various members of the el paso community to work with us. and i want to thank you for your support of our employees during what was a different kind of tragedy at the el paso facility several months ago. something that cut to the heart of clinicians across the country but particularly those serving veterans in el paso. you have my full commitment. >> thank you. i yield back. >> that's not enough.

these veterans -- [ inaudible ] >> we see nothing. >> i'm sorry sir you're out of order. you're out of order. thank you. >> dr. benashack. >> thank you mr. chairman. i want to associate myself with the comments of mr. o' roerk for one thing. the goal seems to be cutting down the amount of narcotics and the same circumstances happen in my district too where people have just had their prescriptions cut off with no alternative treatment. figure it out. it's been a real problem. a couple specifics i want to get to after that. and that is something dr. cod ler said and something mr.

williamson said. mr. williamson said there's not that much -- doesn't seem to be that much follow-up on this your health autopsy program we're learning anything for it. can you remind me what you said in your testimony? you are contradicting what the doctor said. >> we were talking about oversight. very little oversight of that program at the local or the national level to see whether it was accurate and complete. >> right now dr. cutler you said you're doing oversight. and mr. williamson the g.o. says you're not. so what exactly is going on? >> the difference is the two years that have passed since this report was written. not questioning the report at all. in fact, i find the report helpful as a real spur to do more. but at this point we are making a difference in this and we've developed -- >> will you show me the results of the oversight you've done in the last two years? can you get that to me, you know within a reasonable period of time? like a month? >> that's not quite the way it

is i think. i think there's still -- to respond to our recommendations on oversight i don't think v.a. has completed those yet. it's not the two or three-year lag at all. i think what we're talking about -- there have been some changes made. they're now a box checked on the behavioral autopsy report that indicates that oversight has been done. >> that's all you're saying that box, right? >> well, that's one of the things. they are revising guidelines. so they are making progress. but it's not been completed to our understanding. >> i'm not going to give you another chance doctor, sorry. but dr. clancy you said something in your testimony that was very important to me. and that is this seems so simple but the fact is that people who

have an idea they want to hurt themselves have to hang up and dial another 800 number when they're calling in to the v.a. and you spontaneously said you're going to have that fixed and be able to just you know, hit a key and make that work. so what i want to know is when? can you give me a date how it happened? i can call the number to see if it's actually working? >> absolutely. by november or december. one of the things that we have been working very closely with the -- >> great. >> we want to make sure we don't overstress that system when we do it. >> i want to have a date so that if it's not there by november or december. >> yes. >> because i completely agree with the guy that stood up there in the back and was out of order and that it's just great to keep hearing that you're all going to do work, but from where i sit, you know the actual accomplishment of the job does not seem to be happening.

>> no i hear that. >> i will be back to talk to you in january. and hopefully i've called those places and there actually is a number i can hit. i mean i got people calling me all the time. >> i'll be checking before you will but yes. >> all right. with that i yield back the remainder of my time. thank you mr. chairman. >> thank you. mr. waltz of minnesota. >> thank you to the chairman. and thank you all for being here today. i too would like hit on this the osi that was implemented in minneapolis and we followed this closely since october 2013 and we're getting the results but i think my colleagues i would associate with them. and i know this is nothing new to all of you that we saw dramatic increase in our calls to our office after it was implemented, which i think is probably somewhat expected. but i think the lack of maybe being there or the alternative. and i say this very clear, this issue of mental health parody,

mental health treatment certainly is societal wide. very proud of the work that this committee has started to, a small first step on clay hunt, but it's going to be the broader issue. and on the opiate issue this nation has vacillated back and forth from overprescribing to underprescribing and trying to find this as the research gets it. so i hear that. i guess my concern and the frustration -- and you hear authentic frustration from veterans whether it be here or all the time. this pain management thing is a tough one. tough, tough, tough. i always say this but i think it's important for context, i represent the mayo clinic area, so these are folks dealing with this also on a very big issue. but i was very proud back in 2008 one of the first bills i was able to move through was the military pain care act and veterans pain care act. and out of that came the vha's pain directive 2009053.

what it was is we put together through iom the step care pain model, which is the gold standard of best practice is that correct? okay. and i won't go through all of it that's here, but what i would say is that it had a five-year span on it. i want it to go further, but this is the nature of how we do legislation. it expired in 2014 before it was fully implemented. it did not get reauthorized. but when we were out in toma on this issue, dr. clancy, you responded, this is on march 30th that the v.a. doesn't need us to do it that you can put it in yourself. and i said that's wonderful, let's do it. and i followed up with a written letter. and i don't expect to be a high maintenance person but i've heard nothing on my specific question. so the frustration lies in this was seven years ago we were dealing with pain management. seven years ago we implemented

best practices. seven years ago the v.a. started but didn't fully implement it, eight months ago it expired. three months ago i asked about it and now i have to be here. and i hate this exchanges that we continue to have. i hate the pattern of communication that we now have because it does not bode well for our veterans, it does not fit. in fact it's very irritating. i don't set you up because i wanted to start and preface this that i understand the challenge of this issue. i understand the deep societal issues. i understand the positives we're making and the pluses and minuses. the frustration lies more in that this might not have been the fix, but why didn't we do it? why aren't we? >> it has been done. it is still being reviewed internally. and i will be honest and say this is the issue the gao highlighted in putting us on their high risk list. and we've got to get better at the process and updating of our policies and directives. but the pain directive has been updated. all policyies -- >> who knows that?

>> huh? >> would the author of the bill not be someone who needs to know that? >> we're going to tell you as soon as we have reviewed it and made sure we have gotten consensus and haven't missed any details. i apologize i have not personally seen your letter but i will make sure i see it before the day is over. >> part of this, and i go back to that and again i don't expect to be high maintenance. you've got other priorities, but this is one of the issues we've struggled with. not us we built a great coalition from private companies like boston scientific to working with your talented people in this. we got a good piece of legislation on it. we're trying to communicate to implement it and we're left in a no-man's land where we don't know what to think. i don't like going out and hammering on you we haven't heard from it yet but this is important stuff. there's some things and i encourage my colleagues to look at this. the things i hear ranking member putting in, she's intuitively clicking into this that's in the step care management. the things you're hearing from

dr. benashek, make it s.o.p. it would be there. again, i encourage you in many cases. if you're doing something right let us know and talk about it. communicate with us. see us as partners in helping our veterans so the frustration you hear in here and in our districts is reduced. we'll look forward to the follow-up. and i yield back. >> thank you, mr. waltz. dr. row tennessee. >> thank you mr. chairman. just a couple of things. one, data collection and certainly when you draw or produce inadequate data, you draw inadequate results. the results may not be accurate at all. it's extremely important in health care to get that right because wooe going to draw conclusions based on this many patients did this and this many patients did that, i've been involved in those clinical

studies for years. when you put bs in you get bs out. so that's sort of what looks like has happened right here. that's being a little crude but that's absolutely what it looks like you've done. and mr. williamson's pointed out you've got half of the vha templates were incomplete or inaccurate, you draw bad conclusions from that. you can't help but do it. so i think until you get the da da right you're never going to know. and, dr. clancy, you're right what works for one patient may not work for another. and the ranking member certainly has pointed out there are many alternative therapies and what works. and dr. murphy whom i'm sure you know continually complains about when he's at d.o.d. and has a patient stable and then they're separated from the military and they go to the v.a. there's a different formulary.

they're now on something else. i think that's something that needs to be addressed. he was very adamant about he sees it a lot since he's still in clinical practice. and i too with dr. benashack want to associate myself i think the outburst you heard was just frustration from probably a veteran who's either tried to get in or couldn't. and mr. o' roerk has every right to be frustrated when he has people lined up outside his office talking about not being able to get in the v.a. let me share why that's frustrating to me. i've been here six years and change on this committee. and we've increased the budget 74%. it's not money. it's management. and it is not the amount of money that we're spending on our veterans. there's plenty of money out there to spend. and i don't understand why the system isn't functioning better. any comments on that? because mr. williamson, i think you pointed out in your testimony poor oversight, why is that?

no accountability. what happens to someone when we find out they're just not following it? aparnltly nothing. i know outcomes, you mentioned all of those things. mr. williamson. >> so your question is directed at oversight? >> yes, sir. >> you know, there's a lot of reasons why that doesn't happen. and i think a lot of times v.a. does not have the data to real accurate and complete data to do that kind of thing. i don't think there's any willful motive. especially at the local level there just is not that accountability that a supervisor is holding his or her employee accountable for doing their job correctly. >> but that's -- that seems basic to doing your job to me. i mean to hold someone accountable for their job, i mean, that's not rocket science. you're not doing your job.

so what happens when you don't do your job? do you lose your job? what happens? >> i'm not sure i'm the right one to ask that but you know in my ied listic world i would think you would. we're held accountable for the quality of the work that we do. and when we don't do it well we get feedback. first of all we have expectations, then we get feedback. and hopefully corrective action after that. and that's very business 101. >> so, dr. row, if i might i want to say to you and your colleagues, we share your frustration. >> okay. >> and i want to salute my colleague dr. cuddler who is working with others. people who don't do their job should be held accountable if in fact we've given them the resources and capacity to do that job. you can't hold somebody accountable if there are no appointments or ability to see -- >> but it was pointed out there are 20 something people jobs available right now. we claim we have a job problem. there are 24 people that need a

job in el paso, texas and there's money there to fund it. so why aren't positions filled? >> we have tried a lot of varieties of ways to recruit people. mr. o' roerk came in with a group of people from the community and he has my full commitment to looking at that proposal -- >> the v.a. is not making it hard for those veterans to leave that system and go to these private practitioners. it is with a veterans choice card with non-v.a. care because we find that sometimes it's just so hard with all the rules they have to get out it takes forever for someone to get an appointment. one last thing, i know my time is expired. but how long does it take to change a phone number? why does it take six months to have someone you call -- i know how frustrated i get when i call and punch two for this and three for that, makes me want to throw my phone away. how hard is it to do when someone is contemplating suicide to have a phone change to where they go straight to a person.

>> we want to make sure we don't overstress the people who are taking the calls, one of whom recently took their own life. as you can imagine that is a very, very stressful job. so that's the reason we're just testing it first in about 20 different facilities this summer and then we'll roll it out in full steam. >> that might be stressful and i'm very sorry for that family, but it's very stressful on the other end. that's why they're making the call. >> i understand that completely. we want to make sure when you do hit that one number or whatever the number will be that in fact it connects you directly to a counselor. because the only thing worse than not having it is doing it then. and i do have to say that the issue of transitioning service members over to v.a. they continue on the drugs that they were getting in the service. we've gone over this with dr. woodson at the defense -- >> i'll ask dr. murphy again today when i see him on the house floor. he's under a different impression. >> i would be happy to follow up with him as well. because if we've missed

something in our surveys of veterans, we want to know about that and fix it. >> miss rice new york. >> thank you mr. chairman. i mean i hate to say maybe the stress for the poor operators comes from the fact they know they're not going to have the support from the v.a. in getting the callers the help they need. i'd like to take a minute to recognize the work that's being done in my home state and visn that covers the bronx and manhattan. they specifically reject the prescribe first, diagnose later treatment philosophy that i think is all too often adopted by the v.a. they have taken again what shouldn't be a revolutionary approach to pain management but it is, they actually believe the first thing you do is diagnose the patient before developing a path of treatment. and instead of prescribing opiates as the default treatment for veterans suffering from pain. i understand doctors when a patient comes and presents with real pain you want to take away

the pain. i get that that's the doctor's first mode of reaction. but this facility's using alternative approaches such as acupuncture and exercises to relieve pain. what we've seen is veterans who undergo these treatments are relieved from pain without the harmful effects of addictive narcotics. the bronx v.a.'s outstanding approach should become the norm alt all v.a. facilities nationwide. my question is to you, dr. clancy. what is the v.a.'s aversion to alternative forms of treatment like meditation, acupuncture and exercise? >> first of all, let me say i completely share your enthusiasm for i believe it's visn 3 is doing. and i have spoken to those folks. it's wonderful. and we have many thousands of veterans actually using alternative forms of therapy. so there is no aversion whatsoever. for veterans who are already

getting opiates, like other americans and some of whom come to us from active duty on those same medications, the path forward is going to be different. it's not starting from day one. so i love what you're doing in new york. and i have spoken with many veterans and have actually begun to think about how we might use their stories to help those who are struggling to get off opioids and try alternatives. many of the veterans who take opioids would like not to but they'd like to kind of wake up and it would all be okay. the journey there is not so easy. >> we have a system here you know works. and i think it was one of my colleagues who told the story about noah. and clearly he was just prescribed drugs. he was not given any follow-up any alternative, any you know, therapy, anything like that. the doctor who's in charge of

visn 3, she stated -- she made a statement that i thought was very accurate. she said that to be on opiates is to be trapped in a cycle of poor function and poor pain control. and that's what we need to get away from. i'm just imploreing you it's not rocket science. they get it right there. just export it throughout the rest of the country. one other thing i wanted to talk about is a bill that is -- that i happen to be a proud co-sponsor of that's put forth by our colleague from wisconsin. it's hr-1628, the veterans pain management improvement act which would establish a pain management board within each visn to better handle treatment plans for patients with complex clinical pain. they would incorporate doctors patients family members into the decision making process for a veteran's course of treatment. has the vha taken the ideas in this bill under advisement?

>> yes. representative kind asked us for comments and i told him he had my personal full throated support, which may be different than the department's support. but i can't think of anyone -- i can't think of any reason we would not support that fully. it was really inspired by that that in updating our clinical practice guideline i wanted to make sure that we had input from veterans and families in doing just that. and i told him that. i think -- because as heartbreaking as some of the experiences at the veterans are are the experience of families who raise their hand and say i'm worried about my son, daughter, spouse, whatever. >> this is not a family issue. it's not even just a service person issue it's an entire family issue. and i don't think we want to be a nation that says to our brave men and women who fight for us and come back so damaged and so injured that we are going to do our best to keep you in a catatonic state for the rest of

your life as a pain management therapy. that just cannot be where we come down on this. i really am begging you to do everything that you can to look at what they're doing in visn 3 and export it throughout the rest of the country. it is not rocket science. thank you very much mr. chairman. >> i think if i was going to sum up this hear inging with a veterans health administration it would simply be that drugs are a shortcut. they're a shortcut to doing the right thing. they are a shortcut to doing the therapies that are really required to treat our veterans both mentally and physically in terms of pain management and in terms of those suffering from depressive disorders. and i think that that's disconcerting. and it is unfair and hurtful to the men and women who've made tremendous sacrifices for this

country in uniform. one question that i have is how many physiologists or rehabilitation physicians does the veterans administration have, dr. clancy? >> i would have to take that for the record, mr. chairman. >> i've got the number of about 40. so, i mean, therein lies part of the problem. those are the people central when it comes to pain management. and yet we're shortchanging that because again the easy thing to do is to drug somebody. drug them not to feel pain, drug them to get them up in the morning, drug them so they can go to sleep at night. and i think when we look at the suicide rates of our veterans that's reflective of what the veterans administration is doing in terms of having drug reliant therapies. again, as a shortcut for doing the right thing. dr. -- okay i got igt rye nowt right

now. are you a veteran yourself? >> i am not. i'm a neuroscientist for training and prior to the v.a. i worked for the pentagon on behavioral health issues. >> well, i want to thank you for your work on behalf of the men and women who serve this country. what is your view about -- i mean do you believe that in fact the over prescription of drugs is a shortcut? >> i think this is a really complex question to ask because if you look at the history of clinician education, medication has always kind of been at the forefront particularly with pain management. as a neuroscientist i can tell you the research is still very young in understanding how pain manifests, how it manifests in individuals, every individual experiences it differently. and because of that we also don't have a lot of great

treatment options. however, having said that there's a lot of research coming out right now that really supports this idea of integrated management of pain using alternative and complimentary medicines. there are some spinal cord stimulation is a new technology out there and iava has a member veteran who was addicted to opioids, chronic pain suffer and was able to get off of those drugs and through spinal cord stimulation and through alternative practices lives a much better life now as a result. but these are all very new technologies. doctors don't know about them they're not using them. so clinician education is so, so critical to redefining how clinicians look at pain management. >> i think you would agree though it shouldn't be -- drugs should not be the first course of action, they should be the

last course of action. >> absolutely. i think drugs are one option of many. and they might be necessary, but they shouldn't be the end all be all. they need to be a part of a comprehensive plan. >> mr. williamson, how would you view in terms of the principle mo dalties of treatment whether for psycho therapy or for pain management from what we're seeing here in terms of testimony it seems to be kind of the first and preferred method of treatment tends to be drug therapy? >> well, i'm not a clinician, i'm really not qualified to answer that. but we are going to be looking at the v.a. operations relative to opioid program later this year. so we'll -- i'll be much more educated after that. >> well that's not comforting.

i wish you were prepared here. mr. cudler, dr. cuddler what do you think? >> i'm really glad you asked that question. >> uh-oh. i'm not -- >> the bottom line -- >> let's not run the clock here. >> bottom line is this whether it's pain or depression it takes an integrated approach just as was said. and different patients need to start in dimptfferent places. there are patients who say i can't talk about this, i won't talk about this and the medication will make that possible in a depressing case. in a pain case there are people who absolutely need not to go where they mean to go into opiates or come off them, but they believe this is all whatever would work for me. so we need to start where the patient is, where the veteran is and use a mixture. with my patients i've always said, look, i have a lot of different tools. talk therapies and medication this is the good and bad about each of them. what makes sense to you? by the way we can do both. and most cases we end up doing

both but often in a stepped way. >> dr. clancy, in an oig report from 2013 it was recommended the v.a. ensure that facilities take action to improve post discharge follow-up for mental health patients particularly those who are identified as high risk for suicide. what is being done to ensure that this process is being followed? >> a few years ago it was put out veterans must be seen in person or at least by phone in the first seven days after leaving a psychiatric hospital. this is based on statistics that show this is the most vulnerable time -- actually the first two weeks most vulnerable time for a suicide attempt especially after treatment of depression or admission of suicide activity. we've been monitoring this. we're not perfect in this. i can't give you the number now i can provide it later. we are now at a point where all

across the nation we're tracking this. we have automatic alerts, we have teams that do this work with people. we've taken it miles further. i wish i can giff you the exact number now. >> you know what's amazing from what we're hearing on the ground and from what we're hearing in this committee it is a world apart. and if for what we're hearing in this committee were true, we wouldn't be here today having this discussion. >> well, mr. chairman, if i might, we're not saying everything is fine. and i acknowledge that at the outset. what i did want to tell you is that we are committed to getting it right. this is tough work. and we have a lot to improve on. and we very much welcome your support and help. >> very hard to get it right if you're not acknowledging the depth of the problem. ranking member custer. >> thank you very much. thank you mr. chair. and thank you to our committee, to our panel for coming forward and all the comments from the committee. i just want to follow up on how -- where we go from here in terms of sharing best practices.

we've now heard dr. mafuci, i really appreciate again your commentary and your expertise in this area. and to the team from the v.a. we've heard about visn 1, i've talked about some examples in white river junction. how do these best practices get shared and the research that's under way how do we move forward with this to make sure that more veterans and their families will be served by this? and in particular the clinician education because i think we've got to change some of the parameters and some of the sort of go-to answers some of the clinicians have? where do we go from here with this and how can the committee best stay on top of that and continue to work with the v.a. to make sure we are serving these veterans all across the country? and i'll bring el paso up.

obviously one of the challenges is that this involves a very case management intensive approach. and you're right the worst case scenario is just to cancel somebody's medication without follow-up. because as we all know that's why people are turning to heroin on the streets. so how do we get this right? and how do we get it right across the board in the v.a.? and what's the follow up? >> so what i might suggest is you invite us back for a briefing. and we would give you a follow up. you pick the frequency, a couple of months, three months. i did want to didn't get a chance to say before to congressman o' roerk that i do have people monitoring for this abrupt discontinuation of medications. and i'm worried about people changing providers. if we're sending out a message of -- that is absolutely not acceptable. and that is no definition of

success here. so i wanted to be very, very clear on this point. some of these challenges are areas where u.s. medicine is struggling in general. chronic pain in particular. and for mental health we've had to blaze some trails. there is no clear cut blood test that one can do like a blood sugar or blood pressure or whatever to double check on the diagnosis or assessment. it depends a lot on the use of standardized questions. in some cases this we are working very hard on right now. we are changing how we schedule appointments and simplifying it so that it is much easier to get veterans in for that follow-up assessment. but you should hold us accountable. and i would look forward to showing you where we've been and where we're going. in no way do i not want to say we have problems to solve. we do. we own them. and we're stepping up to them and look forward to your support.

where you can help is helping to work with us on reducing stigma. i mean this remains a huge huge problem. and also i think sending a sense that you are supporting the efforts to get better care for clinicians -- i mean for veterans, one of our challenges is that a lot of young people are not choosing to go into these fields. and that is the ultimate recruitment problem. is that if they're not -- we have terrific incentives thanks to the clay hunt act in terms of debt reduction thanks to the veterans choice act and so forth. and those are great tools. but someone has to actually make the decision to go down that path. >> thank you very much. >> thank you ranking member custer. dr. clancy i want to stress again the need for you to turn over documents requested by congress and your failure to do so makes our job very difficult. mr. o' roerke texas. >> dr. clancy, thank you for addressing the el paso issue and the larger issue within the v.a. to make sure you're monitoring

those veterans who are going to be coming off opiates. again, the feedback stands because i'm hearing directly from veterans that that's apparently not happening in el paso. and i think we both must conclude for every veteran who takes the time to come down to a town hall meeting despite whatever they're going through to tell their congressman that they're having this problem in front of 200 other veterans and is admitting they are receiving opiates and now are doing without that there are many others that that person represents who's just given up and says why should i bother. we've got a problem in el paso, perhaps nationally in terms of ramping people down or finding an alternative therapy to pair with their cessation of opiates. i would like you to respond to something we've heard the secretary say and read about in the press that he's got 28,000 positions to fill in the vha. it's something under secretary sloan gibson reiterated four

weeks ago in a hearing here. and when the ranking member and i and some other members of congress and senate were in your command and control center on the eighth floor a few weeks back, we heard that number was not 28,000, it was 50,000 positions to be filled at the vha. could you confirm that number? and could you tell me how you're prioritizing those hires? obviously i'm getting to if we have a crisis in mental health and we're treating all hires the same, we have a problem. if you're prioritizing mental health, here's a chance to tell this committee and the public at large. >> so i did not hear the number 50,000. so i'm going to have to check on that and get back to you directly, i think would probably be the easiest way to say that. with 300,000 employees sorting out normal turnover which is somewhere around 7% or 8% across all disciplines from, you know, areas where we're trying to fill is a little bit challenging. we have identified five areas that are the highest priority.

physicians, nurses mental health professionals, physician assistants and i'm blocking on the fifth one, but mental health professionals is clearly on that list. and in fact we have been way ahead of the curve compared to the rest of the country in terms of hiring mental health professionals from multiple disciplines. they work as teams. we've got them in primary care as well as working in mental health clinics. and so forth trying to do everything to make it almost impossible to seek assistance and get it. if you actually do get care from one of our facilities we have a long way to go. i was simply commenting on the overall pipeline problem. the other area where we are beginning where we do a lot now but i think we could do much more is in tele mental health. so big spring texas, which is not that far from you in texas terms, they tried very very hard to recruit psychiatrists

and had a problem and recreptently recruited one from wisconsin who is not moving. that individual is providing all virtual care. so we're working with them to figure out how to make that business process work as smoothly as possible. many veterans prefer that. they find it a bit less confrontational. >> and i appreciate that. and as i yield my time i'll just conclude you have asked for an additional briefing or hearing to follow up. i hope that when you come back you come back with a plan for el paso or any underserved community. and you say, you know what, we're paying psychiatrists and psychologists and therapists and social workers and counselors x, i'm going to pay them x plus 20% to get them to el paso or that underserved community and then to retain them once they are there because you have a huge problem with retention as well. and that's a suggestion. or some other plan that really treats this as the crisis that it is versus the you know, we're making this a priority

we're going to do this that and the other. i need dollars on the table specific offers, deals that will get that psychiatrist or mental health professional there in the first place and keep them thereafter. i hope to hear specifics next time. appreciate your answers to our questions today and mr. chair and ranking member thank you for holding this hearing. really important. thanks. >> ranking member custer. >> thank you, mr. chair. just briefly i want to follow up for my colleague that we will do a follow-up hearing not only on the types of pain management and techniques that do seem to be working, but in particular i'd like to include tele mental health and maybe we could even do a short demonstration. but just for you that that might be an alternative in this crisis situation that you have. i want to make sure we stay on top of this so that our colleague is getting served.

>> thank you ranking member custer. our thanks to the witnesses. you are now excused. today we have had a chance to hear about problems that exist within the department of veterans affairs with regard to prescription management and veteran suicides. this hearing was necessary to accomplish a number of items. to demonstrate the lack of care and follow-up for veterans prescribing medications for mental disorders to demonstrate the inaccuracies and discrepancies in the data collected by v.a. regarding veteran suicides and those diagnosed with mental disorders and, three to allow v.a. to inform this subcommittee what it plans to do to improve these glaring deficiencies in order to ensure veterans are receiving the care they deserve. i ask unanimous consent that all members have five legislative days to advise and extend their remarks that include extraneous

materials. without objection so ordered i would like to once again thank all of our witnesses and audience members for joining in today's conversation. with that this hearing is adjourned.

it's a look at the u.s. supreme court, its future and a discussion on possible changes to the bench. it's hosted by the american constitution society. you can see it live starting at 4:00 p.m. eastern on our companion network cspan2. the u.s. house has just finished legislative business for the day and for the week but not before debating and voting trade legislation. there are three parts of the legislation members considered today. the trade adjustment assistance program was defeated 302-126 this even after president obama traveled to capitol hill to personally rally support for that measure. the other two legs of the legislation were approved. the trade enforcement and customs bill passed 240-190. and the trade promotion and authority measure approved by a vote of 219-211. shortly after the taa bill was defeated the chair called for a revote on the measure. that's set to happen next tuesday. the hill is reporting only 40 democrats backed taa while 144 voted against it. now, the gop side 158

republicans voted no while 86 republicans voted yes. the vote against taa is a humiliating defeat for the president who had spent weeks lobbying house democrats to support his trade agenda in the face of overwhelming opposition from liberal groups and organized labor under the procedure established for considering the trade package taa had been packaged with fast track authority. and a vote against either doomed the total package. so again the house will be voting -- revoting the taa portion of trade legislation. and that will happen tuesday. on cspan's road to the white house, more announce candidacy for president. former secretary of state hillary clinton will kick off her campaign with a speech that will outline her agenda as a candidate live from the fdr for freedoms park in new york city at 11:00 a.m. eastern. on monday afternoon at 3:00 on cspan3 we're live at miami-dade

college where former florida governor jeb bush will officially announce his candidacy. and on tuesday on cspan.org businessman donald trump announces whether or not he'll make a bid for the presidency at new york's trump towers at 11:00 a.m. eastern. and you can watch all of these events online any time at cspan.org. cspan's road to the white house 2016. here are some of our featured programs this weekend on the cspan networks. on book tv on cspan2 saturday night at 10:00 p.m. eastern fox news contributor kirsten powers says although they were once its champions, liberals are now against tolerance and free speech. on sunday night at 11:00, former deputy director of the cia michael morell on the successes and fill yurs of the agency's war on terror. and on american history tv on cspan3 saturday night at 9:15

author kevin mcmahon on the strategy behind president nixon's supreme court appointments and the impact he had on the court and american politics. and sunday night at 6:00 on american artifacts we visit the national museum of american history. to view the newly restored murals from alabama's talladega college. and the founding of talladega college. get our complete schedule at cspan.org. yesterday the house energy and commerce committee held a hearing on a bill that would reauthorize through 2041 the victims for september 11 2011 terror attacks and eliminate caps to payments of victims. fund. among them two police officers resulting with illnesses from the trade center site in 2001.amilies. pennsylvania republican chairs

the committee.wo hours gene green of texas is ranking democrat. this is two hours 20 minutes. >> the hearing is about two hours. >> ladies and gentlemen, if you will take your seats we will begin. like to ask all of our guests today to please take their seats.aring wi subcommittee will come to order. the chair will recognize himself for an opening statement. today's health subcommittee hearing will examine the world trade center wtc health program that was created in the james 9/11 health and compensation act enacted in 2011. the act allocated $4.2 billion to create the health program which provides monitoring, testing and treatmentr ot for people

who worked in response and recovery operations as well as for other survivors of the 9/11 attacks. the authorization of the health program ends on september 30 2015. another part of the law the september 11 victim compensation fund is under the jurisdiction of the judiciary committee.. it will continue to accept applications until october 3rd 2016, over a year after the zed me health program authorization ends. the wtc health program funds ditions. networks of specialized medical programs. and these programs are designed to monitor and treat those with 9/11-related conditions. for responders the world trade center medical monitoring and treatment program for survivors the nyc health and hospitals

corporation wtc environmental health center for nyfd personnel the fire department of new york responder health program the national program the wtc health program has a nationwide network of clinics with providers across the country for responders and health survivors who live outside the pr new york city metropolitan area. these programs provide free medical services by health care professionals who specialize in and 9/11-related conditions. our colleagues representatives carolyn maloney, peter king and jarel nadler have jointly rizati introduced legislation hr-1786, the james droga 9/11 health and compensation reauthorization act which reauthorizes the act.

this legislation has begun an timely important conversation that willfset r lead to a timely and fully ut how t offset reauthorization of the pr health program. today's hearing will allow us toar from learn more about how the programinstitut is working and whether changes are needed. we will hear from the director of the national institute for occupational safety and health who is responsible for s administering the program as al well as from the medical dire director of the robert wood johnson medical school and two respo first respondersnd who are m. enrolled in the world trade center health program. i look forward to the testimony today. and i would like to yield the balance of my time to the gentleman from new jersey mr representative . lance. >> thank you, mr. chairman.lcome it is my honor to welcome david ew jerse howly, a constituent of mine in mmitte new jersey's seventh vid, t congressional district to the committee this morning.ocate fo david, thank you for making the th u

trip from new jersey to share your story and advocate for those who cannot be with us today. we look forward to your testimony. i first met david several months offi ago when he came into my office in westfield new jersey to discuss the bill before us today. and this reauthorization act is critically important. david has been a tremendous advocate for the legislation e, as because as he will detail in hisfirsth testimony he knows firsthand the importance of these programs forhis fe him and his fellow first resp responders and survivors. david joined the new york police department in 1985 and served in various departments over his 20-year tenure.ement he is a third generation law enforcement official following the tradition of his father and tember grandfather he was serving in the nypd operations division on september 11th 2001.d here and spent the next several months in the dust and rubble of a co

ground zero. i'm proud to have david here with us today. and i'm proud to be a ghost n a sponsor of this critical bifa legislation. it is my hope,shioon mr. chairman that we can work in a bipartisan fashion to move this legislation forward quickly.e hous and i look forward to voting forchairman it not only here and in full tts: t committee but on the floor in lema the house ofn. representatives.e mr. chairman, i yield back the balance of my time. >> chairman thanks the gentleman. and i would also note that some ve of ourth colleagues from the new we w york delegation who are not on the committee but very concerned of this issue and sponsors of legislation have requested to sit on the dice and we welcome them this morning. at this point the chair recognized ranking member of the subcommittee mr. green five minutes for opening statement. >> thank you mr. chairman for ay of holding an important hearing on this program. i thank theming witnesses today for the first responders for bravery of service both on and after the worl tragic day of 9/11. pr thank you for coming today to et the share your personal experiences

with the committee and shed light on the significance of the world trade center health programs. no one here can forget the horrific attacks perpetrated on at the our countr fy in the world trade fter t center in new york pentagon washington and at the field in ters, em shanksville, pennsylvania. during and after thewo attacks and t tens of thousands of first spontders including police, ult of firefighters, emergency medical respon workers jumped into action to assist in rescue recovery and clean up. particulate matter and asbestos.ng this exposure caused many of pirato them to develop a spectrum of the debilitating diseases progr includinamg respiratory disorders.ncti a report on the 9/11 health program suggested that firefighters who responded to the attack "experience a decline in lung function equivalent to trauma that of which produced by 12 years of aging." in addition to the physical

ailments these heroes now have many have suffered post-traumatic stress syndrome ptsd, depression anxiety stemming from psychological trauma they experienced in the aftermath of the attack. nearly one decade after the september 11 terrorist attacks 9/11 health and compensation actlth prog was signed into law.th and the act created the world trade center health program within the department of health and human tion, mo services. the program provided evaluation monitoring and medical necessary, physical and mental e cent health treatments to first responders and certified eligible survivors of the world blishe trade centerd related illnesses. it's also established a network of clinical centers of onders excellence and data centers. for these responders and survivors who reside outside a onal new york area, the act created a national network of health providers who provide the same types of services for world se trade center related rvillnesses. while cancer was not originally listed among the statutory wtc related health conditions, 60 types of cancer were added.tion by

and in 2012 at their petition by memb members of congress. as of may 5th of this year 3,700nsation members of the health program nsatio had cancer. as a the act also established victimsnding compensation fund that provide compensation for harm suffered as a result of debris removal. that action by congress funding for the current health program n will will terminate on september of ram and 2016. the 9/11 health compensation andprogra reauthorization act willm, reauthorize the critical world trade center health program and the victims compensation fund. note as required under the current ur program new york city will continue to paidye 10% of the total cost. it's important to note the wtc health program serves our heroesl area nationwide and extends far beyond the new york area. both these and currently enrolled and future enroll leeees live in all areas of the . country. as of august 2014, 23 of the 405

districts were home to at least one 9/11 survivor.d their own well being on behalf s with of the country in the wake of terrible attacks./11. we have a duty to serve our heroes with complex health care from 9/11.ompens it'sat critically important we to th support the 9/11an health compensation reauthorization act.d al i'd like to thank the firstso responders for their gallant and self-service. also like to thank the doctors and administrators of the pr program for theiogr efforts to n our treat the complex illnesses inflicted on our survivors. >> id like to yield to --

>> allowing me to sit in this ant very importantto hearing. also i want to thank our panelists. it's good that you've shared your experiences and remind america of the importance of america renewing this very important program. this is a t great first step toward reauthorization in a time when the american people are step skeptical about the work of congress. i'm happy that this committee's working in a bipartisan fashion to move expeditiously to renew this important health -- these important health programs. congress must move forward to le, the ensure first responders and survivors of the 9/11 terrorist an fas attacks onhi the world trade center the pentagon and shanksville, pennsylvania continue to receive the care cent they deserve and so sorely need. to with that, mr. chairman mr. ranking member, i yield back theg memb time. >> mr. chairman, i the yield back.

>> chair thanks the gentlemen. now recognize the chair of the . pitt full committee gentleman mr. upton. five minutes for opening ton, fiv statement. >> thank you mr. chairman.n: tha now, back on september 11, '01, rld as the world as w we knew it was turned upside down by the 000 unthinkable acts of terrorism which took the lives of nearly 3,000 individuals in new york, pennsylvania and virginia. left a mark on every american. every one of us was impacted. from the smoldering ruins of the93, th twin towers in the pentagon to the wreckage of united airlines at day flight 93 the painful images nute and, heartbreaking personal stories of that day every minute will not be forgotten. we are remembering the thousands of innocents, lives lost and the loved ones left behind.own by t many of us met with those. we also saw countless acts of leadership shown by the american in the hours of up and downpandemonium.

then for me as chair of the telco subcommittee and on this committee i led a bipartisan delegation both to new york and to the 24/7. first responders spent hours, days, in the air that was thick with dust and smoke digging through the rubble and searching for survivors. when i visited ground zero, new york's typest were still working around the clock in impossible conditions for the recovery efforts and their selfless work took a toll on their health, we know that. federal government provided aid and there was help provided through a discretionary grant program as we should.

2011, the compensation was invented for the victim compensation fund. carolyn maloney and peter king and they introduced now hr 1786 the james ed rogua compensation reauthorization act that would reauthorize both of these program. at today's hearing we'll focus on the world trade center health program as it is the program that falls in this committee's jurisdiction. the authorization for the world war trade center program ends at the end of september, just a few months from now. while the victims compensation fund remains open for applicants until october of 2016. the wtc program helps met -- networks and treat thoses with 9/11 related conditions. the members enrolled in the

programs are not just from the greater new york area. in 2014 there were 71,942 individuals in the world trade center program from 429 of the 453 congressional districts. in fact there are 75 michigan residents enrolled in the wtc health program. today's hearing is yes an important opportunity to learn more about how the world trade center program has operated since the authorization in 2010 and what is needed for it to successfully operate and need the members of the future. i want to thank the witnesses for taking the time to be here and especially thank officer howelly and detective burnett for thur service and sharing the personal stories and struggles with this sub-committee. the bill needs to be passed. and i will look -- look to consider every effort to make sure that we get it to the house floor prior to its -- the end of

september so we'll have an opportunity to make sure that these pictures are taken care of and i yield back the balance of my time. >> thank you. and the chair is pleased to raise the ranking member of the full committee gentleman who has many constituents impacted by this issue, mr. pal own, five minutes for opening statement change chairman pitts and chairman upton. and i particularly want to thank chairman upton for the comments he just made highlighting how we need to perceive this as a national program and impacting people who came and helped out on 9/11 and the aftermath from all parts of the country. my staff probably is tired of my telling this story but i remember within a few days after the attack, we went up to new york city with president bush and i was standing next to this

big yellow fire engine that said hialeah, florida and i said what is this truck doing from hialeah because it was only oun were two days after and i wondered how it got there so quickly and talked to the firemen from hialeah florida and as soon as this happened we got in our fire truck and we drove up from hialeah, florida and we drove up and it struck me how so many people responded from all over the country and so many people were injured because of the fact that they -- that they were there for a few days or a few weeks or a few months even. so this bill is a critical first step at ensuring that the 9/11 health program is extended as soon as possible. as you both already know, this is one of my top priorities for 2015 and i'm grateful for chairman pitts and upton for your willingness to work with us to make sure of the timely passage of this bill. i have to recognize the first

responder who we are here and we owe a depth of gratitude and i want to recognize the doctor who runs the new jersey hospital and thank you for lending your expertise here today and let me mention the new yorkers representative maloney and the sponsor of the bill and representative nadler who has been here from the beginning and representative king who joined the committee today and our representatives yvette clark and eliot engel and my colleague from new york and you have fought to make sure our first responders and survivors are taken care of and i fight alongside you. and we now know that thousands of first responders are suffering debilitating illnesses from the aftermath. and many have lost their lives

to wtc related health conditions and additionally active firefighters and ems personnel and law enforcement were forced to retire due to wtc health related conditions. we understanding how the tons of dust and glass and toxins released into the air that includes mental health conditions and cancer. and that is why the james 911 health and compensation act signed in law is helpful and provides medical temperature to those suffering from world war trade center related diseaseez. but what is important to note is this program isn't there to provide health insurance these are health related conditions that require special expertise to diagnose and treat and that is why the program includes a network of clinics and providers

specifically trained to treat these diseases and ensures that providers and survivors bear no out of pocket costs akoesh ated -- associated with these health conditions. the program provided monitoring and treatment services for more than 71,000 responders and survivors. they reside in every state and in 429 of the 435 congressional districts. if some of you don't know, the law is named for james zag rogua who responded on 9/11 and spend hundred of hours digging through debris who died in 2006 who died of respiratory failure after exposure to toxic dust at the world trade center site. thousands of these people came to our aid and helped others at ground zero and we hope to extend the health program without delay. i just -- i only have 30 seconds

left for mr. engle i apologize but i yield to him. >> thank you, gentlemen for yielding and let me agree with everything you said in the after faj of september 11th it is estimated that up to 400,000 americans were exposed to copious ams of smoke and toxic substances such as asbestos and as a result many of our heroes suffer from debilitating conditions acute respiratory disorders, cancer and post tram at is stress disorder and it is heartbreaking that many must carry the burden of these ailments and the very least we can do to help them and so i was proud to be an original co-sponsor of the health and compensation act and the co-sponsor of the reauthorization we are discussing today. a failure on congress's part to pass this vile at legislation would constitute an agreejous

response to those who gave so many to those americans and i say americans because this spabs the entire united states. the 429 of the 435 congressional districts benefit from these programs. so this is an issue of national performance. so the first responders who rely on the world trade center health program did not hesitate to risk their lives for fellow americans on 9/11 and we should not hesitate to care for them now and it is of critical importance that we permanently authorize the health and compensation act. thank you mr. pal own and mr. chairman. >> chairs thank you, gentlemen. and as usual, all members opening statements will be made part of the record. that concludes our time for opening statement. i have a unanimous consent request. i would like to submit the following documents for the record. statements from representative peter king new york second

district. from the international association of firefighters. from the sergeants benevolent association, from the national association of police organizations, and an article from the new york city patrolman's benevolent association featuring mr. david hally. without objection, so ordered. we have so panels today. on the first panel we have dr. john howard director national institute for occupational safety and health. thank you very much for coming today dr. howard. your written statement will be made part of the record. you'll be recognized for five minutes to make your opening statement at this time you're recognized. welcome. >> thank you mr. chairman and distinguish members of the economy. my name is john howard and i'm the administrator of the world trade center health program. i'm very pleased to appear before you today to discuss the program an