[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
PRESCRIPTION MISMANAGEMENT AND THE RISK OF VETERAN SUICIDE
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HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, JUNE 10, 2015
__________
Serial No. 114-25
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION
MIKE COFFMAN, Colorado, Chairman
DOUG LAMBORN, Colorado ANN M. KUSTER, New Hampshire,
DAVID P. ROE, Tennessee Ranking Member
DAN BENISHEK, Michigan BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana TIMOTHY J. WALZ, Minnesota
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
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of converting between various electronic formats may introduce
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C O N T E N T S
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Wednesday, June 10, 2015
Page
Prescription Mismanagement and the Risk of Veteran Suicide....... 1
OPENING STATEMENTS
Mike Coffman, Chairman........................................... 1
Ann Kuster, Ranking Member....................................... 2
WITNESSES
Carolyn Clancy, M.D., Interim Under Secretary for Health,
Department of Veterans Affairs................................. 7
Prepared Statement........................................... 33
Accompanied by:
Mr. Michael Valentino, Chief Consultant, Pharmacy
Benefits Management Service, Veterans Health
Administration
And
Mr. Harold Kudler, M.D., Chief Consultant, Mental Health
Services, Veterans Health Administration
Mr. Randall Williamson, Director, Healthcare Issues, Government
Accountability Office.......................................... 10
Prepared Statement........................................... 48
Ms. Jacqueline Maffucci, Ph.D., Research Director, Iraq and
Afghanistan Veterans of America................................ 11
Prepared Statement........................................... 63
STATEMENT FOR THE RECORD
The American Legion.............................................. 67
Deliverable...................................................... 73
PRESCRIPTION MISMANAGEMENT AND THE RISK OF VETERAN SUICIDE
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Wednesday, June 10, 2015
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, D.C.
The subcommittee met, pursuant to call at 10:30 a.m., in
Room 334, Cannon House Office Building, Hon. Mike Coffman
[chairman of the subcommittee] presiding.
Present: Representatives Coffman, Lamborn, Roe, Benishek,
Heulskamp, Kuster, O'Rourke, Rice, and Walz.
Also Present: Representative Miller.
OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN
Mr. Coffman. Good morning. This hearing will come to order.
I want to welcome everyone to today's hearing titled
Prescription Mismanagement and the Risk of Veteran Suicide.
Before we begin, I would like to ask unanimous consent that
a statement from The American Legion be entered into the
hearing record. Hearing no objection, so ordered.
This hearing will examine the relationship between veterans
prescribed medications as a result of their mental health and
the increased suicide rate among veterans.
In a report issued in November 2014, which included in part
evidence uncovered by the O&I Subcommittee, GAO examined VA's
data on veterans with major depressive disorder including the
extent to which they were prescribed medications, the extent to
which they received proper care, and whether VA monitored that
care, and the information VA requires VAMCs to collect on
veteran suicides.
It is now clear that VA is not even aware of the population
of veterans with major depressive disorder due to inappropriate
coding by VA physicians. As a result, VA cannot determine if
veterans are receiving care consistent with the clinical
practice guidelines.
These guidelines are crucial to the treatment of mental
disorders as they are designed to provide the maximum relief
from the debilitating symptoms associated with mental health.
It is imperative that our veterans receive the proper care and
follow-up when receiving mental healthcare, especially when
they are being prescribed various medications.
What has also become clear is that VA is receiving and
reporting inaccurate and inconsistent data regarding veteran
suicides. This severely impacts and limits the department's
ability to accurately evaluate its suicide prevention efforts
and identify trends in veteran suicides.
Not only did the committee conduct a hearing in 2010 on
this same issue, but since then, there have been countless
media stories of veterans being over-medicated or experiencing
adverse drug reactions and not receiving the proper care, the
proper follow-up, or the proper monitoring, and the all too
common result of suicide.
One story told of a veteran who went into a hospital
seeking care, but after being, quote, unquote, lost in the
system ended up dying by suicide right in the facility. We will
also hear other similarly tragic stories today that highlight
the tremendous problems occurring with VA for years and
continuing today with regard to treatment of veterans with
mental health concerns, adequate oversight of treatment
programs, and more importantly the actions taken to ensure
veterans who are prescribed countless medications receive
proper follow-up.
Currently VA has approximately ten different programs
dealing with prescription medication and suicide prevention
issues, but it does not appear that any of these programs
interact with one another. No one is talking to anyone else.
How can we ensure that the veterans are getting the proper
care, the proper follow-up, and the proper advice if the right
hand doesn't know what the left hand is doing?
I think it is more appropriate to say based on the
statistics from the GAO report and the numerous media stories
that VA is just throwing out a bunch of different ideas and
programs hoping one of them will stick and they can claim they
have solved the problem. This is unacceptable. We need to know
exactly what VA is doing to change this pattern and what is it
doing to improve protection of veterans.
What is a real way forward? Who will be held accountable
for mistakes that have already been made and have cost veterans
their lives? Who will stand up and take responsibility for
making a change? It is time for answers. It is time for change.
With that, I now yield to Ranking Member Kuster for any
opening remarks she may have.
OPENING STATEMENT OF RANKING MEMBER ANN KUSTER
Ms. Kuster. Thank you, Mr. Chairman.
And good morning to our panel. Thank you for being with us.
This morning, we are addressing a complex healthcare policy
issue affecting veterans and over 100 million American adults.
The statistics on veterans experiencing chronic pain are
staggering. Over 50 percent of all veterans enrolled and
receiving care at VA medical facilities experience chronic
pain, with over a half a million veterans managing pain with
prescribed opioids.
As a Nation and certainly in my district and throughout the
northeast, we face what can only be described as an opioid
abuse epidemic. The Centers for Disease Control and Prevention
has termed opioid abuse the worst drug addiction epidemic in
the country's history, killing more people than heroin and
crack cocaine.
In addition to the issue of pain management and the
problems of addiction, we must remember that many veterans who
experience chronic pain also suffer from mental health
disorders such as posttraumatic stress and traumatic brain
injury. Therefore, it is vital that the VA has in place the
proper oversight mechanisms to monitor the safe use of opioids
for managing veterans' pain.
I am particularly concerned about veterans at risk of self-
medication and addiction being prescribed opioids for pain
management. We know from multiple inspector general and GAO
reports that the VA has struggled to properly monitor
prescribed opioids and the mental health of its patients. And I
am concerned that a potential deadly mix of opioid use, mental
health disorders, and lack of oversight is contributing to our
high rate of veteran suicide.
The newest Drug Enforcement Agency regulations that require
veterans to see a clinician monthly for a refill of opioid pain
medication creates an additional burden on veterans who have
difficulty accessing care at VA medical facilities, leaving
some veterans to suffer from extreme pain and experience opioid
withdrawal symptoms when they are unable to schedule an
appointment to refill.
This hearing provides us with the opportunity to begin to
seriously examine whether the benefits of managing veterans'
pain with opioids is outweighed by the risk and side effects
experienced by veterans and the VA healthcare system's struggle
to properly monitor opioid use.
During this hearing, I would like to hear from our
witnesses how we can better address safe and effective
treatment of veterans while ensuring that care management is
not forgotten.
I would like to discuss whether a higher level of informed
consent is needed to ensure veterans and their families
understand the risks and side effects before choosing to manage
pain with opioids and whether the VA is properly coordinating
mental health and suicide prevention programs with VA medical
facility clinicians and employees responsible for monitoring
patient opioid use.
I am also interested in alternative pain management and as
I get to my comments later, I will talk about what is happening
at the White River Junction VA in bringing down the rate of
opioid prescriptions and how we can help get ourselves out of
this problem, out of this cycle and address the veterans, to
serve their needs without putting them and their families at
risk.
And, finally, I would like to discuss what is 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.
Mr. Coffman. Thank you, Ranking Member Kuster.
I will introduce our witnesses in just one moment, but I
ask that the witnesses stand and raise their right hand.
[Witnesses sworn.]
Mr. Coffman. Please be seated.
I would like to recognize the Honorable Jeff Miller,
Chairman of the full Veterans' Affairs Committee, who has
joined us on the dais.
Welcome, Chairman Miller. You have the floor.
Mr. Miller. Thank you very much, Mr. Chairman.
To the Ranking Member, Ms. Kuster, thank you for the good
work that this subcommittee has been doing over the last
several years.
If I might, instead of giving a typical opening statement,
I want to ask Ms. Clancy a couple questions because I need to
move on to another appointment.
And I believe, Dr. Clancy, that you have been made aware
that I am going to be asking a couple of questions, albeit a
little bit out of order. And I want to talk specifically about
Bradley Stone.
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 would like to know how did VA
come to that conclusion that the veteran was okay, and I say
that in quotes, when he was reporting all of these feelings
prior to the incident.
Dr. Clancy. 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 them.
Mr. Miller. 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?
Dr. Clancy. I had been told that VA had provided the
committee with the files with some redactions and had also
provided--offered an in-camera 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 in camera.
Mr. Miller. And, again, as I have stated in every single
letter that I have sent to the department requesting
information, an in-camera review is not acceptable. That may be
what you want to provide us, but that is not at all acceptable.
And so, you know, the staff has 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 Rubens, 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?
Dr. Clancy. Since I'm under oath, I'm going to be very
careful. I don't--I can't speak for what Diana Rubens is
telling you. I have been informed directly by our lawyers that
we have provided this committee with all the records with the
redactions that I mentioned before, again, Social Security
numbers and some sensitive details about the living family
members of Mr. Stone.
Mr. Miller. Okay. I want to for the record, Mr. Chairman
and Dr. Clancy, I know for a fact that VA has withheld hundreds
of pages related to the Bradley Stone file. And so with that, I
would say that we have requested all the documents every way we
know how.
So I will ask you one more time, can I expect the
department to deliver the complete records by the end of this
week?
Dr. Clancy. 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.
Mr. Miller. Okay. I can assure you it is not redacted. It
is missing, completely missing.
Dr. Clancy. I will bring that message back.
Mr. Miller. 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 in-camera review is
not acceptable.
And I ask will you commit that all the documents that I
have requested will be provided by the end of this week?
Dr. Clancy. The behavioral health autopsy is a unique
feature of what we do at VA healthcare for veterans. Rather
than having a private limited to the people at the facility,
root cause analysis or deep dive of what happens when a veteran
takes his or her own life, this is something that we have
centralized so that we 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.
Mr. Miller. 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 will subpoena it if necessary.
Can I expect to have this information delivered by Friday?
Dr. Clancy. I will take that back, Mr. Chairman.
Mr. Miller. Thank you very much.
And also, 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 that we see being done at the
facilities there. There has been a great change in Dayton in
specifics. And I enjoyed the opportunity to spend a couple of
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 that some of the good things
specifically at Cincinnati would be shared throughout VHA and
the rest of the department.
Thank you very much.
Dr. Clancy. Well, 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----
Mr. Miller. I had a chance to view it.
Dr. Clancy. Did you?
Mr. Miller. I sure did.
Dr. Clancy. It's great. It really is.
Mr. Miller. Thank you very much.
Mr. Coffman. One point, Dr. Clancy. The VA has turned over
behavioral health autopsies to this committee before.
And so, Ranking Member Kuster.
Ms. Kuster. Yes. I just wanted to say for the record as a
healthcare attorney who has 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 is intended for physicians and the medical
team to grow and learn from these experiences.
And I am 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 because these
hearings, as we know, are televised. It is a very public
setting.
And I think we should get to the bottom, but I don't want
to do anything that would have a chilling effect on families
that are sharing the most personal aspects. We already have
such a strong stigma around mental health and about people
seeking treatment. And I would be extremely concerned if we
left the impression today that we are in some way digging into
private affairs.
If there is 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 private
setting or in a redacted way, why this committee would be
trying to determine--and I am not speaking as to if you believe
there are documents that have not been provided. That is a
separate matter.
But I know that under our statutes in the state,
confidential information in this quality assurance process is
confidential and it is not to be shared. And the purpose of
that is so that people will come forward. So that is my only
comment.
Mr. Coffman. Mr. Chairman.
Mr. Miller. Thank you very much, and I appreciate the
expertise that you bring to this committee and to the
subcommittee.
And you can rest assured, and I think you know that what we
are 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 is 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 remind you that we are a federal body, not a state
body. We are 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, the HIPAA laws and other information
to receive that information for us to be able to do our
oversight in this. And it is not political.
Again, we are trying to get to the bottom of a very tragic
event and we are 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. And that is
what we are trying to getting at at this point.
But, again, I thank every member of this subcommittee for
the job that you have been doing and look forward to continuing
the good works.
But thank you, Ms. Kuster.
Mr. Coffman. Thank you, Mr. Chairman.
I ask that all other members waive their opening remarks as
per the committee's custom. Hearing no objection, so ordered.
With that, I would now like to introduce our panel. On the
panel, we have Dr. Carolyn Clancy, Interim Under Secretary for
Health for the 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.
STATEMENTS OF CAROLYN CLANCY, INTERIM UNDER SECRETARY FOR
HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY
MICHAEL VALENTINO, CHIEF CONSULTANT, PHARMACY BENEFITS
MANAGEMENT SERVICE, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS, and HAROLD KUDLER, CHIEF
CONSULTANT, MENTAL HEALTH SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF CAROLYN CLANCY
Dr. Clancy. Good morning, Mr. Chairman Coffman, Ranking
Member Kuster, members of the committee. Thank you for the
opportunity to discuss the overuse of medication in the
provision of mental healthcare to 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 am deeply
saddened by the tragic outcome involving a veteran. So to
families here today or watching this hearing who've lost a
loved one, I want to express my sorrow and regret for your
loss. I appreciate your sharing your experiences with us and
will--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, meeting the increasing demands for mental
healthcare, 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
public 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 most recently at the individual
clinician level.
Starting this July 1, 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.
And in addition to information about effective use of
medications, it also--this approach also works with clinicians
to have the 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 discontinuation is
not possible or actually practical. But we have to continue to
taper these doses.
We've seen some successes and 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 that treatment works. We've identified many
positive outcomes for veterans who are receiving our care. For
example, the rate of repeat attempts 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 percent, at the
same time that the suicide rate for middle-aged men who are not
veterans or who are veterans who don't use our system actually
rose during that time period.
The rate of suicide among women veterans is higher than
other women in the general public, but women veterans who use
our system actually are 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 do not 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 the 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 and 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
healthcare 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, posttraumatic 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. healthcare where utilization of mental health has been
pretty dramatically curtailed or utilization controlled over
the years. So that meant that we have had to work with public
and private science partners to build the basic science, the
epidemiological data, and population health expertise.
We have 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.
You know, 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 healthcare. And in the meantime, 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.
[The prepared statement of Carolyn Clancy appears in the
Appendix]
Mr. Coffman. Thank you, Dr. Clancy.
Mr. Williamson, you are now recognized for five minutes.
STATEMENT OF RANDALL WILLIAMSON
Mr. Williamson. Good morning, Mr. Chairman and Ranking
Member Kuster. I am pleased to be here today to discuss our
November 2014 report on VHA's efforts to monitor veterans with
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 a 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 incidences of MDD among
veterans treated by VA, the extent that VAMC clinicians
prescribe antidepressants to veterans with MDD and monitor
anti-depressant use, and data VAMCs are collecting and
reporting on veteran suicides to inform VHA's suicide
prevention efforts.
VHA data show that about ten percent of the veterans
receiving VA healthcare were diagnosed with MDD and 94 percent
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 that VAMCs did not always correctly
report and record confirmed MDD diagnosis 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 guideline
referred to as CPG that VA has--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 antidepressant
treatment, we found that for 26 of the 30 veterans in our
sample VA clinicians did not use this assessment tool at or
used it within the specified time frame.
While not mandatory for VAMC 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 VAMC 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 evaluated and whether appropriate actions are
taken to mitigate potential significant risk to veterans.
Finally, we found that demographic and clinical data in
VA's--VA--VAMCs collect on veteran suicides to better inform
VHA's 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 BHAP, VAMCs collect data on
veteran suicides such as date of death, number of mental health
visits, and last VA contact. We examined 63 BHAP 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 VAMCs are generally not reviewed at
any level within VHA for 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.
VA has made good progress in addressing the six--six
recommendations to improve weaknesses we noted in our report.
In the six months since our report was issued, one
recommendation has been fully implemented and several others
are very close to being fully implemented.
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
overseeing outcomes, and achieving a recognized standard of
excellence, VA--VHA will continue to fall short of performing
the highest quality and cost-effective care to our Nation's
veterans.
This concludes my opening remarks.
[The prepared statement of Randall Williamson appears in
the Appendix]
Mr. Coffman. Thank you, Mr. Williamson, for your remarks.
Dr. Maffucci, did I say that right?
Ms. Maffucci. Yes, you did. Thank you.
Mr. Coffman. Thank you.
And you are now recognized for five minutes.
STATEMENT OF JACQUELINE MAFFUCCI
Ms. Maffucci. Chairman Coffman, Ranking Member Kuster, and
distinguished members of the subcommittee, on behalf of Iraq
and Afghanistan Veterans of America and our nearly 400,000
members and supporters, 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 SAV Act into law. This was a first step on a long road to
address the challenges of combating suicide among our
servicemembers and veterans.
The issue that we're here to talk about today 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 misuse and abuse
of these 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 servicemembers and veterans. Over 60 percent the
Iraq and Afghanistan veterans seeking VA medical care seek care
for musculoskeletal ailments and this is the most common
category for disability compensation. Nearly 60 percent 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 co-
occurrence with other conditions like depression, anxiety, PTSD
or TBI may 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 that they feel under-prepared to treat these patients
due to lack of training. This includes VHA providers who were
surveyed in 2013.
Adding to the challenge are studies showing that untreated
pain can actually put an individual at higher risk for suicide
and, yet, we also know that prescription medications can result
in strong addictions and provide a means for suicide attempts.
The VA reports that over half of all nonfatal suicide
events among veterans results from over--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 over-
medication and limiting access to powerful prescription
medications must be included in a comprehensive approach to
addressing this issue.
A recent study showed that 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 approach to pain expired in October of 2014. While
it expired in date only and the policy remains active, IAVA is
discouraged that updating this important policy has not been
prioritized. We urge the VA to prioritize this and--and fully
implement it at all VA facilities.
IAVA would also like to emphasize the importance of
minimizing the risk of overdose and over-medication through
formulary take-back programs and prescription drug 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
and this is critical to limiting the possibility of misuse and
abuse of powerful--powerful prescription drugs, yet no action
has been taken.
And while the VA is working to fully implement its
participation in state prescription drug monitoring programs,
full implementation remains to be seen and we urge the VA to--
to prioritize this as well.
Too often we hear the stories of veterans who are
prescribed what seems like an--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 request for a stronger
medication to manage this pain. These are tough challenges and
IAVA remains committed to working 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 continuing to work
with each of you, your staff, and this committee in this
critical year ahead. Thank you for your time and attention.
[The prepared statement of Jacqueline Maffucci appears in
the Appendix]
Mr. Coffman. Thank you, Doctor. I deeply appreciate your
testimony.
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 antidepressant treatment properly.
In your opinion, is policy simply ignored or is there just
a lack of oversight by leadership?
Dr. Clancy. So first I want to say that we regard the GAO
recommendations, feedback as 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 a hundred percent 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
whether we weren't just on the ball. But that is a very
important feature.
Mr. Coffman. 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?
Dr. Clancy. No, they're not, Mr. Chairman.
Mr. Coffman. Dr. Clancy, in response to the GAO report, VA
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?
Dr. Clancy. 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 with
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.
Mr. Coffman. Thank you, Dr. Clancy.
When do you think that report is going to be done?
Dr. Clancy. I would have to double check on when we
committed to having the recommendations done.
Mr. Coffman. VA has 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 also March
2015.
Has this been completed?
Dr. Clancy. I believe that it has. I'd have to double check
my notes here. Here we are.
Mr. Coffman. Well, can you get a copy of it to the
committee?
Dr. Clancy. Yes, absolutely. We'll submit that.
Mr. Coffman. And roughly 63 percent 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?
Dr. Clancy. 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, excuse me, to make sure that we were
getting it right.
Dr. Kudler, do you want to add to that?
Dr. Kudler. Yes. At the time the GAO was--oh, pardon me. At
the time the GAO was conducting this 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, well, 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 the national
level.
We've also created software that crosswalks these to
another suicide prevention tracking system, the SPAN system, so
that we can make sure we're accurately looking at these from
multiple perspectives.
So the system is continuously improving and it's progressed
a great deal since the original report. And we will continue--
continue to work on it.
Mr. Coffman. Dr. Clancy, this subcommittee has requested
the behavioral health autopsies for numerous veterans who have
died by suicide and in all cases except one of Kalisha 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 Ms. Holmes released
to the committee?
Dr. Clancy. I would have to take that question for the
record. I would say in general, the behavioral 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.
Mr. Coffman. Well, I think we are 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 can't do that oversight operation and 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.
Ms. 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,
but 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 is some cutting-edge
research, and I will talk to the chair about perhaps bringing
in some witnesses to share that, but particularly the opioid
safety initiative. And a couple of different things and
whichever is the appropriate witness.
One is getting at the heart of what is causing the pain. 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 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 testing because in our area,
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 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 widely has it been--is it in use and
what can we do to help move that forward?
Dr. Clancy. 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 that we developed with 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'd be happy to submit for the record to brief
anyone any time about some of 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 predictors of veterans who or anyone who's 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 non-narcotic medications and so
forth. We--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?
Mr. Valentino. Yes. Thank you.
So this--the opioid safety program is just shy of two years
old. And we've had to build it from--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
outlier--potential outlier VISNs. So we focused on those, asked
for corrective action plans.
The next iteration was to continue to focus on VISNs, but
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--we've built
the tools and we're--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 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 this.
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--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 patients
receiving opioids and benzodiazepines together which is a known
risk; 75,000 more patients have had a urine drug screen who are
long-term opioids, as you mentioned, because that is definitely
an opportunity for--for diversion and we want to 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
common denominator, morphine equivalent daily doses. And we now
have----
Ms. Kuster. Mr. Valentino, I am sorry. My time is up. I am
very interested----
Mr. Valentino. Okay.
Ms. Kuster [continuing]. In what you have to say, but my
colleagues need their turn as well. So thank you so much and we
can take that on the record.
Mr. Coffman. Mr. Lamborn, Colorado.
And let's see if we can not try and run the clock out on
some of these answers.
Mr. Lamborn. Well, 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 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 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 VA.
They believe their son would still be alive had he received
better care.
Noah was diagnosed with PTSD and received a 50 percent
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,
Venlafaxine, and sent on his way.
Now, we don't know at this time what this drug did or
didn't do, but we know this. He was not referred for suicide
prevention. He was not offered counseling and there was 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 been documented with having
suicidal thoughts or ideation not referred to suicide
prevention? Why wasn't there follow-up from the VA and why
wasn't he offered counseling?
Dr. Clancy. I will look into this personally, Mr.
Congressman. That's heartbreaking. I can't even imagine what
this--I can imagine, but I know it's horrendous what his family
is going through. The picture was worth many, many words as
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.
Mr. Lamborn. Would one of the other witnesses have any
response to my questions, to the family's questions?
Dr. Kudler. You know, 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 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've created a system. A
system can be cold and inhuman, but we need to have a real sit
down with them 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.
Mr. Lamborn. Okay. Thank you both.
Mr. Chairman, thank you for having this hearing and I yield
back the balance of my time.
Mr. Coffman. Mr. O'Rourke, Texas.
Mr. O'Rourke. Thank you.
Dr. Clancy, a question to which I would like to receive a
quick, direct answer. We are touting reduced prescriptions of
opioids as though perhaps that in itself is success.
What I would like to know are the consequences. I have
veterans that show up to my town hall meetings saying that
their prescriptions were cut off without notice, without
transition, without ramping down.
How many of those who are no longer receiving prescriptions
from the VA are now using heroin or other street drugs?
Dr. Clancy. We can't know that without--with the
information that we have. It is something we worry about
constantly. So----
Mr. O'Rourke. Let me tell you another problem. This is just
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 are 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 are suffering. And in
some cases, I would connect that suffering to suicides that we
see in El Paso.
I would also like to give you the following feedback. As I
shared with you when I met with you on Monday, the May 15th
access report from the VA shows that El Paso is ranked 157 out
of 158 for mental healthcare access. We have 115 mental
healthcare positions approved for El Paso. Only 87 of those are
filled, leaving a 24 percent vacancy rate.
Your predecessor, when we would relay anecdotal information
that I was hearing from veterans, told me we were seeing
everybody within 14 days. As you know, we did our own survey
and El Paso found that more than one-third of veterans could
not get a mental healthcare appointment, not in 14 days, not in
a month, just not ever.
That situation, because we are surveying the veterans again
right now and we are receiving the responses back, has not
improved in the year that we have had new leadership there.
This 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 and I am continuing to do that. And I
just did the last time that I was home in El Paso.
As you know, for whatever reason, the VA has been unable to
solve this issue and to treat it as a priority that it should
be and to turn around El Paso. I am glad to hear that there are
good things happening in other parts of the country, but
everything that I do and view is through the prism of the
veterans that I serve in El Paso.
You know that we have a proposal from the community in El
Paso to address this. I want your commitment that you are going
to work with us because the community has come forward in the
vacuum of VA 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 that we all
serve in El Paso.
And 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 go, I want your commitment that you are
going to work with me to resolve this, that it is a crisis for
you, that it is urgent for you, and that we are going to turn
this around.
Dr. Clancy. 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 to those serving veterans
in El Paso. You have my full commitment.
Mr. O'Rourke. Thank you.
I yield back.
[Disturbance in hearing room.]
Mr. Coffman. All right, sir. I am sorry. You are out of
order. You are out of order. Thank you.
Dr. Benishek, Michigan.
Dr. Benishek. Thank you, Mr. Chairman.
Well, I want to associate myself with the comments of Mr.
O'Rourke for one thing and that is I have seen this as well is
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 has been a real
problem.
There are a couple of specifics I want to get to after that
and that is something Dr. Kudler said and then something Mr.
Williamson said. And Mr. Williamson said there is not that
much--there doesn't seem to be that much follow-up on this, the
behavioral health autopsy program or we are learning moving
forward.
Can you remind me what you said in your testimony, Mr.
Williamson, because it seemed like----
Mr. Williamson. We were talking about----
Dr. Benishek [continuing]. You were contradicting what Dr.
Kudler said.
Mr. Williamson. I was talking about oversight. VA conducts
very little over the suicide prevention of that program at the
local or the national level to see whether data were accurate
and complete.
Dr. Benishek. Right, right. Now, Dr. Kudler, you said that
you are doing oversight and Mr. Williamson said the GAO says
you are not. So what is exactly going on?
Dr. Kudler. The difference is the two years that have
passed since this report was written. I'm not questioning the
report at all. In fact, I find the report helpful as a real
spur to do more.
Dr. Benishek. All right.
Dr. Kudler. At this point, we are making a difference in
this. We've developed programs to address----
Dr. Benishek. Could you show me the results of the
oversight that you have done in the last two years? Could you
get that to me, you know, within a reasonable period of time,
like a month?
Mr. Williamson. That's--that's not quite the way it is, I
think. I think there is still--to respond to our
recommendations on oversight, I don't think VA 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.
There's now a box checked on the--on the behavioral autopsy
report that indicates that oversight has been done, but we know
that hasn't----
Dr. Benishek. That is all there is is a box you are saying,
right?
Mr. Williamson. Well, that's one of the things. And--and
they--they are revising guidelines and so on. They are making
progress. I'm not going to--but it's not been completed to our
understanding.
Dr. Benishek. I am not going to give you another chance,
Dr. Kudler. 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 that they want to hurt
themselves have to hang up and dial another 800 number when
they are calling into the VA. And you spontaneously said that
you are 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 when
that all happens that I can call the number and see if it is
actually working?
Dr. Clancy. Absolute----
Dr. Benishek. When is that going to happen?
Dr. Clancy. Absolutely by November or December. One of the
things that we have been working very closely with the
veterans' crisis line----
Dr. Benishek. Great. No.
Dr. Clancy. We just want to make sure----
Dr. Benishek. I don't want you to go on about what
happened.
Dr. Clancy [continuing]. That we don't overstress that
system when we do it.
Dr. Benishek. I just want to have a date so that if it is
not there by November or December----
Dr. Clancy. Yes.
Dr. Benishek [continuing]. Because I completely agree with
the guy that stood up here in the back and was out of order in
that, you know, it is just great to keep hearing that you are
going to all do work, but from where I sit, you know, the
actual accomplishment of the job does not seem to be happening.
So I just----
Dr. Clancy. No, I hear that.
Dr. Benishek [continuing]. I will be back to talk to you in
January and hopefully that I have called those places and there
actually is a number I can hit because, I mean, I got people
calling me all the time.
Dr. Clancy. I'll be checking before you will.
Dr. Benishek. This is ridiculous.
Dr. Clancy. But, yes.
Dr. Benishek. All right. With that, I think I will yield
back the remainder of my time. Thank you, Mr. Chairman.
Mr. Coffman. Thank you, Dr. Benishek.
Mr. Walz of Minnesota.
Mr. Walz. Thank you to the chairman.
And thank you all for being here today.
And I, too, would like to hit on this, the OSI that was
implemented in Minneapolis. And we followed this closely since
October 2013 and we are 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 a
dramatic increase in calls to our office after it was
implemented which I think probably is somewhat expected, but I
think the lack of maybe being there or the alternative. And I
say this very clearly. This issue of mental health parity,
mental health treatment certainly is societal-wide.
I am very proud of the work that this committee has
started, a small first step on Clay Hunt, but it is going to be
the broader issue.
And on the opiate issue, this Nation has vacillated back
and forth from over-prescribing to under-prescribing 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. It is tough and I always say this, but I think it
is 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. And what it was is we put together through
IOM the stepped care pain model which is the old standard, the
best practice; is that correct?
Dr. Clancy. Yes.
Mr. Walz. Okay. And I won't go through all of it that is
here, but what I would say is is that it had a five-year span
on it. I wanted 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, and this was on March 30th, that the VA doesn't need
us to do it, that you can put it in yourself. And I said that
is 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 have 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 VA started but
didn't fully implement it. Eight months ago, it expired. Three
months ago, I asked about it.
And I hate the 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 is
very irritating.
So I don't set you up to get 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 are 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?
Dr. Clancy. It has been done. It is still being reviewed
internally. And I will be honest and say this is an issue that
the GAO highlighted in putting us on their high-risk list. And
we have got to get better at the process and updating of our
policies and directives. But the pain directive has been
updated. All policies----
Mr. Walz. Who knows that?
Dr. Clancy. Yes?
Mr. Walz. Who knows that? Would the author of the bill not
be someone who would need to know that?
Dr. Clancy. Well, we're going to tell you as soon as we
have reviewed it and made sure that we have gotten consensus
and we haven't missed any details. And I apologize. I have not
personally seen your letter, but I will make sure that I do see
it before the day is over.
Mr. Walz. Part of this is, and I go back to that, and,
again, I don't expect to be high man, you got other priorities
to get on here, but this is one of the issues we have struggled
with is this very thing. Our job is tasked to do this.
We think we had a pretty good--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 are trying to communicate to implement
it and we are 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 that we haven't
heard from it yet, but this is important stuff. And there are
some things and I encourage my colleagues to look at this. The
things I hear the ranking member asking to put in, she is
intuitively clicking into this. That is in the stepped care
pain management. The things that you are hearing from Dr.
Benishek are in the stepped care. And if we just get it out
there, get it implemented, make it best practices, make it SOP,
it would be there.
So, again, I encourage you in many cases if you are 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. So we will look forward to the follow-up.
And I yield back.
Mr. Coffman. Thank you, Mr. Walz.
Dr. Roe, Tennessee.
Dr. Roe. Thank you, Mr. Chairman.
And just a couple of things. One on data collection. And
certainly when you draw or produce inadequate data, you draw
inadequate results. And the results may not be accurate at all.
And it is extremely important in healthcare to get the data
right because we are going to draw conclusions based on this
many patients did this and this many patients did that while
the outcome--I mean, I have been involved in those clinical
studies for years.
And when you put BS in, you get BS out. And so that is sort
of what it looks like has happened right here. And that is
being a little crude, but that is absolutely what it looks like
you have done.
And Mr. Williamson has pointed out, I mean, you have got
half of the BHAP 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 are never going to
know. You are going to have one--and, Dr. Clancy, you are
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 am sure you know continually complains about when he is at
DoD and has a patient stable and then they are separated from
the military and they go to the VA, there is a different
formulary there, so they then stop all of what he has taken
forever to get the patient stable on and they are now on
something else.
So I think that is something that needs to be addressed. He
was very adamant about that he sees it a lot since he is 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 has 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 VA.
And let me share why that is frustrating to me. I have been
here six years and change on this committee and we have
increased the budget 74 percent. It is not money. It is
management. And it is not the amount of money that we are
spending on our veterans. There is 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
are just not following it? Apparently nothing. So I know there
are outcomes. You mentioned all of those things.
Mr. Williamson.
Mr. Williamson. So your question is directed at oversight?
Dr. Roe. Yes, sir.
Mr. Williamson. Yes. There's a lot of reasons why oversight
doesn't happen. And VA does not have the data perform to
rigorous oversight.
I don't think there's any willful motive on VA's part. I
think it's just that oversight is missing especially at the
local level. At that level, accountability is missing;
supervisors are not holding employees accountable for doing
their jobs correctly.
Dr. Roe. But that seems basic to doing your job to me. I
mean, to hold someone accountable for their job, I mean, that
is not rocket science. You are not doing your job, so what
happens when you don't do your job? Do you lose your job or
what happens?
Mr. Williamson. I'm not sure I'm the right one to answer
that, but in an idealistic world, I would think you would lose
your job if you are not performing. We should be held
accountable for the quality of the work that we do. When we
don't do it well, we get feedback. First of all, we should be
given expectations, then we get feedback and hopefully
corrective action after that. And that's basically business
101--it's common.
Dr. Clancy. So, Dr. Roe, if I might, I want to say that to
you and your colleagues we share your frustration. And I want
to salute my colleague, Dr. Kudler, who is working with others
to try, yes, so when people who don't do their job 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 in follow-up.
Dr. Roe. But Mr. O'Rourke pointed out that there are 20
something people, jobs available right now. We claim we have a
job problem.
Dr. Clancy. Yes.
Dr. Roe. There are 24 people that need a job in El Paso,
Texas and there is money there to fund it. So why aren't those
positions filled?
Dr. Clancy. 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 be working----
Dr. Roe. And VA is not making----
Dr. Clancy [continuing]. With them more effectively.
Dr. Roe [continuing]. It hard for those veterans to leave
that system and go to these private practitioners. It is with
the veteran's choice card or with a non-VA care because we find
that sometimes. It is just so hard with all the rules they have
to get, it takes forever for someone to get an appointment.
And one last thing. I know my time is expired. But how long
does it take to change a phone number to get--why does it take
six months to have some--when you call--and I know how
frustrated I get when I call. Punch two for this and three for
that. It 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, a
human being----
Dr. Clancy. We wanted to make----
Dr. Roe [continuing]. On the other end?
Dr. Clancy. We want to make sure 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 we'll then
roll it out full steam this fall.
Dr. Roe. That may be stressful and I am very sorry for that
family, but it is very stressful on the other end. That is why
they are making the call.
Dr. Clancy. No, I understand that completely. And we--we
want to make sure that 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
servicemembers over to VA, they continue on the drugs that they
were getting in the service. We've gone over this with Dr.
Woodson at the Defense----
Dr. Roe. I will ask Dr. Murphy today again when I see him
on the House floor. He is under a different impression. So I
will have him check.
Dr. Clancy. Well, and 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.
Mr. Coffman. Ms. Rice, New York.
Ms. Rice. Thank you, Mr. Chairman.
I mean, I hate to say that maybe the stress for the poor
operators comes from the fact that they know that they are not
going to have the support from the VA in getting the callers
the help that they need.
I would like to take a minute to recognize the work that is
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 VA. They have taken again what shouldn't
be a revolutionary approach to pain management, but it is. They
actually believe that 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--and I understand that doctors when a
patient comes and presents with real pain, you want to take
away the pain. I get that that is the doctor's mode of
reaction.
But this facility is using alternative approaches such as
acupuncture and exercises to relieve pain. And what we have
seen is veterans who undergo these treatments experience a
relief from pain without the harmful effects of addictive
narcotics. The Bronx VA's outstanding approach to pain
treatment should become the norm at all VA facilities
nationwide.
My question is to you, Dr. Clancy. What is the VA's version
to alternative forms of treatment like meditation, acupuncture,
and exercise?
Dr. Clancy. First of all, let me say I completely share
your enthusiasm for what I believe it's VISN 3 is doing.
Ms. Rice. Yes.
Dr. Clancy. 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 they'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.
So we actually have to----
Ms. Rice. Because we have a system here that 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 is in charge of VISN 3, Dr. Klingbeil, 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 is what we need to get
away from.
And I am just imploring you. It is not rocket science. They
get it right there. Just export it throughout the rest of the
country.
One other thing that I wanted to talk about is a bill that
I happen to be a proud cosponsor of that is put forth by our
colleague, Ron Kind from Wisconsin. It is H.R. 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?
Dr. Clancy. Yes. Representative Kind asked us for our
comments and I told him he had my personal full thread of
support which may be different than the department's support.
But I can't think of anyone who would--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 that's--because as heartbreaking as some of
the experiences of the veterans are are the experiences of
families who raise their hands and said I'm worried about my
son, daughter, spouse, whatever, and didn't feel----
Ms. Rice. It is a family issue. It is not even just a
serviceperson issue. It is----
Dr. Clancy. Yes.
Ms. Rice [continuing]. An entire family issue. And I don't
think that we want to be a Nation that says to our brave men
and women who fight for us----
Dr. Clancy. I agree.
Ms. Rice [continuing]. 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.
So I am begging you to do everything that you can to look
at what they are doing in VISN 3 and export it throughout the
rest of the country. It is not rocket science.
Thank you very much, Mr. Chairman.
Mr. Coffman. Thank you.
I think if I was going to sum up this hearing with the
Veterans Health Administration, it would simply be that drugs
are a shortcut. They are 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 management and in terms of those suffering from
depressive disorders. And I think that that is disconcerting
and it is unfair and hurtful to the men and women who have made
tremendous sacrifices for this country in uniform.
And one question that I have is, how many physiologists or
rehabilitation physicians does the Veterans Administration
have, Dr. Clancy?
Dr. Clancy. I would have to take that for the record, Mr.
Chairman.
Mr. Coffman. Well, I've got the number of about 40.
Dr. Clancy. And I'll get back to you.
Mr. Coffman. 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 are 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 is 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. Maffucci----
Dr. Maffucci.
Mr. Coffman. Maffucci. Okay. I got it right now?
Dr. Maffucci. Yes.
Mr. Coffman. And are you a veteran yourself?
Dr. Maffucci. I am not. I'm a neuroscientist by training
and prior to IAVA worked for the Pentagon on behavioral health
issues with the Army Suicide Prevention Task Force and other--
other programs.
Mr. Coffman. Well, I want to thank you for your work on
behalf of the men and women who served this country.
What is your view about--I mean, do you believe that, in
fact, the over-prescription of drugs is a shortcut?
Dr. Maffucci. I think this is a really complex question to
ask because if you look at the history of--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 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 right now that really supports this idea of
integrated management of pain using alternative and
complementary medicines. There is--there are some--spinal cord
stimulation is a new technology that's out there.
And IAVA actually has a member veteran who was addicted to
opioids, was a chronic pain sufferer 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. And so clinician education
is so, so critical to redefining how clinicians look at pain
management.
Mr. Coffman. Well, I think you would agree, though, that
drugs should not be the first course of action? They should be
the last course of action?
Dr. Maffucci. Absolutely. I think drugs are--drugs are one
option of many and they might be necessary, but they shouldn't
be the--the end all be all. They need to be a part of a
comprehensive plan.
Mr. Coffman. Mr. Williamson, how would you view in terms of
the principal modalities or treatment, whether for
psychotherapy or for pain management? From what we are seeing
here in terms of testimony, it seems to be kind of the first
and preferred method of treatment tends to be drug therapy.
Mr. Williamson. Well, I'm not a clinician and I'm really
not qualified to answer that. But GAO will be looking of the
opioid program, later this year. So I'll be much more educated
after we finish with that study.
Mr. Coffman. Well, that is not comforting. We were prepared
here to know.
Dr. Kudler, what do you think?
Dr. Kudler. I'm really glad you asked that question.
Mr. Coffman. Yes
Dr. Kudler. No.
Mr. Coffman. Let's----
Dr. Kudler. No, no. The bottom line----
Mr. Coffman [continuing]. Not run the clock here.
Dr. Kudler. The bottom line is this. Whether it's pain or
depression, it takes an integrated approach just as Dr.
Maffucci was saying. And different patients need to start in
different places. There are patients who will say I can't talk
about this. I won't talk about this. And the medication will
make that possible in the depression 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 that would ever work for me. So we
need to start where the--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 the bad about each of them. What makes sense to you
and, by the way, we can do both. And in most cases, we end up
doing both, but often the stepped way.
Mr. Coffman. Dr. Clancy, in an OIG report from 2013, it was
recommended that VA 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?
Dr. Kudler. A few years ago, VA put out as a performance
measure that veterans must be seen in person or at least by
phone in the first seven days after leaving a psychiatric
hospital. And this is based on statistics that show this is the
most vulnerable time. Actually, the first two weeks, the most
vulnerable time for a suicide attempt, especially after
treatment of depression or admission for suicide activity.
We've been monitoring this. We are not perfect in this, but
we have--we--we are--I--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. And we've taken it miles
further. I wish I could give you the exact number right now. I
can provide it.
Mr. Coffman. You know what is amazing is from what we are
hearing on the ground and from what we are hearing in this
committee, it is a world apart. And if for what we are hearing
in this committee were true, we wouldn't be here today having
this discussion.
Ranking Member Kuster.
Dr. Clancy. Well, Mr. Chairman, if I might, we're not
saying everything is fine and I acknowledged 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.
Mr. Coffman. Very hard to get it right if you are not
acknowledging the depth of the problem.
Ranking Member Kuster.
Ms. Kuster. 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 where we go from here in terms
of sharing best practices. We have now heard Dr. Maffucci. I
really appreciate again your commentary and your expertise in
this area and to the team from the VA. We have heard about VISN
1. I talked about some examples in White River Junction.
How do these best practices get shared and the research
that is underway, 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
have got to change some of the parameters and some of the, you
know, sort of go-to answers that some of the clinicians have?
Where do we go from here with this and how can this committee
best stay on top of that and continue to work with the VA to
make sure that we are serving these veterans all across the
country?
And I will bring El Paso up. Obviously one of the
challenges is that this involves a very case management
intensive approach. And you are right. The worst case scenario
is just to cancel somebody's medication without follow-up
because as we all know, that is why people are turning to
heroin in the streets.
So how do we get this right and how do we get it right
across the board in the VA and what is the follow-up?
Dr. Clancy. So what I might suggest is that 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.
And I did want to--didn't get a chance to say before to
Congressman O'Rourke that I do have people monitoring for this
abrupt discontinuation of medications. And I'm really worried
about it when people change providers, right? If we're sending
out a message that says we want to see fewer veterans on
opioids, it's much, much easier when someone changes providers
to just say no. 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, whatever, to double check on the diagnosis or
assessment.
It depends a lot on the use of standardized questions in
some cases. And 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 that 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.
Ms. Kuster. Thank you very much.
Mr. Coffman. Thank you, Ranking Member Kuster.
And, Dr. Clancy, I want to stress again the need for you to
turn over documents when requested by Congress. And your
failure to do so makes our job very difficult.
Mr. O'Rourke, Texas.
Mr. O'Rourke. And, Dr. Clancy, thank you for addressing the
El Paso issue and the larger issue within the VA to ensure that
you are monitoring those veterans who are going to be coming
off of opiates. But, again, the feedback stands because I am
hearing it directly from veterans that that is apparently not
happening in El Paso.
And I think we both must conclude that for every veteran
who takes the time to come down to a town hall meeting despite
whatever they are going through to tell their congressman that
they are having this problem in front of 200 other veterans and
is admitting that they are receiving opiates and now are doing
without that there are many others that that person represents
who have just given up and says why should I bother.
So we have got a problem in El Paso, perhaps nationally in
terms of ramping people down or finding an alternate therapy to
pair with their cessation of opiates.
I would like you to respond to something that we have heard
the secretary say and read about in the press that he has got
28,000 positions to fill in the VHA. It is something that Under
Secretary Sloan Gibson reiterated three weeks ago, four weeks
ago in a hearing here.
And then when the ranking member and I and some other
Members of Congress and the Senate were in your command and
control center on the 8th Floor a few weeks back, we heard that
that number was actually 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
are prioritizing those hires? And obviously I am getting to if
we have a crisis in mental health and we are treating all hires
the same, we have a problem. If you are prioritizing mental
health, here is a chance to tell this committee and the public
at large.
Dr. Clancy. 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 seven or eight percent across all the
disciplines from, you know, what we're--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 could do much more is in tele-mental health. So
Big Spring, Texas which isn't that far from you in Texas terms,
you know, they tried very, very hard to recruit psychiatrists
and had a problem and recently recruited one from Wisconsin who
is not moving. It--that individual is providing all virtual
care.
So we're working with them to try 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.
Mr. O'Rourke. And I appreciate that. And as I yield my
time, I will 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 under-served
community. And you say you know what, we are paying
psychiatrists and psychologists and therapists and social
workers and counselors X. I am going to pay them X plus 20
percent to get them to El Paso or that under-served community
and then to retain them once they are there because you have a
huge problem with retention as well, and that is a suggestion,
or some other plan that really treats this as the crisis that
it is versus the, you know, we are making this a priority. We
are 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 then keep them there after. So I hope to
hear specifics next time.
So appreciate your answers to our questions today.
And, Mr. Chair and Ranking Member, thank you for holding
this hearing. Really important. Thanks.
Mr. Coffman. Ranking Member Kuster.
Ms. Kuster. Thank you, Mr. Chair.
And just briefly I want to follow-up for my colleague that
we will do a follow-up hearing and not only on the types of
pain management and techniques that do seem to be working but
in particular, I would 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 that we stay on top of this so
that our colleague, his region gets served.
Thank you.
Mr. Coffman. Thank you, Ranking Member Kuster.
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 prescribed medications
for mental disorders, to demonstrate the inaccuracies and
discrepancies in the data collected by VA regarding veteran
suicides and those diagnosed with mental disorders and, three,
to allow VA 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 revise and extend their remarks and 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.
[Whereupon, at 12:12 p.m., the subcommittee was adjourned.]
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