with public and private science partners to build the basic science, the data, and the population health expertise. we have learned a lot, made significant gains, and seen the successes of treating mental health problems. but we have so much to do to dispel the stigma of mental health issues. it wasn't that long ago that cancer inspired that whispering and people didn't talk about it out loud. because of fears and misinformation. 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. and in the mean time we're focusing on creating an atmosphere of trust and privacy. i want to just close by saying that we're committed to improving our existing programs. taking every available action to create new opportunities. and most importantly, improving the quality of life for veterans.

we're compassionately committed to serve those who have served. we're proud to have this honor and privilege, and 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. williamson you are now recognized for five minutes. >> good morning, mr. chairman. and ranking member kuster. i am pleased to be here to discuss our november 2014 report on vha's effort to monitor major depressive disorder referred to as mdd, who were prescribed one or more antidepressants. 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 of vha's suicide prevention program. specifically i will discuss the incidence of mdd among veterans treated by v.a.

the extent that v.a. and clinicians describe antidepressants to veterans with mdd, and monitor antidepressant use and data v.a. mc's are collecting on veteran suicides. vha data showed that about 10% of the veterans receiving v.a. health care were diagnosed with mdd and 94% of those veterans with mdd were prescribed one or more antidepressants. however the estimate of veterans with mdd may be low because in reviewing a sample of medical records from selected vamcs we found they did not always correctly report and record confirmed mdd diagnoses among veterans. at six vamcs we reviewed a sample of veterans with mdd that were prescribed one or more antidepressants and found that they did not always receive

recommended care for three important recommendations in the clinical practice guidelines referred to as cpg, and vha has established to guide its clinicians in treating mdd. for example, although the cpg recommends a veterans depressive systems be assessed using a standardized assessment tool at four to six weeks after init o sample, the v.a. clinicians did not use while not mandatory cpg recommendations are based on evidence based data from clinical trials research, and other proven and reliable sources and are mens to enhance outcomes for veterans are mdd. moreover vha does not have a process at any level to

systematically monitor the extent that vamc clinicians deviate from cpg recommendations. with little, if any, visibility over whether the care provided is consistent with the cpg, the v.a. is unable to ensure that deviations from recommended care are identified and evaluated and whether appropriate action are taken to mitigate potential significant risk to veterans. finally we found that demographic and clinical data in v.a.'s -- vamcs collect on veteran suicide to better inform vha's suicide prevention program were often incomplete and inaccurate. for example, as part of v.a.'s behavioral health autopsy program which i'll refer to as vhap, vamcs collect date of death, number of mental health visits and last v.a. contact. we examine 63 bhapp reports from

five vamcs and found that about two thirds of them contained inaccurate and incomplete information. moreover, this situation is further exacerbated because bhap reports prepared by vamc rst generally not reviewed at any level within vha or accuracy completeness or consistency. lack of accurate and complete bhap 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. the v.a. made good progress in addressing the six recommendations to improve weaknesses we noted in our report. in the six months since the report was issued one recommendation has been fully implemented and several others are very close to being fully implemented. more globally, this work illustrates 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 v.a. instills a culture throughout the organization that holds its staff and managers truly accountable for effectively performing their responsibilities appropriately overseeing 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 right? >> yes you did. >> thank you. you're now recognized for five minutes. >> chairman kofman ranking member kuster and distinguished members of the subcommittee on

behalf of iraq and afghanistan veterans of america, thank you for the opportunity to share our views and recommendations on prescription management and the potential risk of veteran suicide. in 2014 iava launched its campaign to combat suicide. in february with your help we celebrated the signing of the clay hunt save act into law. this was the first step stop a long road to address the challenges of combatting suicide among our service members and vet vans. the issue we are here to talk about is complex because it is two topics. providing care for veterans seeking relief from chronic pain, mental injuries and other conditions and recognizing the potential for misuse and abuse of the powerful drugs. and while these drugs are extremely powerful, they can also be extremely effective for a veteran who has not found relief elsewhere. a 2011 report estimates that chronic pain affects approximately 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 members and veterans. over 60% of the iraq and afghanistan veterans seeking v.a. medical care seek care for muscular skeletal elements. this is the most common category for disability. 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 antidepressant 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 lifelong impacts of nerve and skeletal damage. treatment of pain in these instances can be even more complex, because cooccurrence with other conditions, like

depression anxiety, ptsd or tbi, my limit treatment options. for clinicians, assessing pain and devising a 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 feel underprepared to treat the patients due to lack of training this includes v.a. providers surveyed in 2013. added to the challenge are studied showing that untreated pain can actually put an individual at higher risk for suicide. yet we know that prescription medications can result in strong addictions and provide a means for suicide attempts. the v.a. reports that over half of all nonfatal suicide events 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 v.a. 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 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 v.a.'s clinical practice guidelines reduced this significantly. this shows the critical need not only for these guidelines, but full implementation of those guidelines. v.a.'s 2009 directive on pain management which outlines a stepped care approach to pain

expired in october of 2014. while it expired and the policy remains active iava has encouraged updating this important policy has not been prioritized. we urge the v.a. to prioritize this and fully implement it at all v.a. facilities. iava would also like to emphasize the importance of minimizing the risk of overdose and overmedication through formulary takeback programs and prescription drug monitoring programs. last year an important change to dea regulation expanded authorization for drug drop-off sides. this change gave v.a. the ability to stand up drug takeback programs in their hospitals, and this is critical to limiting the possibility of misuse and abuse of powerful prescription drugs. yet no action has been taken. while the v.a. is working to fully implement its participation in state prescription drug monitoring programs, full implementation remains to be seen, and we urge the v.a. to prioritize this as

well. too often we hear the stories of veterans who are prescribed what seems like an assortment of anti-psychotic drugs, and/or opioids with very little oversight or follow-up. and yet we also hear stories of veterans with enormous pain and doctors who won't consider their requests for stronger medication to manage this pain. these are tough challenges. and iava remains committed to working with the v.a., and congress, to address them. again, thank you for the opportunity to offer our views on this important topic, we look forward to continuing to work 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. who is next? okay.

our thanks to the witnesses. dr. clancy according to a j.a.o. report, v.a. deviated from recommending guidelines in most all of the 30 veterans cases reviewed by not assessing antidepressant treatment properly. in your opinion, is policy simply ignored? or is there just a lack of oversight by leadership? >> first, i want to say we regard the gao recommendations, feedback as very important a gift, if you will, to help us get better. i am 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 were having access

problems and it was hard to get people back in or whether we weren't just on the ball. but that is a very important feature. >> dr. clancy in our case reviews we found veterans who died of drug toxicity who reported hallucinations and subsequently died by suicide and reported homicidal thoughts. are these the improved outcomes you are referring to? >> no, they are not. >> dr. clancy in response to the gao report, v.a. noted that 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 both by the gao report and other feedback by dr. kudler and a couple of the other national mental health

leaders in our system, to try to figure out who are the veterans who 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. who do you think that report is going to be done? >> i would have to double-check on when we committed to having the recommendations done. >> the v.a. stated it would examine associations between treatment practices and indicators of recovery or adverse outcomes for veterans being treated with antidepressants. the target date of completion was march 2015. has this been completed? >> i believe it has. i would have to double check my notes. >> can you get a copy of it? >> absolutely. i will submit that. >> and 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 whatsoever 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 about two years ago. and 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 and frankly some iteration to make sure that we were getting it right. dr. kudler do you want to add to that? >> at the time the gao was conducting the study the behavioral health autopsy program was just being launched. the forms were new.

they were in need of refinement. they've been continuously refined as has the training of the suicide prevention coordinators, 300 of them across the country at over 150 facilities, who fill them out. there were questions about what data goes where and how do you count this or where do you go with that? that's now been addressed through training and upgrading of our manuals. we're now reviewing all of these centrally at national level. we've also created software that cross walks these to another suicide prevention tracking system the span system so that we can make sure we're accurately looking at these for multiple perspective. this is continuously improving and progressed a great deal since the original report and we will continue to work on it. >> dr. clancy this subcommittee has requested the behavioral health autopsies for numerous veterans who have died by suicide, and in all cases except one, calitia holmes v.a. 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 ms. holmes released to the committee? >> i would have to take that question for the record. i would say in general the behavior health autopsy reports, i think the ranking member kuster described this more clearly than i could, this is part of 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. >> i think we're very concerned about the fate of our veterans. and this subcommittee and the committee as a whole has a responsibility -- oversight responsibility for your operation and we can't do that oversight operation, in doing -- making policy that is 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 very much, mr. chair. and thank you to all of our witnesses, and particularly dr. maffucci i really appreciate you being here and sharing with us the recent experience of the veterans returning from as you mentioned 14 years of conflict. and that the injuries are much more complex. i mean the good news is people are surviving the difficulty is that as you say they have chronic lifelong issues. i want to focus in on how we move forward. i share 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 am very interested, as i mentioned, i had a meeting with the team up at white river junction facility and there's some cutting-edge research, and i'll talk to the chair about perhaps bringing in some witnesses to share that but in

particular the opioid safety initiative, and a couple of 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 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. i would like to find out what is 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, and particularly emphasizing patient education close monitoring. they talked about actual drug tersing, because in our area,

the selling these opioids on the market, what happens sometimes is people will not use the medication themself, and they can determine that through frequent drug testing which as you can imagine is not popular with the patients. but, unnecessary. 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 widely has it been? is it in use? and what can we do to help move that forward? >> those are all terrific questions. i will start and turn to mr. valintino. like the case with depression, we do have a clinical practice guideline that we developed with our colleagues from the department of defense on the management of chronic pain that was published in 2010. it will, as of september of this year, it will be updated which is about the frequency you'd want to update these guidelines. and we will be having input from veterans, and family members.

the guideline does include urine drug testing periodically, and we have, as i mentioned, probably too quickly in my opening statement, made in a series of steps that i would -- the umbrella of which i would refer to as the opioid safety initiative made data about prescribing patterns at the network level, the facility level, and most recently at the individual clinician level available and visible. so that clinicians can actually see what has this patient been on over time? what other drugs are they on? and so forth? getting to the root of the problem, i think is incredibly important. i would be happy to submit for the record to brief anyone any time about some of the exciting research we have in process. i think it is very important. i think there is a lot we need to learn in two areas. one is what are the predictors of veterans who, 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 who 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 a lot more to learn. mike, do you want to add to that? >> yes, thank you. so the opioid safety program is just shy of two years old. and we have had to build it from the ground up and as dr. clancy mentioned it's been very iterative so initially we focused on this data collection, aggregation, to identify outlyer problems. we focused on those for corrective action plans. the next iteration was to drill

down to v.a. 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 poised right now at this moment, and we built the tools, and we're validating them for accuracy to drill down to the individual provider and patient level. this is very complex as you 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 name -- 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 ben zoe die as pins together which is a known risk. 75,000 more patients have had a urine drug screen who are on long-term opioids as you mention because that is definitely an opportunity for diversion, and we want to make sure that 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 common denominator. morphine equivalent daily doses. and we now have -- >> 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. so thank you so much. we can take that on the record. >> mr. ran born colorado. 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 would like to tell you the story of noah. a former marine who served in iraq with honor 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 work on a business degree at the university of colorado at 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 could serve this great nation. unfortunately his parents are appalled by the care that their son didn't receive from the v.a. they believe their son would 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 v.a. clinic, where medical notes from his visits state that he had suicidal thoughts or suicidal identifiation, specifically. noah was prescribed a psycho troepic drug and sent on his way. we don't know at the 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 counselling. and there is no follow-up from the v.a. he went missing the evening of may 4th and 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 been given documented -- who'd been

documented with having suicidal thoughts or ideation not referred to suicide prevention? why wasn't there follow-up from the v.a.? and why wasn't he offered counselling? >> i will look into this personally, mr. congressman. that's heartbreaking. i can't even imagine -- i can 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? >> as a psychiatrist as somebody

who's 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 i want to make sure this family's been reached out to directly and that we have a chance to collect this information. as i say we've created a system, a system can be cold and inhuman, but we need to sit down and understand everything that happened from their point of view, questions that 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. 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 anecdotal information i was hearing from veterans we are seeing everyone within 14 days. as you know we did our own survey in el paso, found that more than one-third of veterans could not get a health care appointment, not in 14 days not a month, just 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 and 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 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 -- >> -- the end result. we've seen nothing. we can't even have -- >> i'm sorry, sir. you're out of order. you're out of order. thank you. dr. benishek, michigan? >> thank you, mr. chairman. i want to associate myself with

the comments of mr. o'rourke for one thing, and that is i've seen this as well, that 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 something dr. kudler said, and then 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? mr. williamson? you're contradicting what dr. kudler 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 said the gao said 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 dr. benishek. mr. walz, 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, parity 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 2009-053. 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 wanted to get 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 policies -- >> 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 pain management. the things that you're hearing from where benishek are in the s. -- and if we could 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 both here and out in our districts is reduced. we'll look forward to the follow-up. and i yield back.

>> thank you mr. walz. dr. roe, 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 we're going to draw conclusions based on this many patients did this and this many patients did that. the outcome -- i've been involved in the clinical studies for years. when you put b.s. in you get b.s. out. and so that's sort of what looks like has happened right here. and that's being a little crude, but that's absolutely what it looks like you've done. and mr. william an ses pointed out, you've got half of the vhap 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 data 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. so they then stop all of what he's taken forever to get the patient stable on and 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. benishek want to associate myself. i think the outburst that you heard was just frustration from probably a veteran who's either tried to get in or couldn't. and mr. o'rourke 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? apparently nothing. so i know there are then 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. on v.a.'s part. i think it's just all the times, 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 idealistic world i would think you would. i mean 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. roe, 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. kudler who is working with others to try yes, somewhat -- people who don't do their jobs should be held accountable if, in fact, we have given them the resources and the capacity to do that job. you can't hold somebody accountable if there are no appointments and no ability to see a patient -- >> but mr. o'rourke 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 the positions filled? >> we have tried a lot of varieties of ways to recruit people. mr. o'rourke came in with a group of partners from the community, and i think i'm very much looking forward, and he has my full commitment to looking at that proposal to see how we can work more effectively -- >> the v.a. is not making it hard for those veterans to leave

that system gand to these private practitioners with the veterans choice card or non-v.a. care because we find that sometimes. it's just so hard with all the rules to get out. it takes forever for someone to get an appointment. one last thing. i know my time's expired but how long does it take to change a phone number? why does it take six months to have someone when you call. i know how frustrated when i call and punch 2 for this and 3 for that makes me want to throw my phone away. how hard is it to do when someone contemplating suicide to have a phone changed to where they go straight to a person? >> we want to make shurs that 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 this fall. >> 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. so i'll have him check. >> 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 in a 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 management, but it is. they believe the first thing they do is diagnose the patient before developing a path of treatment. instead of prescribing opiates -- 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 is using alternative approaches such as acupuncture and exercises to relieve pain. veterans who undergo these treatments receive relief from train. the bronx va's approach to treatment should become the norm for all facilities nationwide.

my question is to you, dr. clancy, what's the va's version to alternative forms of treatment like meditation, acupuncture and exercise? >> i share your enthusiasm for what -- i believe it's vision three is doing. i have spoken to those folks. it's wonderful. we have many thousands of veterans, actually using alternative forms of therapy. 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. i have spoken with many veterans and have actually begun to think how we might use their stories to help those who are struggling to get offopeioids and try alternatives. many veterans would like not to

take opiates. they would like to wake up and it would be okay. the journey there is not so easy. >> it doesn't have a system here that you know works. 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 is in charge of visn 3 she stated -- she made the statement i thought was very accurate. she said it should be on opiates is to be trapped in a cycle of poor function and poor pain control. we need to again away from that. i am imploring 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 -- i happen to be a proud co-sponsor of that's put forth by our

colleague, ron kind from wisconsin. hr-1628. the veteran's pain management improvement act which would establish a pain management board within eachkish visn. they would incorporate family members veterans into the decision making process. has the vha taken the idea in this bill under advisement? >> yes, representative kind asked us for comments. i told him he had my personal support, which may be different than the department's support. but i can't think of anyone who -- i can't think of any reason we would not support that fully. it was really inspired that by updating our clinical practice guideline i wanted to make sure we had input from veterans and families in doing just that. i told him that. i think that's -- because as heartbreaking as some of the

experiences of the veterans are, are the experiences of families who raised their hands and said i'm worried about my son, daughter or spouse, whatever. and didn't -- >> this isn't a family issue, or a service person issue. it's an entire family issue. we don't want to be a nation that says to our men and women who fight for us and come back so damaged and injured 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 cannot be where we come down on this. i'm begging you to do everything 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 am going to sum up this hearing with veteran's health administration would simply be that drugs are a shortcut.

they're a shortcut to doing the right thing. they're 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's disconcerting. and it is unfair and hurtful to the men and women who have made tremendous sacrifices for this country in uniform. one question i have is how many physiologists or rehabilitation physicians does the veteran's administration have? dr. clancy? >> i would have to take that for the record, mr. chairman. >> i've got the number of about 40. and so, i mean therein lies part of the problem. those are the people central when it comes to pain management. yet, we're short changing 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 and go to sleep at night. and i think when we look at the suicide rates of our veterans, that's reflective of what the veteran's administration is doing in terms of having drug reliant therapies. again, as a shortcut for doing the right thing. doctor, are you a veteran yourself? >> i am not. i am a neuroscientist by training and prior to that i worked for the pentagon on behavioral health issues with army suicide prevention task force and other programs. >> i want to thank you for your work. what is your view -- do you believe that in fact the over prescription of drugs is a shortcut? >> i think this is a really

complex question to ask. if you look at the history of clinician education, medications have 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 manifest 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 is a lot of research coming out that supports this idea offent integrated management of pain using alternative and complimentary medicines. there are spinal cord stimulation is a new technology that's out there. and iva actually has a member veteran who was addicted toope

toopeioids 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. these are all very new technologies. doctors don't know about them. they're not using them. clinician education is so, so critical to redefining how clinicians look at pain management. >> i think you would agree drugs should not be the first course of action they should be the last course of action? >> absolutely. 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 the -- in terms of the principal modalities of treatment whether for psychotherapy or for pain management, from what we're seeing here, in terms of

testimony, it seems to be it's kind of the first and preferred method of treatment tends to be drug therapy? >> well, i'm not a clinician. i'm not qualified to answer that. we are going to be looking at the operation, va operations relative to opioid program later this year. i'll be much more educated after that. >> well, that's not comforting. i wish we were prepared here. mr. cutler, dr. cutler, what do you think? >> well i'm really glad you asked that question. >> let's not -- >> the bottom line -- >> let's not run the clock here. >> whether it's pain or depression, it takes an integrated approach. different patients need to start in different places. there are patients who will say i can't or won't talk about this and the medication will make it

possible in a depression case. in a pain case there are people who absolutely need not to go where they mean to go into opiates or come opof them. they believe is this is what will work with me. we need to start where the veteran is. with my patients i have said i have a lot of different therapies, talk therapies and medication. these are the good and bad, what makes sense to you. by the way we can do both. and in most cases we end up doing both, but onften in a stepped way. >> in an ig report from 2013 it was recommended that va insure 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 insure this process is being followed? >> a few years