[Senate Hearing 110-328]
[From the U.S. Government Publishing Office]
S. Hrg. 110-328
HEARING ON PENDING LEGISLATIVE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
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October 24, 2007
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Printed for the use of the Committee on Veterans� Affairs
Available via the World Wide Web:
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COMMITTEE ON VETERANS' AFFAIRS
DANIEL K. AKAKA, Hawaii, Chairman
JOHN D. ROCKEFELLER IV, West Virginia RICHARD M. BURR, North Carolina,
PATTY MURRAY, Washington Ranking Member
BARACK OBAMA, Illinois LARRY E. CRAIG, Idaho,
BERNARD SANDERS, (I) Vermont ARLEN SPECTER, Pennsylvania
SHERROD BROWN, Ohio JOHNNY ISAKSON, Georgia
JIM WEBB, Virginia LINDSEY O. GRAHAM, South Carolina
JON TESTER, Montana KAY BAILEY HUTCHISON, Texas
JOHN ENSIGN, Nevada
WILLIAM E. BREW, Staff Director
LUPE WISSEL, Republican Staff Director
C O N T E N T S
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OCTOBER 24, 2007
SENATORS
Page
Akaka, Daniel K. U.S. Senator from Hawaii ....................... 1
Burr, Richard K., U.S. Senator from North Carolina .............. 3
Murray, Patty, U.S. Senator from Washington ..................... 4
Craig, Larry E., U.S. Senator from Idaho ........................ 6
Brown, Sherrod, U.S. Senator from Ohio .......................... 6
Isakson, Johnny, U.S. Senator from Georgia ...................... 7
WITNESSES
Kussman, Michael L., M.D., M.S. MACP, Under Secretary for Health, U.S.
Department of Veterans� Affairs� Accompanied by Walter Hall, Assistant
General Counsel, U.S. Department of Veterans Affairs ............ 8
Prepared statement ............................................ 12
Response to written questions submitted by:
Hon. Daniel K. Akaka ........................................ 19
Blake, Carl, National Legislative Director, Paralyzed Veterans of
America ....................................................... 29
Prepared statement .......................................... 30
Ilem, Joy J., Assistant National Legislative Director, Disabled
American Veterans ............................................. 32
Prepared statement ............................................ 34
Response to written questions submitted by:
Committee on Veterans' Affairs .............................. 38
Murdough, Brenda, MSN, RN-C, Military/Veterans Initiative Coordinator,
American Pain Foundation ........................................ 40
Prepared statement ............................................ 42
Response to written questions submitted by:
Hon. Daniel K. Akaka ........................................ 44
Smith, Brien J., M.D., Medical Director, Comprehensive Epilepsy Program,
Henry Ford Hospital ............................................. 45
Prepared statement ............................................ 46
Response to written questions submitted by:
Hon. Daniel K. Akaka .......................................... 49
Hon. Patty Murray ............................................. 48
Walker, Capt. Constance A., USN (Ret.), National Alliance on Mental
Illness Member, NAMI Veterans Council; President, NAMI Southern
Maryland ...................................................... 49
Prepared statement .......................................... 53
HEARING ON PENDING LEGISLATION
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WEDNESDAY, OCTOBER 24, 2007
U.S. SENATE,
COMMITTEE ON VETERANS' AFFAIRS,
Washington, D.C.
The Committee met, pursuant to notice, at 9:29 a.m., in room
562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman
of the Committee, presiding.
Present: Senators Akaka, Murray, Brown, Burr, Craig, and
Isakson.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman AKAKA. Aloha and good morning, everyone.
Before we begin the formal hearing, I ask for your indulgence for
a brief ceremony. Kim Lipsky, will you please stand? Kim has no
idea what is about to happen this morning, so you will excuse her
for the look of confusion.
[Laughter.]
Chairman AKAKA. Congratulations, Kim, and mahalo. Thank you
with warmest aloha for 12 years of outstanding and productive
service to the U.S. Senate and to the Veterans� Affairs Committee.
I am pleased that the practice of awarding a 12-year service pin
and certificate gives me and the Committee the opportunity to recognize
and thank you for your vital role you play in helping us to
meet our obligations to our veterans on crucial health services
issues.
To cite but a few recent examples, largely as a result of your
efforts before and during and after our hearings in Hawaii, we have
been able to provide the best possible access to quality care to Hawaii
veterans as close to home as possible. We did this by improving
care, increasing staffing, or both, throughout the Islands, Oahu,
Maui, Molokai, Lanai, and the Big Island and Kauai. This is an
accomplishment much appreciated by veterans who are now spared
not only the inconveniences of going to another island, but also the
expenses of traveling and possibly lodging.
I am especially pleased with the results of our hearings in Hawaii
this year, for they lend a great deal of credibility to the Committee
and the veterans� community and the community at large
when we went to listen, and then acted.
Kim, I value your expertise and judgment, particularly on health
issues. The force of your logic based on a deep well of knowledge
leads to balanced solutions to problems that I find most helpful. I
appreciate your tireless efforts to make this possible and want to
express my heartfelt mahalo to you.
Having said that, I also want you to know that I value your
friendship on a personal level and I think of you as being a part
of the Akaka Office Ohana, which is family. I always think of you
as a friend. As we go into this hearing today, I cannot help but
observe what a fortuitous coincidence it is that as we recognize your
wonderful first 12 years of service, the Committee is taking up two
proposals which you developed to improve VA health care in the
areas of mental health care and pain management. Thank you for
your continuing dedication and efforts for our veterans.
Here is the Senate�s formal recognition of your first 12 years of
service. Let me just present this to you, Kim.
[Applause.]
Chairman AKAKA. Kim, thank you again, and there is a pin and
also a certificate.
Again, aloha and good morning, everyone. I want to welcome you
to this hearing on pending legislation.
Today, the Committee will hear testimony on five bills from a
number of witnesses. The bills under consideration are largely in
response to the needs of the newest generation of veterans, but
hold promise for all veterans.
Mental health issues remain an important part of our work in
the Committee. Based upon the valuable testimony gathered at our
mental health hearing in April, I introduced S. 2162, the Mental
Health Improvements Act of 2007. I am pleased that Senator Burr
has joined me as a cosponsor and, of course, I am repeating when
I say I am so glad to have him here as our Ranking Member. Now,
more than ever, VA must make mental health services a priority.
New approaches and programs aimed at substance use or disorder,
PTSD, and readjustment services are included in this legislation.
Also on the agenda is legislation which recognizes the need for
improvements in VA�s pain care management program. VA�s current
pain care efforts are worthwhile, but are unfortunately too
inconsistent and are not standardized to adequately meet the needs
of our veterans. S. 2160 will enhance VA�s pain management program
on a national, systemwide level through better clinical practices,
research, and professional education.
Senator Murray and Senator Craig have proposed S. 2004, which
would require VA to create Epilepsy Centers of Excellence. These
centers would focus their attention upon research, education, and
clinical care related to epilepsy. Epilepsy is anticipated to be an
increasingly prevalent condition among veterans. We have learned
that veterans with TBI are at a substantially increased risk to develop
Post-Trauma seizures months or even years after their injury.
We also have before us a bill by Senator Brown to clarify how
non-VA emergency care needs to work. Senator Brown chaired a
field hearing earlier this year which highlighted problems with the
reimbursement problems for veterans and private hospitals when
emergency care and treatment is needed. Senator Brown�s bill
would improve the emergency treatment of veterans at non-VA facilities
by removing uncertainty through a mandatory reimbursement
system and a clarification of transfer procedures.
We will have a Committee mark-up next month. My expectation
is that we can move some of this legislation forward to the full
Senate.
In closing, I note that the Committee has moved much legislation
through its process. Several large authorization bills are on the
Senate calendar presently. As Chairman, I am working with our
new Ranking Member on time agreements so that we can expedite
the path to enactment. I am hopeful that we will be able to reach
agreement and get the pending bills to the floor by next week or
soon after that.
I would like to yield to our Ranking Member, Senator Burr.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, U.S.
SENATOR FROM NORTH CAROLINA
Senator BURR. Thank you, Mr. Chairman. I want to thank you
for holding this hearing on five important bills that we are currently
considering in the Committee. I also want to welcome our
witnesses. It is always good to see them.
Mr. Chairman, I think the bills before us today are truly deserving
of action by this Committee. Certainly the issues addressed by
these bills, particularly the issues of mental health and mental
health treatment and Traumatic Brain Injury research, are extremely
important to our veterans.
I want to especially single out your bill, Mr. Chairman, which
seeks to expand treatment and research for substance abuse and
Post-Traumatic Stress Disorder. Unfortunately, too many veterans
who suffer from PTSD are turning to drugs and alcohol to help
them cope with this illness. Thanks to the recent report from the
Institute of Medicine, we know that certain treatments work to
help improve the lives of those suffering from PTSD. We also know
that more research and work needs to be done in the area of treating
veterans with co-morbid conditions, such as PTSD and substance
abuse. Your bill speaks to the exact issue and I am proud
to be a cosponsor of it.
I also want to thank you and your staff for your willingness to
work with me and the minority staff in making some minor
changes, I hope improvements, to the bill prior to its introduction.
You often talk about this Committee�s long record of bipartisan
cooperation and you have certainly shown that with this bill.
Mr. Chairman, as you know, recent reports to Congress from the
Disability Commission and the Institute of Medicine have presented
us with a challenge when it comes to the care and treatment
of veterans with mental illness, particularly PTSD. Both of
these distinguished groups have separately come to the same conclusion,
that the VBA and the VHA need to approach compensation,
treatment, and rehabilitation of veterans with PTSD and
other mental illnesses differently. I think we owe our veterans our
best effort to not only compensate them for their injuries and treat
their illness, but to improve their overall health and well-being.
I hope that this Committee will take some time to explore these
new findings and consider new ways we might be able to improve
the VA system to respond to the challenge presented to us. I look
forward to working with all of you to do that.
I would also like to compliment the Senator from Ohio, Senator
Brown, for his bill on emergency care. I think his legislation is a
fine example of what elected representatives do here in Washington.
A flaw in the VA�s reimbursement policy was brought to his
attention. He worked with the administration to explore the source
of the problem and now we have legislation that enjoys overwhelming
bipartisan support to correct that law.
I would also like to comment for a moment on Senator Domenici's
bill, S. 38, by saying that I think any effort to expand the
cadre of people who can help our returning war veterans readjust
to civilian life is worthy of support.
Finally, Mr. Chairman, I understand that next month you are
planning to move forward a few naming provisions at a mark-up
of pending legislation. I respectfully would ask of you that you
include H.R. 2546, a bill to name the VA Medical Center in Ashville,
North Carolina, after Private First Class Charles George.
George was a member of the Eastern Band of the Cherokee Indians
from North Carolina. He was awarded the Medal of Honor for
his actions on the night of November 30, 1952, when he pushed a
fellow soldier out of the way of an exploding grenade. Fully aware
of the consequences of his action, he absorbed the full blast of the
explosion himself. Charles George is an American hero and all of
us in North Carolina are proud to claim him as one of our heroes.
With that, Mr. Chairman, once again, I thank you for holding
this hearing. I look forward to working with all the Members as we
work toward completion of the legislation that we are here to talk
about today, but also the legislation that we have pending. I yield.
Chairman AKAKA. Thank you very much, Senator Burr.
Senator MURRAY?
STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM
WASHINGTON
Senator MURRAY. Thank you very much, Mr. Chairman, for holding
today's hearing.
Veterans' Day is only a few weeks away and many of us go home
to our States and celebrate the day with veterans at remembrance
ceremonies and events. But we have to remember that Veterans'
Day is not just a ceremony, a holiday. It is also a time that we
should be asking if we have done enough for those who have served
our country, and that is a very timely question today with so many
veterans coming home from places like Iraq and Afghanistan, and
with an aging population of veterans who do need more care. When
these brave men and women signed up to serve our country, we
agreed to take care of them. They kept their part of the bargain.
Now it is time for us to keep our part.
Today's hearing is, in essence, about this country keeping its
commitment to our veterans and ensuring that we are giving them
everything that they need. And importantly, Mr. Chairman, this is
the third legislative hearing that has been held by this Committee.
The Veterans' Affairs Committee has held two previous legislative
hearings several months ago when we considered other benefits
and health bills, and many of the bills that were considered during
those two hearings were eventually included in the health and benefits
omnibus bills that have passed out of this Committee and, as
the Chairman indicated, are awaiting floor time.
The fact that we have had to schedule a third legislative hearing
is, I think, a real testament to the amount of concern all Members
of this Committee have about the way the VA is being run, and
near the top of that list is the VA�s ability to care for veterans with
mental health problems.
Last week, USA Today reported that the number of Iraq and Afghanistan
veterans seeking care for Post-Traumatic Stress Disorder
at the VA increased by almost 70 percent last year. And unfortunately,
that number of returning veterans with PTSD and other mental health
ailments is probably too low. Many of our servicemembers and veterans
don't seek care because of the stigma surrounding treatment or because
they fear that a mental health diagnosis may hurt their career.
Mr. Chairman, as troops are deployed overseas now for the third,
fourth, and I am even hearing fifth tour of duty, the likelihood of
PTSD and other mental health conditions increases dramatically.
We have all heard about the lack of providers across the country
and the lengthy delays in getting an appointment. The VA is facing
some real challenges on this front.
The two mental health bills that are being considered today provide
slightly different approaches to dealing with this challenge
and I look forward to hearing from our witnesses about which approach
they think is best.
I am also looking forward, Mr. Chairman, to talking about a bill
that I introduced earlier this year with Senator Craig which would
ensure that the VA is prepared and equipped to deal with what
may be one long-term effect of Traumatic Brain Injury, the occurrence
of epilepsy. Our bill would establish six Epilepsy Centers of
Excellence in the VA system, and it is based on the successful MS
Centers of Excellence and Parkinson�s Disease Research, Education,
and Clinical Centers that are already operated by the VA.
At a May hearing in this Committee, Dr. John Booss, who is a
former National Director of Neurology at the VA, testified that
VA-funded research done with the Department of Defense found that
more than half of veterans who suffered a penetrating TBI in Vietnam
developed epilepsy within 15 years. For these veterans, the
relative risk for developing epilepsy more than ten to 15 years after
their injury was 25 times higher than non-veterans in the same
age group. Dr. Booss expressed strong concern that the VA lacks
a national program for epilepsy with clear guidelines on when to
refer patients for further assessment and treatment of epilepsy. He
urged this Committee to create a network of Epilepsy Centers of
Excellence.
Now, it is too early to determine the impact of TBI-induced epilepsy
created by the Iraq and Afghanistan wars, but we do know
from past wars that many injuries associated with service take
years or even decades sometimes to develop. So our bill will ensure
that the VA is prepared to care for those veterans who need care
down the road, and I hope to work with my colleagues to make this
important idea a reality soon.
Thank you very much, Mr. Chairman.
Chairman AKAKA. Thank you, Senator Murray.
Senator CRAIG?
STATEMENT OF HON. LARRY E. CRAIG, U.S. SENATOR FROM
IDAHO
Senator CRAIG. Mr. Chairman, I will be brief. Thank you for the
hearing and thank, of course, Ranking Member Burr for working
with you to produce this legislative hearing.
The reason I will be brief is because both you and Senator Murray
have already spoken to S. 2004, a bill that she and I cosponsored
to create at least six Epilepsy Centers of Excellence. Now, I
understand and realize that the VA generally opposes Congressionally
directed research. At the same time, the hearings we have held
determine that we really do need to focus much more on this tragic
ailment and result of head trauma in a way that attempts to get
to the bottom of it, and hopefully through our research and effort
can keep men and women out of epilepsy, as Senator Murray has
mentioned, as much as 15 years down the road.
We know that one cause is head trauma, or Traumatic Brain Injury,
that certainly is related to many combat injury. So that is
why we want to focus as we are proposing in this legislation to not
only improving the medical treatment of many veterans, but at the
same time hopefully deter the emergence of epilepsy later on in
life.
We have every reason to be phenomenally proud of the kind of
research ongoing at the VA. Across medical science today, VA
fingerprints of work done inside its facilities that has gone out into
the private sector to not only care for the veterans within its
facilities, but citizenry outside. I believe these kinds of Centers of
Excellence focused on epilepsy can not only help our veterans, but also
help our civilian population at large, and I think it is the right
thing to do and I am pleased that we are holding a hearing on it
today. Thank you.
Chairman AKAKA. Thank you, Senator Craig.
Senator BROWN?
STATEMENT OF HON. SHERROD BROWN, U.S. SENATOR FROM
OHIO
Senator BROWN. Thank you very much, Mr. Chairman.
There are several important pieces of legislation on today�s agenda,
but in the interest of time, I would like to focus on S. 2142, the
Veterans Emergency Care Fairness Act.
Earlier this year, I received a letter from Terry Carson, the CEO
of Harrison Community Hospital in rural Southeastern Ohio. Harrison
is a 25-bed community hospital in Cadiz. The community of
Cadiz is the home of Clark Gable and General Custer, I might add.
Terry alerted me to a reimbursement problem with the VA that
was taking a financial toll on his hospital.
In late May, Representative Zack Space and I held a joint field
hearing on issues facing veterans in rural Appalachia and we invited
Terry to be a witness. He spoke of his experience serving veterans
coming to the hospital for emergency treatment. Often after
the veteran has received the initial urgent care, the hospital
encounters problems when they attempt to transfer the veteran to an
appropriate VA facility for further treatment. Mr. Carson testified
that the hospital can wait days for transfer approvals, and in some
instances, those approvals are withdrawn during the actual transfer
of the veteran. Current law does not take this into consideration.
Under current law, non-VA facilities are reimbursed for the cost
of stabilizing a veteran who needs emergency care and then they
are expected to transfer the patient to a veterans� facility. If no
facility is available, no veterans� facility is available, there is a
coverage gap. The veteran still needs care, the hospital still provides
the care, but the VA is not required to cover any associated costs.
This anomaly in the law is unfair to veterans and hospitals alike.
This bill closes the loophole and requires the VA to cover the cost
of care provided while a transfer is pending as long as the hospital
documents reasonable attempts to complete that transfer. I want to
thank Chairman Akaka and Ranking Member Burr and the Veterans
Administration for working with me on this legislation.
I thank you, Mr. Chairman. I apologize for having to leave early
today. The farm bill is being marked up, so I appreciate the good
work you do in this Committee. Thank you.
Chairman AKAKA. Thank you, Senator Brown.
Senator ISAKSON?
STATEMENT OF HON. JOHNNY ISAKSON, U.S. SENATOR FROM
GEORGIA
Senator ISAKSON. Thank you, Chairman Akaka. Thank you,
Ranking Member Burr, for the bill that you have introduced focusing
on mental health.
I took the month of August on our break to visit the VA hospitals
in Georgia for a couple of reasons: One, to see firsthand what was
going on, and second, to lend moral support, if I could, because I
understand the tremendous pressure those hospitals are under and
the VA is under. And while there are problems with that pressure,
I saw some remarkable things happening in those hospitals.
At the Uptown Augusta Medical Center, which is near the Eisenhower
Medical Center, I saw a seamless transition from DOD to
Veterans Health Care. I had the privilege of meeting a young lady,
Sergeant Harris, who on the second day of duty in Iraq was in an
IED explosion in her Humvee and suffered a Traumatic Brain Injury.
The Department of Defense released her from duty because
of her injury. She went to the Uptown Augusta Medical Center
where doctors there corrected the damage from the Traumatic
Brain Injury and she reenlisted in the United States Army, which
is a testimony to what the VA health care is doing at the Uptown
Augusta facility in dealing with TBI.
But we have got a long way to go and I think it is very appropriate
that we have this hearing today with the focus on mental
health, epilepsy, and emergency services. It is very important to
see to it that we give the VA not only the direction, but the financial
support and the moral support to meet the challenges they will
have not just in the months and years ahead, but in the rest of the
first half of this century with the results of the injuries coming
back from the War in Iraq and the War in Afghanistan.
I look forward to hearing from our witnesses and I thank you for
the time, Mr. Chairman.
Chairman AKAKA. Thank you very much, Senator Isakson.
I want to welcome the first panel from the Department of Veterans
Affairs, Dr. Michael Kussman, Under Secretary for Health at
VA. This is the first time that you have been before the Committee
since our field hearings in Hawaii, and again, I want to thank you
so much for your participation in those hearings.
Dr. Kussman is accompanied by Walter Hall. Mr. Hall is the Assistant
General Counsel at VA. Dr. Kussman, before you begin
your prepared testimony, will you please tell the Committee about
the impact the Southern California fires have had on our VA operations.
STATEMENT OF MICHAEL J. KUSSMAN, M.D., M.S., MACP,
UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY WALTER HALL,
ASSISTANT GENERAL COUNSEL, U.S. DEPARTMENT OF
VETERANS AFFAIRS
Dr. KUSSMAN. Aloha, Mr. Chairman, and mahalo nui loa. It is a
pleasure to be here. If you indulge me for just a second, I would
like to thank Kim Lipsky for all her support with us and the collegial
working relationship we have had with her over the years. I
particularly wanted to thank her for inviting me for the field trip
to Hawaii. I know she was responsible for that.
[Laughter.]
Dr. KUSSMAN. Mr. Chairman, you asked for a quick update on
the California wildfires. So far, this tragic event that is unfolding,
there have been no injuries to employees or veterans in VA facilities,
no damage to VA facilities as of the latest report that I have
gotten. The Loma Linda Health Care System is fully operational,
but there has been some road access and some other things that
have been a challenge with the fires.
The VA San Diego Health Care System is operational and has
initiated emergency response activities. There have been some
challenges with limited staffing because a significant number of
members have been required to evacuate their homes and it has
been hard for them to get to work, but it hasn�t so far denigrated
the services that we can provide at the facility. We have housed
more than 95 people as a shelter in place and 13 patients, all
veterans, have been transferred to us from the local community.
The Greater Los Angeles Health Care System has had no major
impacts. Some staff have evacuated their homes and are on standby
to evacuate.
If you will bear with me, I will talk a little bit about the VBA
and the NCA, too, even though their under secretaries are not
here. The San Diego Regional Office Director reports that all employees
have been accounted for and has opened with 12 essential
personnel. The National Cemetery Administration has continued to
cancel burials at the Riverside Cemetery and the Rosencrantz National
Cemetery is closed due to road closures related to the fire.
But so far, we have been lucky.
There haven't been any, we know of any damage to our facilities
as well as no veterans, but we are watching it very closely and we
all pray that the winds will calm down and shift and the brave fire
fighters and all the people working on that will be able to get control
of these several fires that are going on.
Again, good morning, Mr. Chairman and Members of the Committee.
Thank you for inviting me here today to present the administration's
views on five bills that would affect the Department of
Veterans Affairs' programs. With me today, as mentioned, as Walter
Hall, the Assistant General Counsel. I would like to request
that my written statement be submitted for the record.
Chairman AKAKA. Without objection, it will be.
Dr. KUSSMAN. S. 2142, the Veterans Emergency Care Fairness
Act of 2007, would make mandatory enhanced VA authorities to
pay for a veteran's receipt of emergency treatment in a non-VA
facility.
The authorities under which VA may currently pay these
claims are discretionary in nature and use different standards to
define a medical emergency.
VA strongly supports S. 2142. It would standardize authorities
by applying the prudent layperson definition of emergency treatment
to all claims and define emergency treatment as continuing
until the point in time where the veteran is stabilized and is
transferred to a VA or other Federal facility, or until such time as
a VA facility or Federal facility agrees to accept the transfer. I am
happy to be ``Dr. Yes'' on that, versus ``Dr. No,'' or ``Dr. Maybe.''
In regards to S. 38, the Veterans Mental Health Outreach and
Access Act of 2007, while we strongly support Section 3, we do not
support Section 2. Section 2 would require VA to establish a program
to provide OEF/OIF veterans with peer outreach services,
peer support services, readjustment counseling services, and mental
health services along with related family support services to assist
in the veteran's readjustment to civilian life, the veteran's recovery,
and the readjustment of the family following return of the
veteran. The bill would require VA to contract with community
mental health centers and other qualified entities to provide covered
services in areas the VA determines are not adequately
served.
Mr. Chairman, veterans of OEF/OIF combat operations are already
qualified for readjustment counseling services and related
mental health services under existing authority. VA�s readjustment
counseling authority provides for mental health services, consultation,
professional counseling, and training for combat veterans, immediate
family members as needed for the veteran�s effective and
successful readjustment back to civilian life. Veterans Centers are
also authorized to contract for readjustment counseling services
and related mental health services. Veterans Centers routinely rely
on contracted services to meet the readjustment needs of veterans
residing in rural areas. Also, veterans centers already provide veteran
peer outreach and counseling services.
In 2004, VA began an aggressive outreach effort which included
the hiring of OEF/OIF combat theater veterans to provide outreach
services and peer counseling to their fellow veterans. To date, the
veterans center program has hired 100 OEF/OIF outreach workers,
and Al Bottras, who runs the program, is in the process of hiring
a second 100 OEF/OIF outreach peer counselors. Combat theater
veterans who enroll in VA�s health care system are also eligible for
all needed mental health services as part of VA�s medical benefits
package. Family support services are currently available to a veteran's
immediate family members as necessary in connection with
VA's treatment of the veteran�s service-connected disability.
Section 3 of S. 38 would extend from 2 to 5 years combat theater
veterans' window of eligibility to enroll without regard to whether
they have a service-connected disability or their income level. As
the leading researcher in PTSD medicine, VA has known the onset
of symptoms or adverse health care effects related to PTSD and
even mild to moderate brain injury can often be delayed and not
manifested clinically for more than 2 years. VA strongly supports
this provision, since it will provide combat theater veterans with an
additional 3 years within which they can enroll in VA's health care
system.
S. 2004 would require VA to designate at least six VA facilities
as Epilepsy Centers of Excellence. VA does not support this bill. As
a clinician as well as the Under Secretary of Health, I am concerned
about statutory mandates for disease-specific centers have
the potential to fragment care in which this otherwise well-designed
world class health care integrated system is based. I am increasingly
concerned about the proliferation of these disease-specific
models and its impact on patient care in VA's integrated
health care system. As it relates to a particular disease, I believe
it is much more important for VA to be sure to demonstrate the
best evidenced practice across the whole system than to establish
centers that provide for care of a particular disease. In essence,
every one of our centers ought to be a Center of Excellence for
these diseases.
S. 2160, the Veterans Pain Care Act of 2007, would require VA
to carry out an initiative on pain care management at each VA
health care center. We do not support this bill, as well. Pain
management is already a subject of systematic and systemic-wide
attention in the VA health care system. In 2003, VHA established a
national Pain Management Strategy to provide a systemwide approach
to pain management to reduce pain and suffering for veterans.
Under that strategy, VA uses a system-wide standard of
care for pain management, ensures pain assessment is performed
in a consistent manner, and ensures pain treatment is prompt and
appropriate, provides for continual monitoring and improvement in
outcomes of pain treatment, and ensures VA clinicians are prepared
to assess and manage pain effectively. In addition, pain management
protocols have been established and implemented in all
our settings and VA health care facilities have implemented processes
for measuring outcomes in the quality of the pain management.
Title 1 of S. 2162, the Mental Health Improvement Act of 2007,
includes multiple provisions related to VA treatment programs for
substance abuse disorders and mental health disorders, particularly
PTSD. While VA respects the attention this Committee is giving
these critical issues, we do not support Title 1. It attempts to
mandate the type of treatments to be provided to covered veterans,
the treatment settings, and the composition of the treatment
teams. Treatment decisions need to be based on professional medical
judgments, and experienced health care providers and managers are in
the best position to decide how best to deliver needed health care
services at the local level.
Title 2 of S. 2162 deals with mental health accessibility
enhancements, including the requirements for VA to establish a 3-year
pilot program to assess the feasibility and advisability of providing
eligible OIF/OEF veterans with peer outreach services, peer support
services, and readjustment counseling services, and other
mental health services. VA would be required to contract these
services with community mental health services and Indian Health
Service facilities for veterans residing in rural areas. As we
discussed in connection with Section 2 of S. 38, these services are
already available to OIF/OEF veterans, including those who served
in the National Guard or the Reserves. As such, we don't believe
these needs to exist for a pilot program with additional authorities
which are duplicative of current existing authorities.
Title 3 of S. 2162 would require that the VA carry out a program
of research into co-morbid PTSD and substance abuse disorders
and would charge VA's National Center for PTSD with the responsibility
for carrying out and overseeing this program. This is overly
prescriptive and unnecessary. Therefore, with the exception of the
extension of the Special Committee on PTSD through 2012, we are
unable to support the provisions of Title 3. VA is a world recognized
leader in the care of both PTSD and substance abuse disorders,
particularly when these conditions coexist in an individual.
The activities required by Title 3 are duplicative of the VHA's ongoing
efforts in this area, particularly in research efforts being carried
out by the VA's National PTSD Center and the VA's Office of
Research and Development. We would be happy to meet with the
Committee staff to provide them information on these ongoing efforts.
Title 4 of S. 2162 addresses assistance for families of veterans.
However, it is unclear how these readjustment and transition assistance
services the bill would require VA to pilot are intended to
differ from or interact with the readjustment counseling services
and related mental health services already made available to veterans
and their families through the veterans centers. In our view,
this provision would conflict with many aspects with the VA's existing
authorities and lend confusion to what is otherwise a highly
successful program. Client satisfaction with the veterans centers is
the highest in the VA's program, at 98 percent. The services they
provide already include marriage and counseling services to family
members as necessary to further the veteran's adjustment.
Second, we do not agree that there is a need for additional study
of the merits of using organizations for the provision of these
services. Let me again assure you that our veterans centers readily
contract with appropriate organizations and providers to ensure
veterans and their families receive covered family services when
necessary. In sum, we do not believe this provision would enhance
current authorities and the veterans center activities. Rather, we
see that it has a serious potential to create confusion and disruption
for both VA and our beneficiaries.
I appreciate the Committee's continued interest and support in
meeting the needs of our veterans. I know we share a common interest
in providing the best care to veterans and we would welcome
the opportunity to brief the Committee on VA�s ongoing programs
and activities in these areas as well as the Office of Mental Health
on overseeing PTSD and substance abuse programs.
This concludes my prepared statement and I would be pleased to
answer any questions you or other Members of the Committee
might have. Mahalo.
[The prepared statement of Dr. Kussman follows:]
PREPARED STATEMENT OF MICHAEL J. KUSSMAN, M.D., MS, MACP,
UNDER SECRETARY FOR HEALTH
Good morning Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the Administration's
views on several bills that would affect Department of Veterans Affairs
(VA) programs that provide veterans benefits and services. With me
today is Walter A. Hall, Assistant General Counsel. I will address the
five bills on today�s agenda and then I would be happy to answer any
questions you and the Committee Members may have.
S. 2142 ``VETERANS' EMERGENCY CARE FAIRNESS ACT OF 2007''
S. 2142 would make mandatory, standardize, and enhance the two
existing authorities the Secretary has to pay for expenses incurred in
connection with a veteran's receipt of emergency treatment in a non-VA
facility. The two authorities under which the Secretary may currently
pay these claims are discretionary in nature (``may reimburse'' as
opposed to ``shall reimburse'') and cover different veteran
populations and use different standards to define a medical emergency.
As background, the Secretary is authorized to pay the reasonable
expenses incurred by a veteran for non-VA emergency treatment of a
service-connected disability, a non-service-connected disability
aggravating a service-connected disability, any disability of a
veteran with a permanent and total disability, or for a covered
vocational rehabilitation purpose. In these claims, VA medical
professionals must determine whether a medical emergency existed
(i.e., if there was an actual emergency of such nature that delay in
obtaining treatment would have been hazardous to life or health.)
Expenses incurred after the medical emergency has ended, that
is, after the point in time the veteran could have been transferred
safely to VA or another Federal facility, may not be reimbursed.
The Secretary may also reimburse or pay a veteran for expenses
incurred for non-VA emergency treatment of a non-service connected
disability. In these claims, the law requires use of a prudent
layperson standard to determine the need for the non-VA emergency
treatment. Thus, if it turns out that the veteran's condition was not
an actual medical emergency, VA can still pay the expenses if a prudent
layperson would have thought it reasonable for the veteran to seek
immediate medical treatment. This happens, for instance, when a
veteran goes to the nearest emergency room because of the belief he or
she is having a heart attack, but turns out only to have a severe case
of heartburn. Similar to claims for service-connected conditions, the
Secretary is only authorized to pay for the emergency treatment
expenses, and the emergency ends at the point the veteran can be
transferred safely to a VA facility or other Federal facility.
S. 2142 would amend both existing authorities by requiring the
Secretary to pay the expenses of any veteran who meets eligibility
criteria. It would also standardize these programs by applying the
prudent layperson definition of ``emergency treatment''
in both situations. And most importantly it would define ``emergency
treatment'' as continuing until (1) the point in time the veteran can
be transferred safely to a VA or other Federal facility, or (2) such
time as a VA facility or other Federal facility agrees to accept such
transfer if, at the time the veteran could have been transferred
safely, the non-VA provider makes and documents reasonable attempts
to transfer the veteran to a VA facility or other Federal facility.
VA strongly supports S. 2142; effective emergency room reimbursement
has been an issue of concern to the Department. In fact, VA is in the
process of drafting regulations to address these concerns within the
authority it has under current law.
It is VA's expectation that facilities aggressively work to accept
the transfer of a veteran in these situations. We are aware, however,
that there have been cases where VA has been unable to find a facility
that had the bed, capability, staff, or resources needed to furnish the
care required by the veteran. In those cases, which we believe are the
exception and not the norm, the non-VA providers ultimately billed the
veterans for those expenses. This can impose a serious monetary
hardship for our beneficiaries.
S. 2142 would properly put the financial onus on the Department to
provide appropriate care either in the VA or Federal system or at the
non-VA facility. Enrolled veterans are eligible for needed hospital or
medical care. Good medical practice demands we furnish such care in a
manner that advances a seamless continuum of care and reduces
fragmentation of such care. Clearly these goals are best achieved
by bringing the veteran into the VA health care system as soon as
possible. In those rare cases where VA cannot immediately agree to
accept the patient transfer, it would be entirely appropriate for VA to
be responsible for the expenses related to the veteran's needed
continued hospital care in the private facility until the point
VA can take over.
When VA initiated drafting regulations for this program choice, it
determined funds were available within the FY 2008 President's Budget
level for this expanded benefit.
As a final and more technical matter, I would like to clarify that if
a veteran currently meets the eligibility criteria on which his or her
claim is based, VA invariably pays the claim. Thus, changing the
Secretary's authority from ``may'' to ``shall'' for purposes of both
types of claims would have no practical effect. Nevertheless, we do
not object to such a change.
S. 38 ``VETERANS' MENTAL HEALTH OUTREACH AND ACCESS ACT OF 2007''
SECTION 2 OF S. 38
Section 2 of S. 38 would require the Secretary to establish, not
later than 180 days after enactment of the bill, a program to provide
veterans of Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) ``peer outreach services, peer support services, readjustment
counseling services, and mental health services.'' As part of this
program, the Secretary would be required to furnish education, support,
counseling, and mental health services to a veteran�s immediate family
members to assist: in the veteran's readjustment to civilian life, the
veteran's recovery, and the readjustment of the family following the
return of the veteran.
S. 38 would also require the Secretary to contract with community
mental health centers and other qualified entities to provide the peer
related, readjustment, and mental health services in areas the
Secretary determines are not adequately served by VA health care
facilities. Such contracts would require, to the extent practicable,
that veterans providing peer related services receive training from a
national not for-profit mental health organization, which contracts
with VA for this purpose. In addition, the contractor�s clinicians
would be required to (1) complete mandated training to ensure the
clinicians can provide services in a manner that recognizes
factors that are unique to the experience of OEF/OIF veterans and (2)
to utilize best practices and technologies.
The centers and entities would have to comply with applicable VA
protocols before incurring any liability on behalf of the Department;
submit specified reports and certain clinical information to the
Secretary; and meet any other requirements established by the
Secretary.
VA supports many of the initiatives and certainly the stance of
aggressive outreach that underlies this provision. VA does not,
however, support section 2 as it is unnecessary and duplicative of
current authorities. Veterans of OEF/OIF combat operations already
qualify for readjustment counseling services and related mental health
services under existing authority. (While limited mental health
services are available in the Vet Center program, Vet Centers refer
veterans with complex mental health conditions to VA medical centers.)
VA's readjustment counseling authority provides for the furnishing of
mental health services, consultation, professional counseling, and
training to the combat veteran's immediate family members as
needed for the veteran's effective and successful readjustment back to
civilian life.
Vet Centers are also authorized to contract for the provision of
readjustment counseling services and related mental health services.
Vet Centers routinely rely on contracted services to meet the
readjustment needs of veterans residing in rural areas. Hence, the
additional authorities related to the provision of readjustment
counseling services and related mental health services for OEF/OIF
veterans (either through the Vet Centers or by contract) are generally
duplicative and simply not needed.
Vet Centers are already providing veteran-peer outreach and
counseling services. In 2004, VA began an aggressive outreach effort,
which included the hiring of OEF/OIF combat-theater veterans to provide
outreach services and peer-counseling to their fellow veterans. To
date, the Vet Center program has hired 100 OEF/OIF out-reach workers.
The Vet Center program is also undergoing the largest expansion in
its history. This expansion complements the Vet Center peer outreach
services initiative.
These efforts together enable our Vet Centers to ensure there are
sufficient staff and resources to provide the professional readjustment
services needed by the new veterans as they return home.
OEF/OIF combat-theater veterans are also already eligible to enroll
within 2 years of the date of discharge or release from active duty in
VA's health care system and receive VA�s comprehensive medical benefits
package.
As to family support services, VA is already required to provide
immediate family members of a veteran being treated for a
service-connected disability with such mental health services,
consultation, professional counseling, and training as necessary
in connection with that treatment.
If a veteran is being treated for a non-service connected disability,
the law currently authorizes the Secretary to provide family services
if: the services are initiated during the veteran's hospitalization and
the continued provision of these services on an outpatient basis is
essential to permit the discharge of the veteran from
the hospital.
We believe no additional authority is needed as the vast majority of
family members of returning OEF/OIF veterans already qualify for these
services. However, neither existing authority extends to providing a
veteran's family members with mental health services for their
individual mental health needs that are separate and apart
from the veteran's treatment needs. It is unclear whether S. 38 is
intended to authorize individual mental health benefits for family
members beyond services needed to assist the veteran's treatment and
readjustment. If that is the case, we could not support that provision
for the following reasons.
Mental health conditions often manifest with physical symptoms or
sequella. In those cases, providing only mental health services to
assist in a family member's readjustment could result in fragmented and
inadequate treatment. The receipt of other medical care could be equally
essential for that member�s successful readjustment, and the failure to
receive such care could impair the ability of the family as
a whole to successfully readjust to the veteran's return. For that
reason, we believe it would be more reasonable, from a health care
perspective, to continue linking family support services to those that
are essential for the veteran's readjustment. Family members should
continue to receive needed mental health services from their regular
providers who can treat them from a whole-person perspective and
concurrently address all of their medical needs.
Also, when VA contracts for services in the community, community
health centers may compete for those contracts. The provision to
require VA to contact specifically with that entity may reduce the
opportunity for the veteran to be cared for by the most highly
qualified competent contractor.
We also note that OEF/OIF veterans who are permanently and totally
disabled from a service-connected disability are able to sponsor their
spouses and children in VA's Civilian Health and Medical Program
(commonly referred to as ``CHAMPVA''). Once enrolled in that program,
their family members will be eligible to receive relatively
comprehensive VA medical benefits.
As a final comment on this section, we are uncertain what is meant
by the provision requiring centers to comply with VA protocols before
incurring any liability on behalf of the Department.
SECTION 3 OF S. 38
Section 3 of S. 38 would extend from 2 to 5 years, combat-theater
veterans' window of eligibility to enroll without regard to whether
they have a service connected disability or their income level. VA
strongly supports section 3. As the leading researcher in PTSD
medicine, VA has known that the onset of symptoms or adverse health
effects related to PTSD and even Traumatic Brain Injury can often be
delayed and not manifest clinically for more than 2 years after a
veteran has left active service. As a result, OEF/OIF may not seek VA
health care benefits until after their 2-year window of eligibility has
already closed. Without that basis of eligibility, they may be
ineligible to enroll because of the current bar on enrolling new
veterans in Category 8.
We are also aware that many of these veterans are not career military
and are less familiar with veterans benefits and the procedures for
obtaining them. For that reason they may fail to enroll in a timely
fashion.
Providing combat-theater veterans with an additional 3 years within
which to enroll in VA's health care system will help ensure that none
of them is denied the care they need and deserve for reasons wholly
beyond their control. VA estimates the costs associated with enactment
of section 3 to be $15.7 million in Fiscal Year 2008, and this
expansion can be accommodated within the FY 2008 President's Budget
level. This estimate includes both expenditures and lost co-payment
revenue.
S. 2004 ``EPILEPSY CENTERS OF EXCELLENCE''
S. 2004 would require the Secretary, not later than 120 days after
enactment of this provision, to designate at least six Department
health-care facilities as epilepsy centers of excellence based on the
recommendation of the Under Secretary for Health (USH). The mandate to
establish and operate these centers, however, would be subject to the
availability of appropriations for this purpose.
The bill defines an ``epilepsy center of excellence'' as a Department
health-care facility that has (or in the foreseeable future can
develop) the necessary capacity to function as a center of excellence
in research, education, and clinical care activities in the diagnosis
and treatment of epilepsy. To qualify as a center, the facility would
need:
affiliation with an accredited medical school that provides
education and training in neurology (or may reasonably be anticipated
to develop such an affiliation).
The ability to attract scientists of ingenuity and
creativity.
An advisory committee composed of veterans and appropriate
health-care and research representatives of the facility and of the
affiliate.
The capability to effectively evaluate the activities of the
centers.
The capability to coordinate the centers education, clinical
care, and research activities.
The capability to develop a national consortium of providers
with interest in treating epilepsy at VA medical centers; the
consortium would have to include a designated epilepsy referral
clinical in each Veterans Integrated Service Network.
The capability to assist in the expansion of VA's use of
information systems and databases to improve the quality and delivery
of care.
The capability to assist in the expansion of VA�s tele-health
program to develop, transmit, monitor, and review neurological
diagnostic tests.
The ability to perform epilepsy research, education, and
clinical care activities in collaboration with VA�s Poly Trauma
Centers.
A number of specific requirements governing the competitive selection
of the six facilities are set forth in the bill, including a
requirement that the Secretary consider appropriate geographic
distribution when making the selections.
S. 2004 would further mandate the designation of an individual in VHA
to act as a national coordinator for VHA�s epilepsy programs. The bill
includes a list of duties for that position, including that such
individual report to the VHA official responsible for neurology.
The bill would authorize $6 million for each of fiscal years 2008
through 2012 to establish and operate the centers; such sums as may be
necessary for operating the centers for each fiscal year after fiscal
year 2012 would also be authorized. For the first 3 years of the
centers operation, the bill would require that the centers be
designated as a special purpose program in order to avoid funds for the
centers being allocated through the Veterans Equitable Resource
Allocation system. In addition to those amounts, the USH would be
required to allocate such amounts as he deems appropriate from other
funds made available to VHA. The bill includes a separate authorization
of appropriations to fund the national coordinator position.
VA does not support S. 2004. As I have discussed in the past, I am
concerned that statutory mandates for ��disease specific�� centers have
the potential to fragment care in what is otherwise a well-designed,
world-class integrated health care system. I am increasingly concerned
about the proliferation of this disease-specific model and its impact
on patient care and VA�s integrated health care model. As it relates to
a particular disease, I believe that it is much more important for VA
to disseminate the best in evidence-based practices across its health
care system than to establish centers that provide care for a
particular disease.
Treating epilepsy, like every other serious condition, requires an
interdisciplinary approach. By mandating new ��education, research, and
clinical centers�� that are disease-specific, flexibility to respond to
changing combinations of related conditions is reduced. The centers'
mandated collaboration with VA�s Poly trauma Centers would not cure
this short-coming.
It is also important to note that the ��models�� on which these
Epilepsy Centers are based, the successful Geriatric Research,
Education and Clinical Center (GRECC) and Mental Illness Research,
Education and Clinical Center (MIRECC) programs, are not narrowly
focused on a disease process but address a wide gamut of issues facing
a significant portion of the veteran population.
S. 2160 ``VETERANS PAIN CARE ACT OF 2007''
S. 2160 would require the Secretary to carry out an initiative on
pain care management at each VA health care facility. Under the
initiative, each individual receiving treatment in a VA facility would
receive: (1) a pain assessment at the time of admission or initial
treatment and periodically thereafter, using a professionally
recognized pain assessment tool or process; and (2) appropriate pain
care consistent with recognized means for assessment, diagnosis,
treatment, and management of acute and chronic pain, including, when
appropriate, access to specialty pain management services. The
initiative would have to be implemented at all VA health care
facilities by not later than January 1, 2008, in the case of inpatient
care and by not later than January 1, 2009, in the case of outpatient
care.
The bill would further require the Secretary to carry out a program
of research and training on acute and chronic pain within VHA�s Medical
and Prosthetic Research Service. These programs would be directed to
meet the purposes specified in the bill. The Secretary would also be
required to designate an appropriate number of facilities as
cooperative centers for research and education on pain. Each such
center would focus on research and training in one or more of the
following areas: acute pain; chronic pain, or a research priority
identified by VHA. The Secretary would also need to designate at
least one of those centers as a lead center for research on pain
attributable to central and peripheral nervous system damage commonly
associated with the battlefield injuries characteristic of modern
warfare. Another center would be the lead for coordinating the pain
care research activities conducted by the centers and responsible for
carrying out a number of other duties specified in the bill.
The measure would permit these centers to compete for funding from
amounts appropriated to the Department each year for medical and
prosthetics research. It would also charge the USH with designating an
appropriate official to oversee their operation and to evaluate their
performance.
VA health care is delivered in accordance with patient-centered
medicine. Fundamental to this is effective pain management. In 2003 VHA
established a National Pain Management Strategy to provide a
system-wide approach to pain management to reduce pain and suffering
for veterans experiencing acute and chronic pain associated with a wide
range of illnesses. The national strategy uses a system-wide standard
of care for pain management; ensures that pain assessment is performed
in a consistent manner; ensures that pain treatment is prompt and
appropriate; provides for continual monitoring and improvement in
outcomes of pain treatment; uses an interdisciplinary, multi-modal
approach to pain management; and ensures VA clinicians are prepared to
assess and manage pain effectively. The national strategy also called
for pain management protocols to be established and implemented in all
clinical settings and directed all VHA medical facilities to implement
processes for measuring outcomes and quality of pain management.
To oversee implementation of the National Pain Management System, VHA
established an interdisciplinary committee. Part of the Committee's
charge is to ensure that every veteran in every network has access to
pain management services. The committee is also responsible for making
certain that national employee education is provided to VHA clinicians
so that they have the needed expertise to provide high quality pain
assessment and treatment and for identifying research opportunities
and priorities in pain management. It also facilitates collaborative
research efforts and ensures that VHA pain management standards have
been integrated into the curricula and clinical learning experiences of
medial students, allied health professional students, interns, and
resident trainees.
Because pain management is already a subject of systematic and
system-wide attention in the VHA health care system, S. 2160 is
superfluous and duplicative of what is already happening in VA
healthcare. We would be very happy to meet with the Committee to
discuss VA's ongoing pain management program and activities.
S. 2162 ``MENTAL HEALTH IMPROVEMENTS ACT OF 2007''
TITLE I. SUBSTANCE USE DISORDERS AND MENTAL HEALTH CARE
Mr. Chairman, title I of this bill focuses on VA treatment programs
for substance use disorders and mental health disorders, particularly
PTSD. Section 102 would require the Secretary to ensure the provision
of the following services for substance use disorders at every VA
medical center:
Short term motivational counseling services.
Intensive outpatient care services.
Relapse prevention services.
Ongoing aftercare and outpatient counseling services.
Opiate substitution therapy services.
Pharmacological treatments aimed at reducing cravings for drugs
and alcohol.
Detoxification and stabilization services.
Such other services as the Secretary deems appropriate.
The Secretary could, however, exempt an individual medical center or
Community-Based Outpatient Clinic (CBOC) from providing all of the
mandated services.
Annually the Department would have to report to Congress on the
facilities receiving an exemption under this provision, including the
reason for the exemption.
Section 103 would require the Secretary to ensure that VA treatment
for a veteran's substance use disorder and a co-morbid mental health
disorder is provided concurrently by a team of clinicians with
appropriate expertise.
Section 104 would require the Secretary to carry out a program to
enhance VA's treatment of veterans suffering from substance use
disorders and PTSD through facilities that compete for funds for this
purpose. Funding awarded to a facility would be used for the six
purposes specified in the bill, in addition to the conduct of peer
outreach programs through Vet Centers to re-engage OEF/OIF veterans who
miss multiple appointments for PTSD or a substance use disorder.
Another specified purpose for the funds would be to establish
collaboration between VA's urgent care clinicians and substance use
disorder and PTSD professionals to ensure expedited referral of
veterans who are diagnosed with these disorders.
Not later than 1 year after the bill�s enactment, the Secretary would
need to submit a report to Congress on this program and the facilities
receiving funding.
S. 2162 would provide for funding by requiring the Secretary to
allocate $50 million from appropriated funds available for medical care
for each of fiscal years 2008, 2009, and 2010. The bill would require
the total expenditure for PTSD and substance use disorder programs to
not be less than $50 million in excess of a specified baseline amount.
(The bill would define the baseline as the amount of the total
expenditures on VA's treatment programs for PTSD and substance use
disorders for the most recent fiscal year for which final expenditure
amounts are known, as adjusted to reflect any subsequent increase in
applicable costs to deliver those programs.)
Section 105 would require the Secretary to establish not less than
six national centers of excellence on PTSD and substance use disorders.
These centers would provide comprehensive inpatient treatment and
recovery services to veterans newly diagnosed with these disorders.
Sites for the centers would be limited to VA medical centers that
provide inpatient care; that are geographically situated in an area
with a high number of veterans that have been diagnosed with both PTSD
and substance use disorder; and that are capable of treating PTSD and
substance use disorders.
This provision would also direct the Secretary to establish a process
to refer and aid the transition of veterans receiving treatment in
these centers to programs that provide step down rehabilitation
treatment.
Section 106 would require the Secretary, acting through the Office of
the Medical Inspector (MI), to review all of VA�s residential mental
health care facilities and to submit to Congress a detailed report on
the MI's findings.
Section 107 would provide for title I of this bill to be enacted in
tribute to Justin Bailey, an OIF veteran who died while under VA
treatment for PTSD and a substance use disorder.
While VA respects the attention this Committee is giving these
critical issues, Title I is overly prescriptive and attempts to mandate
the type of treatments to be provided to covered veterans, the
treatment settings, and the composition of treatment teams. Treatment
decisions should be based on professional medical judgments in light of
an individual patient�s needs, and experienced health care managers
are in the best position to decide how best to deliver needed health
care services at the local level. With regard to the proposed centers
of excellence, we reiterate our concerns about disease-specific
treatment centers and models, although we appreciate the Committee's
efforts thereby to hasten the eradication of those particular diseases.
For all of the above reasons, we do not support this title.
TITLE II. MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS
Section 201 would require the Secretary to establish a 3-year pilot
program to assess the feasibility and advisability of providing
eligible OEF/OIF veterans with peer outreach services, peer support
services, and readjustment counseling services, and other mental health
services. This pilot would begin not later than 180 days after the
bill's enactment. Eligible veterans would include those who are enrolled
in VA's health care system and who, for purposes of the pilot program,
receive a referral from a VHA health professional to a community mental
health center or to a facility of the Indian Health Service (IHS).
In providing readjustment counseling services and other mental health
services to rural veterans who do not have adequate access to VA
services, section 201 would require the Secretary, acting through the
Office of Rural Health, to contract for those services with community
mental health centers (as defined in 42 CFR 410.2) and IHS
facilities.
Sites for the pilot would need to include at least two Veterans
Integrated Service Networks (selected by the Secretary), and at least
two of the sites would have to be located in rural areas that lack
access to comprehensive VA mental health services.
A center or IHS facility that participates in the pilot program must,
to the extent practicable, provide readjustment counseling services and
other mental health services to eligible veterans through the use of
telehealth services. It would also need to provide the services using
best practices and technologies and meet any other requirements
established by the Secretary. A participating center or IHS facility
would also have to comply with applicable VA protocols before incurring
any liability on behalf of the Department and provide clinical
information on each veteran to whom it furnishes services.
The Secretary would be required to carry out a national program of
training for (1) veterans who would provide peer outreach and peer
support services under the pilot program; and (2) clinicians of
participating centers or IHS facilities to ensure they can furnish
covered services and that such services will be provided in a manner
that accounts for factors unique to OEF/OIF veterans. This provision
would also establish detailed annual reporting requirements for
participating centers and facilities.
As we discussed in connection with section 2 of S. 38, all of these
services are already available to OEF/OIF veterans, including those who
served in the National Guard or the Reserves. As such, no demonstrated
need exists for the pilot program or these additional authorities,
which are duplicative of currently existing authorities. And VA is
already working with other entities to provide treatment to veterans
at the local level if VA is not able to provide the needed care;
therefore, the requirement to contract specifically with a community
health center or IHS facility would limit the local VA providers'
flexibility in finding the most appropriate care for our veterans.
TITLE III. RESEARCH
Section 301 would require the Secretary to carry out a program of
research into co-morbid PTSD and substance use disorder. The purpose of
this program would be to address co-morbid PTSD and substance use
disorder; provide systematic integration of treatment for these two
disorders; develop protocols to evaluate VA's care of veterans with
these disorders; and, facilitate the cumulative clinical progress of
these veterans. This provision would charge VA�s National Center for
PTSD with responsibility for carrying out and overseeing this program,
developing the protocols and goals, and coordinating the research, data
collection, and data dissemination.
Section 301 would also authorize $2 million to be appropriated for
each of fiscal years 2008 through 2011 to carry out this program and
specifically require these funds be allocated to the National PTSD
Center. The funds made available to the Center would be in addition to
any other amounts made available to it under any other provision of
law.
Section 302 would continue the Special Committee on PTSD (which is
established within VHA) through 2012; otherwise the Committee�s mandate
would terminate after 2008.
While well-intended, this title is overly prescriptive and more
importantly altogether unnecessary. Therefore, with the exception of
the extension of the Special Committee, VA does not support the
provisions in title III. VA is a world-recognized leader in the care of
both PTSD and substance use disorders, particularly when these
conditions co-exist in an individual. The activities required by title
III are essentially duplicative of VHA's on-going efforts in this area,
particularly the research efforts being carried out by VA�s National
PTSD Center. We would welcome the opportunity to brief the Committee on
VA's achievements and efforts in this area, plus the role of the Office
of Mental Health in overseeing the PTSD and substance abuse programs.
TITLE IV. ASSISTANCE FOR FAMILIES OF VETERANS
In connection with the family support services authorized in chapter
17 of title 38, United States Code (i.e., mental health services,
consultation, professional counseling, and training), section 401 would
amend the statutory definition of ``professional counseling'' to
expressly include marriage and family counseling. This provision
would also ease eligibility requirements for these family support
services by authorizing the provision of these services when considered
appropriate (as opposed to essential) for the effective treatment and
rehabilitation of the veteran. Section 401 would further clarify that
these services are available to family members in Vet Centers, VA
medical centers, CBOCs, or other VA facilities the Secretary considers
necessary.
Section 402 would require the Secretary to carry out, through a
non-VA entity, a 3-year pilot program to assess the feasibility and
advisability of providing ``readjustment and transition assistance'' to
veterans and their families in cooperation with Vet Centers.
Readjustment and transition assistance would be defined as readjustment
and transition assistance that is preemptive, proactive, and
principle-centered. It would also include assistance and training for
veterans and their families in coping with the challenges associated
with making the transition from military to civilian life.
This provision would require services furnished under the pilot
program to be furnished by a for-profit or non-profit organization(s)
selected by the Secretary (pursuant to an agreement). To participate in
the pilot, a participating organization(s) must have demonstrated
expertise and experience in providing those types of services.
The pilot program would have to be carried out in cooperation with 10
geographically distributed Vet Centers, which would be responsible for
promoting awareness of the assistance available to veterans and their
families through the Vet Centers, the non-VA organization(s) conducting
the pilot, and other appropriate mechanisms.
Section 403 would establish detailed reporting requirements and
authorize $1 million to be appropriated for each of fiscal years 2008
through 2010 to carry out the pilot program. Such amounts would remain
available until expended.
VA does not support title IV. First, it is unclear how these
``readjustment and transition assistance'' services are intended to
differ from, or interact with, the readjustment counseling services and
related mental health services already made available to veterans and
their families through the Vet Centers. In our view, this provision
would conflict in many respects with VA's existing authorities to
provide readjustment counseling and related mental health services and
lend confusion to what is otherwise a highly successful program
(particularly with respect to client outreach). Indeed, client
satisfaction with the Vet Centers is the highest of VA's programs (98
percent). The services they provide already include marriage and
counseling services to family members as necessary to further the
veteran's readjustment.
We also do not understand the perceived need for reliance on non-VA
organizations for the provision of these services. Let me again assure
you that our Vet Centers readily contract with appropriate
organizations and providers to ensure veterans and their families
receive covered family support services. In sum, we do not see how this
provision would effectively enhance current authorities or Vet Center
activities; rather, we see that it has serious potential to create
confusion and disruption for both VA and our beneficiaries.
We are currently developing cost estimates on the provisions of these
bills, which we will share with the Committee once completed. This
concludes my prepared statement. I would be pleased to answer any
questions you or any of the Members of the Committee may have.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY MICHAEL J. KUSSMAN,
M.D., TO HON. DANIEL K. AKAKA, CHAIRMAN, SENATE COMMITTEE OF
VETERANS' AFFAIRS
Question 1. Please highlight the current VA research programs that
are examining how to treat veterans who suffer from both substance use
disorder and PTSD.
Response. The Department of Veterans Affairs (VA) continues to be a
leader in supporting research related to the mental and physical health
consequences of military service, including Post Traumatic Stress
Disorder (PTSD). VA researchers and clinicians are working together to
understand how co-occurring disorders like substance abuse and PTSD
affect a patient's treatment, and are striving to develop the most
effective treatments through rigorous research. VA�s National Center
for PTSD and several of VA�s mental illness research education and
clinical centers (MIRECCs) are engaged in studies of PTSD and
co-occurring substance use disorders.
Examples of some of the current ongoing research programs sponsored
by the Office of Research and Development include:
VA scientists supported by VA and the Department of Defense
(DDD), have collected risk factor and health information from military
personnel prior to their deployments to Iraq. Compared to the
retrospective studies of past conflicts, this landmark study represents
the first time scientists will be able to prospectively examine
differences between pre-deployment and post-deployment performance and
health outcomes, including PTSD and other health conditions;
VA's Alcoholism Research Center is recognized as one of the
world leaders in understanding genetic contributions to substance
abuse. Currently, this center is exploring novel treatments for
reducing withdrawal symptoms and drinking;
VA scientists are exploring the genetic determination of
traits related to ethanol withdrawal severity, considered important to
reducing relapse events;
VA scientists are examining the effectiveness of opioid
substitution therapy to reduce substance abuse;
VA's quality enhancement research initiative (QUERI) is
sponsoring an initiative to improve the detection and treatment of
misuse of psychoactive substances in many co-occurring conditions; and
VA is supporting research to identify risk factors in
subgroups of smokers who are at risk for both increased smoking and
difficulty in smoking cessation that could lead to important prevention
and intervention efforts.
SOME RECENT ADVANCES BY VA INVESTIGATORS INCLUDE:
In the largest randomized clinical trial to date involving
women veterans with PTSD, VA investigators found that
prolonged-exposure therapy--a type of cognitive behavioral therapy--was
effective in reducing PTSD symptoms and that such reductions
remained stable over time (JAMA, 2007;297(8):820-830).
Investigators found that prazosin, an inexpensive generic
drug already used by millions of Americans for high blood pressure and
prostate problems, improves sleep and reduces trauma nightmares for
veterans with PTSD (Biological Psychiatry. 2007; 61 (8):928-934). A
large, multi-site study is underway to confirm the drug's
effectiveness.
VA researchers found that opioid substitution therapy is as
effective at reducing substance use in PTSD patients as it is in
patients without PTSD, but additional services are needed for treatment
of psychological problems that are largely unchanged by treatment for
addiction (J Stud Alcohol. 2006 Mar;67(2):228-35).
Question 2. The Institute of Medicine's report ``Treatment of PTSD:
An Assessment of the Evidence'' released on October 18, 2007 makes a
number of observations and recommendations on the need for more
research. Accordingly, is VA prepared to assume the leadership role in
PTSD research suggested, and does VA have plans to collaborate with the
full panoply of Federal and private health organizations focused upon
this area to define outcome measures and coordinate future research?
Response. VA, in the continuing role as leader for combat-related
PTSD research and treatment, has a well-developed plan to collaborate
with other organizations to define outcome measures and coordinate
future research. We are particularly proud of the VA scientists who
contributed to establishing the evidence supporting the effectiveness
of prolonged-exposure therapy which is a psychotherapeutic approach
highlighted as the treatment with the highest level of evidence in the
Institute of Medicine's (IOM) report. We gratefully acknowledge the
veterans who willingly participated in this scientific research.
The IOM report details important research recommendations that will
guide future PTSD interventional studies in meeting the highest
accepted standards for randomized controlled trials. The
recommendations include: (a) standardizing the measures used to
determine a modality's effectiveness; and (b) analysis and design
improvements that will lead to more solid conclusions about
effectiveness of a treatment modality. These issues are best addressed
within the scientific and clinical communities. Accordingly, VA has
already begun organizing the working group, which will be convened by
VA with other Federal research funding agencies early in 2008. Specific
outcomes from the working group will be guidance for the scientists
developing PTSD interventional studies, as well as for expert peer
review panels evaluating research proposals.
Question 3. Clearly, VA and the Committee agree upon the important
role families play in providing care for veterans. As VA invests more
energy and resources into caring for veterans in their home it is
imperative to respond to the needs of the family members fulfilling the
role of care giver. At this time, what services is VHA providing to
veterans' families? Do you believe these services are being provided
consistently throughout VA?
Response. In areas such as mental health and rehabilitation of
veterans with multiple wounds from blast injury, for example, support
of families can be essential to the veteran's rehabilitation, Many VA
psychologists and social workers are trained and credentialed family
therapists. Innovative supports for family members include home health
care services and the use of tele-health approaches to make care of
wounded or otherwise severely disabled veterans easier for caregivers
at home. VA is continuing to explore ways to make these services more
``family friendly'' in particular for families of severely wounded
veterans who bear a heavy burden of care giving.
Family counseling is available at Vet Centers, as needed, in
connection with readjustment counseling services furnished to a combat
theatre veteran for his or her psychological or social readjustment
problems. Providing family counseling services at Vet Centers is not
time limited and is available as necessary for the veteran's
readjustment throughout the life of the veteran. The Vet Center program
has an extensive cadre of licensed clinical social workers,
psychologists and nurse psychiatric clinical specialists that provide
family assessments, education, preventive health care information,
supportive social services, basic counseling and referrals. A number of
the program's licensed mental health providers also have the
professional expertise to provide marriage and family counseling. The
Vet Centers have a cadre of other counselors with master degrees who
hold a license in marriage and family counseling.
The polytrauma system of care (PSC) has developed consistent and
comprehensive procedures for patients and their families. Families of
injured servicemembers require particular assistance in making the
transition from the acute medical setting to a rehabilitation setting,
including home care. This support encompasses medical care,
psychosocial support, and logistical support. For psychosocial support,
the proactive case management system provides ongoing support and
problem solving in the home community while continually assessing for
new and emerging problems. Finally, in terms of logistical support,
each polytrauma rehabilitation center (PRC) team carefully assesses the
expected needs at discharge for transportation, equipment, home
modifications, and other such needs and makes arrangements to provide
the needed services to meet the assessed needs.
The Veterans Health Administration�s Polytraumal Traumatic Brain
Injury (TBI) system of care is designed to assure lifelong care and
support for injured soldiers and veterans. As part of this commitment,
VA assesses the unique needs of all polytraumal TBl patients and, where
indicated, engages the expertise of the private sector. Depending upon
the severity of the injury, the needs of veterans with TB] are met
either through long-term care for veterans who cannot return home and
require institutional care or through extended care support services
for veterans who can return to their communities, but not live
independently.
The types of non-institutional care that VA currently provides for
veterans who can return to their communities, but cannot live
independently, include: home based primary care (HBPC); adult day
health care (ADHC); respite cam/purchased skilled home health care;
homemaker/home health aid (H/HHA); and care coordination/home
tele-health (CC/HT).
Question 4. While I am glad to hear that VA supports S. 2142, I
remain concerned over VA's record on emergency treatment. VA�s Office
of General Counsel (OGC), in a memorandum dated November 16, 2005,
concluded that VA may deny reimbursement for care furnished by a non-VA
facility when a patient is stabilized, despite the fact that a transfer
to a VA facility cannot take place due to the lack of an available bed.
What assurance can you provide the Committee that, in the future, VA
will take care of all veterans eligible for this benefit?
Response. Although VA makes every effort to accept transfer of a
stabilized patient as soon as possible, the Department�s current
interpretation of regulations, as stated in the November 16, 2005 GGC
memorandum, does not allow VA to provide reimbursement or payment for
the non-VA hospital care expenses that are incurred while the
stabilized patient is awaiting transfer to VA care.
As VA has testified on the Hill, VA fully supports S. 2142, which, in
general, would amend VA's statutory authority to reimburse or pay for
emergency treatment furnished by a non-VA provider when the veteran is
stabilized and awaiting transfer to VA. Prior to this bill's
introduction, VA had independently decided to amend current regulations
to implement an alternate, valid interpretation of VA's existing
statutory authority that would achieve the same overall goal as the
pending legislation. Please note, however, that those proposed
regulation changes are only in the very early stages of drafting and
still subject to all the procedures and requirements of the
Administrative Procedures Act. But this beginning effort should make
clear that VA and the Congress are, indeed, of the same mind in
attempting to ensure a stabilized veteran in need of continued
hospitalization is not penalized (by incurring personal financial
liability for the costs of the continued care) due to VA�s inability
to immediately effect a transfer of the patient to a Department
facility.
Question 5. Your prepared testimony described S. 2160 as
``superfluous and duplicative'' of VA's current efforts on pain care.
However, other witnesses at the hearing raised a number of concerns
over the adequacy of VA's current efforts. I share in the concern over
the lack of uniformity and the apparent variance in the quality of pain
care services available at different facilities. Specifically, I
question whether all veterans, including those in rural areas, are
receiving an adequate level of pain care services?
Response. VA has made pain management a national priority and
continues to work aggressively to assure timely access to the highest
quality pain care for all veterans seen at VA healthcare facilities,
including access in more remote, rural areas. Assuring all veterans
(including those returning from Afghanistan and Iraq and those who have
experienced polytrauma) are provided immediate and appropriate access
to effective pain care, is a top priority for VA.
VA implemented a National Pain Management Strategy in 1998 and
published a directive on pain management in 2003 to promote a
system-wide approach to pain management. Several publications document
the broad successes of this strategy. Of particular note, external peer
review data document that routine screening for the presence and
intensity of pain, pain plans of care, and reassessment of the
effectiveness of the interventions occur with consistency across all VA
settings of care.
Extensive educational efforts have been ongoing for the past several
years to support the development of provider competency in the area of
pain management, including national, Veterans Integrated Service
Network (VISN), and facility educational conferences, monthly
educational teleconferences, a national pain management website,
dissemination of evidence-based information letters and toolkits on
pain assessment and management. Practice guidelines have been developed
and disseminated to promote safe and effective chronic opioid therapy,
post-operative pain care, and management of low back pain. Patient and
family educational resources have been developed and disseminated. VA's
support for basic science and clinical research on pain and pain
management has grown by 500 percent over the past 5 years.
VA remains committed to ensuring that quality pain care services are
available to all veterans receiving care through the Department.
Question 6. Regarding S. 2160, does providing a statutory basis for
VA's pain initiative cause a problem for the Department?
Response. Because pain management is already a subject of system-wide
attention in VA, statutorily mandating a pain initiative is not
necessary. Creating fenced research centers and legislatively mandating
specific clinical activities will limit the ability of the Department
to adjust health care allocations in response to changes in health care
needs.
Question 7. Is VA prepared for the anticipated increase in veterans
suffering from chronic pain, especially those who are suffering with
polytrauama?
Response. Yes. VA is already engaged in numerous new initiatives
designed to build on prior successes and to further improve consistency
of pain care for veterans.
For example, VA now has a revised computerized pain assessment and
reassessment polytrauma template/reminder system, which is currently
being implemented in two of the four Polytrauma Rehabilitation Centers
prior to more widespread dissemination. Also, there are multiple
research and clinical programs underway to address pain in patients
with PTSD or TBI. Finally, a multi-pronged, multi-disciplinary project
to enhance the safe and effective use of opioid medications for pain
has recently begun.
Chairman AKAKA. Mahalo. Thank you very much, Dr. Kussman.
Because of time, I am going to try to move this along. I was just
notified that we expect a number of votes beginning at 11. So as a
result, I am going to ask you just one question and I will ask the
other members, as well.
Dr. Kussman, you testified that you do not support the provisions
of S. 2162 but that you do support the goals and intentions
of this mental health legislation. So to be clear, there is agreement
that there is a demonstrated need for changes in mental health
services. However, Congress has yet to receive the draft legislation
from VA regarding improvements to mental health. Do you believe
that there are no deficiencies in VA mental health services and
that you have all the legal tools available to reach all veterans in
need?
Dr. KUSSMAN. Mr. Chairman, thank you for the question and let me try
to be very clear with this. I never would suggest that we are perfect.
I would never suggest that we don�t need to improve. That is what we
do. That is why we developed our Mental Health Strategic Plan. That is
why we have all the programs that we do, and those are viable growing,
building programs.
What I was saying is that I believe that we do need to continue
to improve. I do not believe that there are any legislative impediments
for us to continue to improve and I don�t think that the legislation
is needed and that is why we haven�t put any legislation
forward. I believe we already have the ability, legally or otherwise,
to provide good care for our veterans.
Chairman AKAKA. Thank you, Dr. Kussman. I will submit my other
questions to you and call on Senator Burr for his questions.
Senator BURR. Thank you, Mr. Chairman. I will be brief, as well.
Dr. Kussman, specifically the pain care legislation. Advocates
believe, and I think with good reason, that there are inconsistencies
within the VA relative to the pain care and how it varies from location
to location. In some cases, it is good. In others, it is not as good.
Do you agree with the view that the delivery of pain care is
inconsistent across the system, and if not this approach, what
suggestions do you have to bring that consistency?
Dr. KUSSMAN. Thank you, Senator Burr. I would never suggest that,
whether it is pain care or others, that there isn't potential for
inconsistency around our system. We are a large system with 1,400 sites
of care. I believe that if we are not providing what we say we are
providing and there are inconsistencies or inappropriate or inadequate
care, that is my job and the VHA�s job to be sure that that is being
done, and we would be happy to meet with advocacy groups from wherever
or Members of the Committee to determine what those inconsistencies
are.
Pain management is a very important thing for us, as you know, and
that is why we set up our standard in 2003. We have a Committee that
meets regularly to look at what we are doing. We are developing
performance standards to ensure that there is consistent delivery of
care.
We are reviewed regularly by this. This is one of the tenets of the
Joint Commission on Health Care Organizations. They always come and
look at whether you are in pain. Every time I go to the doctor, they
ask me, ``Are you in pain at this time?'' It is part of the
introductory evaluation. I keep asking, what kind of pain are you
talking about, physical, mental, or whatever kind of pain, not to make
light of what we are talking about.
But I think that if we are not doing the job and we have
inconsistencies or inadequacies in what we are doing, it is my job to
fix it and that we will look aggressively on that and work with the
advocacy groups. I don�t think that the legislation itself will solve
that.
Senator BURR. Mr. Chairman, I am going to hold myself to one
question, but I also want to make this statement relative to S. 2162,
given the nature of your last answer and you will hold yourself to what
is proven. The Institute of Medicine found that the literature that
existed as it related to the Veterans Affairs process on PTSD and
co-morbidity conditions, such as anxiety, substance abuse, and
depression along with PTSD, that the literature was uninformative.
So I heard your objection to S. 2162. We have an independent IOM
study that suggested there are deficiencies. I will hold you to exactly
the answer you gave me on the last one. If that is, in fact, an
accurate assessment by IOM, then I would hope you would make the
correct changes.
Dr. KUSSMAN. Senator Burr--can I answer that question? Are you asking
me something?
Senator BURR. It was not in the form of a question, so I am going
to let the Chairman control this.
Dr. KUSSMAN. Can I have the opportunity to respond?
Chairman AKAKA. If it is brief.
Dr. KUSSMAN. I will try to be brief, although everybody says I talk
too much. But we chartered the study. It was done by the VHA asking the
IOM to look at what we were doing. I believe what the IOM said was that
the literature�not just the VHA literature, only 10 of the 50 studies
that they have looked at were VHA studies, they looked at the whole
country's studies on mental health, particularly PTSD. And what they
said was there are gaps in the adequacy and the peer review of these
studies, and they didn't suggest that the treatment we were doing was
inadequate. They just said that the outcomes of the studies couldn't
prove that it was adequate, but they weren't suggesting what we were
doing didn't work. The only one that they said that there was good
scientific study was a study done by us with the immersion and
cognitive therapy. But we are doing studies already to get better
results, particularly with drugs and other therapy, on PTSD and
substance abuse. So it is already going on. Thank you, sir.
Chairman AKAKA. Thank you. Senator Murray?
Senator MURRAY. Thank you very much, Mr. Chairman.
Dr. Kussman, while you are here, I wanted to ask you, I saw an
article from the Charlotte Observer that was out recently that was
really disconcerting about wait times for veterans and it said that
most VA hospitals showed lags in delivering outpatient care for serious
problems. And according to that newspaper�s analysis, 24 percent of
appointments nationwide for Traumatic Brain Injury care exceeded the
30-day mark last summer. At the Salisbury VA Hospital, 61 percent of
appointments for the seriously wounded were scheduled more than 30 days
out of the summer, one of the worst records nationwide. And at the
Charleston VA in South Carolina, 13 of 14 patients slated to be seen
for brain injury waited for more than a month.
I was really discouraged to see this and I was even more discouraged
to see that the VA's response to that report was really attacking their
own data, saying that the reports can't be used to judge service
because they don't show all appointments. So I am compelled to ask you,
why is the VA spending money on these reports if that is the case?
Dr. KUSSMAN. Senator Murray, thank you for the question. As you and I
have talked before, waiting times is a very important issue to me. I
have been concerned for a long time about what the information I get
and what is perceived and real out there.
We believe and have responded to the newspaper and had dialogue
with them greatly, we believe that their interpretation of the
data did not reflect what is going on. But it is a very--complex
issue and I will be happy to--
Senator MURRAY. Why doesn�t it reflect what is going on?
Dr. KUSSMAN. Because we believe that there were snapshots in time
and did not reflect the way that the data is accurately collected and
what it reflected in the true waiting times for people. But I will be
happy to come and talk to you about that--
Senator MURRAY. Well, let me ask--
Dr. KUSSMAN.�but if I could finish, just for a second, as you know,
these are very important things, whether waiting times for TBI or
anything else that we are doing. The issue of the electronic wait
list, we have pretty much eliminated. Those were things that came up
early on about the number of people who couldn�t even get an
appointment to be seen, and I believe that that number now is around
200 people systemwide.
But because of all these issues related to wait times, I have
contracted with a group to look at our whole wait times measure to find
out and tell me whether there are inadequacies or breakdowns in how we
are collecting the data, because I have no interest, as you know--I am
a veteran and a retiree myself--to come up and tell you that data is
not accurate.
Senator MURRAY. So you can�t tell us right now how long it actually
takes veterans to see a doctor, not just schedule an appointment
but, actually see a doctor?
Dr. KUSSMAN. Yes, I can, and I don�t believe that the numbers
that were used by the Charlotte reflect the accurate numbers and
we will be happy to get that to you.
Senator MURRAY. What do you think that number is?
Dr. KUSSMAN. I believe that, as we have reported, 95 percent of our
patients get their appointment within 30 days of when they want it or
was clinically appropriate.
Senator MURRAY. Can you tell this Committee how long wait times are
for different generations of veterans, for different priority groups,
for different types of injuries or illnesses? Do you have that
information?
Dr. KUSSMAN. We do have a breakout, and I will have to get it to you,
for OIF/OEF, but I don�t think we have it by age group, but I will have
to get back to you on that.
Senator MURRAY. OK. Can you give us today what the wait times are?
Dr. KUSSMAN. For?
Senator MURRAY. For all veterans. Can you tell us what the wait time
is?
Dr. KUSSMAN. As I reported, we believe on the basis of the data that
we have, 95 percent of the 39 million appointments that we see every
years are done within the 30-day expectation. These are not urgent or
emergency appointments, but routine appointments and things for
veterans within 30 days of when they ask for it.
Senator MURRAY. Can you give me a reason why the Charlotte Observer's
information is so different?
Dr. KUSSMAN. I will have to get back to you on that. I think it is a
very involved issue of how they interpret the data versus snapshots in
time versus continuum, but we have tried to work with the Charlotte and
other people to get an accurate assessment.
Senator MURRAY. You can't give me a couple sentences, any view that
might make that real for us?
Dr. KUSSMAN. As I said, they used a snapshot in time, not a
continuum, and I believe that is a fundamental problem with that. But I
will be happy to get the subject matter experts to talk to you about
what the differences are.
Senator MURRAY. What I would like you to do is give it to this
Committee, because I believe that--
Dr. KUSSMAN. I would be happy to do that.
Senator MURRAY.--We all have a very deep concern about the
wait times, and it is not just a newspaper article. We continue to hear
that from our veterans. They don�t care whether they are a snapshot or
a continuum. They actually care that they are waiting a very long time,
and it is deeply disconcerting when we--
Dr. KUSSMAN. And as you know--
Senator MURRAY.--continue to hear this and we continue to see it.
Dr. KUSSMAN. It is disconcerting to me, too, and that is why I said
we have contracted with somebody to come in and do an objective
assessment of how we are trying to collect data on wait times and
identify any glitches in how we do our business.
Senator MURRAY. OK. Mr. Chairman, I am compelled to ask, as well. We
have been 3 months without a Secretary or even a nominee for the VA. I
am beginning to hear from a lot of veterans who are very, very
concerned that a lack of a nominee sent to the Senate signals that the
administration doesn't have a priority for veterans, at a time when we
are at war and we know we have issues with wait times and mental health
problems and all the other things this Committee has been discussing.
Dr. Kussman, do you have any idea why we have not had a nominee sent
over for the Secretary of the VA yet?
Dr. KUSSMAN. No, Senator, I don't, but I can assure you that we
are still doing our job to take care of veterans.
Senator MURRAY. I know everybody is working their hardest, but we
need somebody at the top that is accountable, and whoever is listening
out there, we need an independent, someone who is going to stand up for
our veterans when we are at a time of war, and I hope that we get an
administration soon that will take this as a priority, Mr. Chairman.
And just really quickly, on the legislation that we are talking about
today, I wanted to ask you about Senator Craig's and my bill on the
TBI-induced epilepsy. Dr. John Booss, who is a former Director of
Neurology at the VA, testified before this Committee in May that there
would be a dramatic increase in epilepsy due to TBI and that the VA has
no national plan to cover it. Does the VA anticipate an increase in the
number of veterans that develop epilepsy as a result of TBI?
Dr. KUSSMAN. Senator, I know John Booss very well, obviously,
and I have not talked to him. I believe that the literature that exists
says that 53 percent of people with penetrating wounds of the head,
severe TBI, as we would call it, have an increased incidence of--they
will develop epilepsy 53 percent of the time after suffering a
penetrating wound.
Senator MURRAY. So more than half the time?
Dr. KUSSMAN. With a penetrating wound. I think everybody understands
that and we are watching those people very closely. As you know, these
are the ones who transfer from the military health system to our
polytrauma centers. There have been about 413 of them that have been
transferred. Everybody acknowledges and knows that any time there is a
penetrating wound to the head, there is an increased incidence of
seizure disorder and--
Senator MURRAY. Just so I understand, there are 413 with penetrating
wounds?
Dr. KUSSMAN. With severe TBI. I don�t know the number of penetrating
wounds versus severe non-penetrating wounds.
Senator MURRAY. Do you know how many people have come into the VA
with Traumatic Brain Injury at this time?
Dr. KUSSMAN. Well, if you want to talk about the full spectrum of
TBI, because it is not all the same, as you know, the mild to moderate
TBI is one that is hard to diagnose and we have in place a screening
mechanism to try to identify those people because that is very
important to us to develop the registries and follow people because it
appears with mild to moderate, the incidence of seizure disorder or
long-term sequelae is much less than it is for the more severe, the
moderate to severe TBI. But the literature doesn't help us with that
very much and so we need to put in place research and longitudinal
studies, good epidemiologic studies to follow these people.
Senator MURRAY. Is that what you have done?
Dr. KUSSMAN. We are doing that, yes.
Senator MURRAY. And do you know how many people that is?
Dr. KUSSMAN. I would have to--again, we are screening everybody and I
don't have the recent data of how many people screened positive.
Senator MURRAY. For any TBI, severe, mild--
Dr. KUSSMAN. Yes, that is correct.
Senator MURRAY. When would we be able to get that?
Dr. KUSSMAN. As soon as I have that data, I will be happy to give it
to you.
Senator MURRAY. Thank you so much, Mr. Chairman.
Chairman Akaka. Thank you very much, Senator Murray.
Senator ISAKSON?
Senator ISAKSON. I will be very brief. I really have one question.
You know, in all my experience on this Committee, my travels to Iraq,
and my visits to veterans' hospitals, I can't remember a complaint
about the quality of care the physicians render or the facilities do.
The complaints generally--not generally, almost always involve
accessibility, appointments, and time.
The example I used in my opening remarks about Augusta's Uptown
facility and the Eisenhower Medical Center in Augusta, they
created a seamless transition which solved a lot of those problems.
In fact, Sergeant Harris that I mentioned whose TBI was moderate
to mild, as you put it, was actually corrected and she went back
into active duty, which is an example of that seamless transition
and no skip in quality or accessibility of service.
Now, I know you have veterans all over the country and there
are not a lot of cities that have two, a veterans� hospital and a
military hospital, but there are a number, San Antonio and others
around the country. Are you all working on some of those innovations
like what took place in Augusta to replicate them around the
country?
Dr. KUSSMAN. Sir, this is one of the most important things for
us, is to be sure that both severe and other injured veterans,
servicemembers, come to us with a minimum or none, no complications
of the bureaucracies. I believe we put in place a very significant
infrastructure with VA benefits counselors and social workers
at the major military treatment facilities, military people at our
facilities, and we are�it will never be perfect because things happen,
but I believe the infrastructure is there to do exactly what you are
describing in Augusta throughout the country.
Senator ISAKSON. Thank you, Mr. Chairman.
Chairman AKAKA. Thank you very much, Senator Isakson.
I want to thank our first panel very much for being here. We will
place in the record further questions that we have for you to respond
to. I want to thank you for your service. We are looking forward
to working together to try to improve it throughout our country. The
signs are beginning to show where there is strain and we need to
correct these. So we look forward to continuing to work with you. Thank
you.
Dr. KUSSMAN. Mahalo, Mr. Chairman.
Chairman AKAKA. Mahalo.
I want to introduce our second panel and extend a warm aloha and
welcome to the second panel. I want you to know that I appreciate each
of you being here today and look forward to your testimony.
First, I welcome Carl Blake. Mr. Blake is the National Legislative
Director for Paralyzed Veterans of America.
I welcome Joy Ilem. Ms. Ilem is the Assistant National Legislative
Director for Disabled American Veterans.
I also welcome Brenda Murdough, who is a registered nurse and holds a
Masters of Science in Nursing. She is the Coordinator of the
Military/Veterans Initiative of the American Pain Foundation.
I also welcome Dr. Brien Smith. Dr. Smith is Director of the Epilepsy
Monitoring Unit at Henry Ford Hospital in Detroit, Michigan.
Finally, I welcome Constance Walker. She is a retired Navy Captain
and is the President of the Southern Maryland Chapter of the National
Alliance on Mental Illness. She also serves on the Maryland Governor's
Task Force on Improving State Programs directed at Iraq and Afghanistan
veterans and their families.
Each of your statements will appear in the record of today's hearing
and I ask that you limit your direct testimony to no more than 5
minutes so that we have time for questions.
Mr. Blake, will you please begin.
STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE
DIRECTOR, PARALYZED VETERANS OF AMERICA
Mr. BLAKE. Chairman Akaka, Ranking Member Burr, and Members of the
Committee. I would like to thank you on behalf of PVA for the
opportunity to testify today. In the interest of time, I will keep my
statement as short as possible.
PVA supports the provisions of S. 38 that direct the Secretary to
establish a program for peer support and counseling, readjustment
counseling, and mental health services. We particularly believe in the
importance of peer counseling in the rehabilitation and readjustment
process. This is something that PVA as an organization does in all of
the Spinal Cord Injury Centers around the country. Every PVA chapter
designates individual members to pair up with the newly injured
veterans to help them get through the early stages of recovery and
beyond.
PVA principally supports S. 2004, a bill that would create six
Epilepsy Centers of Excellence within the VA health care system. Much
like the MS Centers and Parkinson�s Disease Centers of Excellence
permanently authorized last year, this proposal recognizes the
successful strategy of the Veterans Health Administration to focus its
systemwide service and research expertise on a critical care segment of
the veteran population.
PVA generally supports the provisions of S. 2142, the Veterans
Emergency Care Fairness Act, as the legislation is in accordance with
the recommendations of the Independent Budget for FY 2008. However, we
remain concerned about some of the eligibility criteria that determine
what veterans are eligible for this reimbursement. In accordance with
the IB for fiscal year 2008, we believe that the requirement that a
veteran must have received care within the past 24 months should be
eliminated. Furthermore, we believe that the VA should establish a
policy allowing all veterans enrolled in the health care system to be
eligible for emergency services at any medical facility, whether the VA
or private facility, when they exhibit symptoms that a reasonable
person would consider a medical emergency.
First, I would like to say that PVA generally supports S. 2162, which
improves services provided by the VA to veterans with PTSD and
substance use problems. However, PVA does remain concerned with the
pilot program outlined in Title 2 of the bill. While we certainly
support the emphasis placed on peer counseling and outreach, as
expressed in our written statement earlier, we maintain our concerns
about contract services with community mental health centers. The VA
should be able to provide the services described in this legislation
through judicious application of its already existing fee-basis
authority.
We do, however, appreciate the emphasis on ensuring that the non-VA
facilities are compliant with VA standards, particularly through
additional training managed specifically by the VA, a requirement that
is also included in S. 38. However, we still believe that at this time,
the energy and money that would be expended here could best be used to
upgrade the VA system itself.
Mr. Chairman and Members of the Committee, PVA would once again like
to thank you for the opportunity to testify and I would be happy to
answer any questions that you might have.
[The prepared statement of Mr. Blake follows:]
PREPARED STATEMENT OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA
Chairman Akaka, Ranking Member Burr, and members of the Committee, on
behalf of Paralyzed Veterans of America (PVA) I would like to thank you
for the opportunity to testify today on the proposed health care
legislation. The scope of issues being considered here today is very
broad. We appreciate the Committee taking the time to address these
important issues, and we hope that out of this process meaningful
legislation will be approved to best benefit veterans.
S. 38, THE ``VETERANS MENTAL HEALTH AND OUTREACH ACT''
PVA supports the provisions of this legislation that directs the
Secretary to establish a program for peer support and counseling,
readjustment counseling, and mental health services. We particularly
believe in the importance of peer counseling in the rehabilitation and
readjustment process. This is something that PVA as an organization
does in all of the Spinal Cord Injury Centers around the country. Every
PVA chapter designates individual members to pair up with newly injured
veterans to help them get through the early stages of their recovery. I
know first hand that being able to talk to someone who has experienced
what you have experienced and has dealt with the same problems you are
dealing with can help you overcome bouts of depression, sadness, and
anger as you first come to grips with your condition. The peer
counselor serves as a motivator to get you moving in the right
direction. I credit my own peer counselor while I went through spinal
cord rehabilitation with driving me to help other veterans.
PVA opposes the provisions of this legislation which would authorize
VA to contract with community mental health centers to meet the needs
of veterans dealing with mental illnesses. As we testified earlier this
year, we oppose any effort to allow the VA to contract out care when it
can do a better and more cost effective job in its own system.
Furthermore, by allowing the VA to send these veterans out of the
system to receive their care, it effectively relieves itself of the
obligation it has to these men and women. The VA must be appropriated
adequate funding and it must be provided in a timely manner if it is
going to have any chance of meeting these veterans' needs.
Moreover, Congress must continue to conduct aggressive oversight to
ensure that funding specifically allocated for mental health
initiatives is properly spent. As explained in the Government
Accountability Office (GAO) report of November 2006, the VA did not
allocate all of the funding it planned to commit in fiscal year 2005
for new mental health initiatives, nor did it spend all of the funds
planned for fiscal year 2006. VA must be held accountable to ensure
that it lives up to the goals established in its National Mental Health
Strategic Plan. Until such time as the VA meets these goals, the burden
for mental health care should not be shifted to the community.
PVA does support the provision of this legislation which would extend
the eligibility for hospital care, medical services, and nursing home
care from 2 to 5 years for a veteran who served on active duty in a
theater of combat operations during a period of war after the Persian
Gulf War or in combat against a hostile force after November 11, 1998.
This provision has proven especially important to the men and women who
have recently served in Iraq and Afghanistan and have exited military
service.
S. 2004, EPILEPSY CENTERS OF EXCELLENCE
PVA principally supports S. 2004, a bill that would create six
Epilepsy Centers of Excellence within the VA health care system. Much
like the Multiple Sclerosis (MS) and Parkinson's disease Centers of
Excellence permanently authorized last year, this proposal recognizes
the successful strategy of the Veterans Health Administration (VHA) to
focus its system-wide service and research expertise on a critical care
segment of the veteran population. The designation of these six Centers
of Excellence will provide open access to centers engaged in marshaling
VA expertise in diagnosis, service delivery, research and education.
Furthermore, these programs will be available across the country
through the ``hub and spokes'' approach. We also hope that this
legislation will sow the seeds for broader based research and
development into Traumatic Brain Injury (TBI), as we believe the same
concept could be crucial for better treatment for veterans in the
future.
S. 2142, THE ``VETERANS' EMERGENCY CARE FAIRNESS ACT''
PVA generally supports the provisions of S. 2142, the ``Veterans
Emergency Care Fairness Act,'' as the legislation is in accordance with
the recommendations of The Independent Budget for FY 2008. However, we
remain concerned about some of the eligibility criteria that determine
what veterans are eligible for this reimbursement. In accordance with
The Independent Budget for FY 2008, we believe that the requirement
that a veteran must have received care within the past 24 months should
be eliminated. Furthermore, we believe that the VA should establish a
policy allowing all veterans enrolled in the health care system to be
eligible for emergency services at any medical facility, whether at a
VA or private facility, when they exhibit symptoms that a reasonable
person would consider a medical emergency.
S. 2162, THE ``MENTAL HEALTH IMPROVEMENTS ACT''
First, I would like to say that PVA generally supports this proposed
legislation which improves services provided by the VA to veterans with
Post-Traumatic Stress Disorder (PTSD) and substance use problems.
Current research highlights that Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF) combat veterans are at higher risk for
PTSD and other mental health problems as a result of their military
experiences. In fact, the most recent research indicates that 25
percent of OIF/OEF veterans seen at a VA facility have received mental
health diagnoses.
We are pleased with the provisions of Section 102 and 103 of the
legislation. In fact, The Independent Budget is set to recommend that
VA provide a full continuum of care for substance use disorders
including additional screening in all its health care facilities and
programs--especially primary care. We also believe outpatient
counseling and pharmacotherapy should be available at all larger VA
community-based outpatient clinics. Furthermore, short-term outpatient
counseling including motivational interventions, intensive outpatient
treatment, residential care for those most severely disabled,
detoxification services, ongoing aftercare and relapse prevention, self
help groups, opiate substitution therapies and newer drugs to reduce
craving, should be included in VA�s overall program for substance abuse
and prevention.
Although we support the creation of PTSD Centers of Excellence
outlined in Section 105 of the legislation, we wonder whether this step
is necessary. The VA already maintains a broad network of PTSD
treatment centers. Furthermore, in 1989, the VA established the
National Center for Post-Traumatic Stress Disorder as a focal point to
promote research into the causes and diagnosis of this disorder, to
train health care and related personnel in diagnosis and treatment, and
to serve as an information clearinghouse for professionals. The Center
offers guidance on the effects of PTSD on family and work, and notes
treatment modalities and common therapies used to treat the condition.
This center already functions as a center of excellence. At the very
least, it should be incorporated into this new network of centers of
excellence.
PVA has some concerns with the pilot program outlined in Title II of
the bill. While we certainly support the emphasis placed on peer
counseling and outreach, as expressed in our statement earlier, we
maintain our concerns about contract services with community health
centers. The VA should be able to provide the services described in the
legislation through judicious application of its already existing fee
basis authority. We do, however, appreciate the emphasis on ensuring
that the non-VA facilities are compliant with VA standards,
particularly through additional training managed specifically by the
VA.
While we also support Title III of the legislation regarding research
into comorbid PTSD and substance use disorder, we wonder if this is
duplicative with activities already taking place at the National Center
for PTSD. However, PVA has long supported research initiatives into
various types of conditions and the treatments associated with them.
Finally, we recognize the unique challenge associated with providing
mental health services to families of veterans. This is an area that
the VA has had little experience with in the past. Likewise, we see no
problem with the VA examining the feasibility of providing readjustment
and transition assistance to veterans and their families. It is
certainly an issue that has become more apparent as more men and women
return from conflicts abroad broken and scarred. The impact that this
has on the veteran and his or her family cannot be overstated.
S. 2160, THE ``VETERANS PAIN CARE ACT''
PVA supports the draft legislation that would establish a system-wide
pain care initiative within the VA. We agree with the finding that
comprehensive pain care in not consistently provided across the entire
system. We have seen firsthand the benefits of pain care programs as
each VA facility that supports a Spinal Cord Injury (SCI) unit also
maintains a pain care program. Veterans with Spinal Cord Injury know
all to well the impact that pain, including phantom pain, can have on
their daily life. The pain care programs that SCI veterans have access
to have greatly enhanced their rehabilitation and improved their
quality of life.
The one concern we have is the expectation that every facility in the
VA should have a pain care program. Does this suggest that every
community-based outpatient clinic (CBOC) should have a similar program?
This might be an unreasonable expectation. We do support the idea of
cooperative centers for research and education on pain. The work done
at these locations can only benefit the provision of pain care services
throughout the system.
Mr. Chairman and Members of the Committee, PVA once again thanks you
for the opportunity to testify. We look forward to working with you to
ensure that veterans continue to have access to the best health care
services in America.
I would be happy to answer any questions that you might have.
William Carl Blake National Legislative Director Paralyzed Veterans
of America at PVA's National Office in Washington, D.C. He is
responsible for the planning, coordination, and implementation of PVA's
relations with the U.S. Congress and Federal departments and agencies.
He develops and executes PVA's Washington agenda in areas of budget,
appropriations, health care, and veterans' benefits issues. He also
represents PVA to Federal agencies including the Department of Defense,
Department of Labor, Small Business Administration, and the Office of
Personnel Management.
Carl was raised in Woodford, Virginia. He attended the United States
Military Academy at West Point, New York. He received a Bachelor of
Science Degree from the Military Academy in May 1998.
Upon graduation from the Military Academy, he was commissioned as a
Second Lieutenant in the Infantry in the United States Army. He was
assigned to the 504th Parachute Infantry Regiment (1st Brigade) of the
82nd Airborne Division at Fort Bragg, North Carolina. He graduated from
Infantry Officer Basic Course, U.S. Army Ranger School, U.S. Army
Airborne School, and Air Assault School. His awards include the Army
Commendation Medal, Expert Infantryman�s Badge, and German Parachutist
Badge. Carl retired from the military in October 2000 due to injuries
suffered during a parachute operation.
Carl is a member of the Virginia-Mid-Atlantic chapter of the
Paralyzed Veterans of America.
Carl lives in Fredericksburg, Virginia with his wife Venus, son
Jonathan and daughter Brooke.
Chairman AKAKA. Thank you very much.
Ms. ILEM?
STATEMENT OF JOY J. ILEM, ASSISTANT, NATIONAL
LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS
Ms. ILEM. Mr. Chairman and Members of the Committee, thank you for
inviting the DAV to testify today at this legislative hearing. In the
interest of brevity, I will focus my oral remarks on two mental health
bills being considered by the Committee.
S. 38, the Veterans Mental Health Outreach and Access Act of 2007,
would require VA to establish a VA-contracted peer outreach, peer
counseling, and mental health program for veterans who served in
Operations Iraqi and Enduring Freedom who are not adequately served by
VA. The bill would also authorize members of the immediate families of
such veterans to receive mental health services to assist in the
readjustment of the veteran and their family.
The final provision in the bill would extend eligibility for VA
health care services from 2 to 5 years for this group.
We appreciate the bill�s intent to better serve veterans in rural
areas, which has historically been a challenge for VA. Although DAV
believes that VA contract care is an essential tool in providing timely
access to medical services, we feel strongly that VA should use this
authority judiciously.
Our main concern with this bill is that VA over the past several
years has received a significant amount of new funding targeted to
providing better access to mental health services to enrolled veterans.
Over the past few years, VA has hired 3,500 new mental health
providers and established a significant number of new initiatives and
programs within the system to address the mental health needs of
enrolled veterans, including OEF/OIF veterans. Before Congress
authorizes a program such as the one envisioned in S. 38, we recommend
VA determine a degree of unmet need after it has done as much as
practical to meet that need directly. Additionally, we point out that
VA's Office of Rural Health has already been charged with evaluating
and presenting solutions to address the needs of this population.
For these reasons, with the exception of the extension of eligibility
for health care for combat veterans from 2 to 5 years, we cannot
support this measure at this time.
We have also been asked to comment on S. 2162, the Mental Health Care
Improvements Act of 2007, a comprehensive bill that focuses on programs
for treatment of veterans who suffer from both PTSD and substance use
disorders. This measure would require VA to offer a complete package of
services for substance use disorders at all VA facilities unless
specifically exempted. It would also establish six new national Centers
of Excellence on PTSD and substance use disorders to provide a
comprehensive inpatient treatment and recovery services, as well as a
targeted research program in co-morbid PTSD and substance use
disorders, and a ten-site pilot program for providing specialized
mental health transition assistance in coordination with veterans
centers to veterans and their families.
Title 2, Section 201 of the measure would authorize a pilot program
of peer readjustment counseling and other mental health services at
non-VA community mental health centers for OEF/OIF veterans not
adequately served by VA. While we support the peer counseling concept,
we continue to have concerns about contracting with non-VA mental
health providers for specialized PTSD. While we appreciate the
Chairman's efforts to address unmet needs of veterans in underserved
areas, we have the same concerns about this provision that we
expressed regarding contract care in S. 38.
Mr. Chairman, like you, we are concerned that over the past decade,
VA has drastically reduced its substance use treatment and related
rehabilitation services and has made little progress in restoring them,
even in the fact of increased demand for such services from veterans
returning from current conflicts. There are multiple indications that
PTSD and readjustment issues in conjunction with the misuse of
substances will continue to be a significant problem for our newest
generation of combat veterans, and therefore we agree VA should adopt
new programs and services to meet these unique needs.
We are especially pleased about the provisions in the bill expanding
mental health services for family members at VA facilities. These
families of these veterans are suffering, too, and are the core support
for veterans struggling to rehabilitate and overcome readjustment
issues related to their military service. We hope at the same time
previous generations of veterans and their families can also benefit
from these expanded programs and services.
Thus, with the exception of the sections in the bill dealing with
contracted care, we believe these are very timely provisions and we
fully support them.
For the record, we believe the remaining measures being considered by
the Committee today would also be beneficial to sick and disabled
veterans and, therefore, have no objection to their passage,
specifically S. 2004, which seeks to establish six Epilepsy Centers of
Excellence within VA, S. 2142, the Veterans Emergency Care Fairness Act
of 2007, and S. 2160, the Veterans Pain Care Act of 2007. We refer the
Committee to our written statement for DAV's complete analysis of these
bills.
Mr. Chairman, again, DAV appreciates the opportunity to appear before
you today to give our testimony and view on these bills and we are
pleased to answer any questions you may have. Thank you.
[The prepared statement of Ms. Ilem follows:]
PREPARED STATEMENT OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE,
DIRECTOR OF THE DISABLED AMERICAN VETERANS
Mr. Chairman, Ranking Member Burr and other Members of the Committee:
Thank you for inviting the Disabled American Veterans (DAV) to testify
at this important legislative hearing of the Committee on Veterans
Affairs. DAV is an organization of 1.3 million service-disabled
veterans, and devotes its energies to rebuilding the lives of disabled
veterans and their families.
You have requested testimony today on five bills primarily focused on
health care services for veterans under the jurisdiction of the
Veterans Health Administration, Department of Veterans Affairs (VA).
This statement submitted for the record reviews our positions on all of
the proposals before you today. The comments are expressed in numerical
sequence of the bills, and we offer them for your consideration.
S. 38--THE VETERANS� MENTAL HEALTH OUTREACH AND ACCESS ACT OF 2007
S. 38 would require the VA Secretary to establish a VA-contracted
peer outreach, peer counseling and mental health care program to
provide readjustment and certain mental health services to veterans who
served in Operations Iraqi and Enduring Freedom (OIF/OEF), and are not
adequately served by VA. It would also require VA to train peer
counselors and professional providers to ensure their cultural
competency to care for veterans of OIF/OEF, and specifically those who
live remotely from VA facilities in circumstances in which they have no
access to direct VA programs.
The bill would also authorize, for a 3-year period immediately
following combat deployment to Iraq and Afghanistan, members of the
immediate families of such veterans to receive VA services, such as
orientation and education, support, counseling and mental health
services, to assist in the readjustment of veterans and their families,
especially in the case of a veteran who sustained injury or illness
during military deployment.
We appreciate the intent of the bill in serving veterans in rural
areas, which has historically been a challenge for VA. On a positive
note, this bill would be consistent with VA's principles to use
coordinated contract care only when services are unavailable in the
VA--a firm position that DAV holds. At the same time, the legislation
would address the needs of the veteran�s immediate family as it relates
to his or her recovery and would build on the tested concept of having
peers with similar personal military experiences from which they have
recovered, to provide outreach and support--an approach that probably
would increase the likelihood of engaging veterans in readjustment and
treatment and may provide new vocational rehabilitation options for
some veterans who provide this counseling.
Although DAV believes that VA contract care is an essential tool in
providing timely access to quality medical care, we feel strongly that
VA should use this authority judiciously. Current law limits the use of
VA purchased care to specific instances\1\ so as not to endanger VA
facilities� ability to maintain a full range of specialized services
for enrolled veterans and to promote effective, high quality care for
veterans, especially those disabled in military service and those with
highly sophisticated health problems such as blindness, amputations,
spinal cord injury or chronic mental health conditions.
Unfortunately, in most cases where VA authorizes care to veterans by
contract providers, VA has not established a systematic approach to
monitor that care, consider any alternatives to its high cost, analyze
patient care outcomes, or even establish patient satisfaction measures.
In fact, VA knows very little about the care for which it now
contracts.
Any bill that would authorize contract care by VA without addressing
these concerns would essentially shift medical resources and veterans
from VA to the private sector, to the detriment of the VA health care
system and eventually would be deleterious to the interests of sick and
disabled veterans themselves. DAV could not support this or any similar
bill without such protections. It is unclear how the services that
would be authorized by this bill would be triggered and controlled by
an accountable VA health care professional. Typically, a veteran is
authorized contract care after VA establishes that it cannot provide a
particular service or that the veteran is geographically or otherwise
hampered from access to VA services. A VA health care professional
makes this determination. Also, legal eligibility determination is a
necessity to ensure an individual veteran is eligible for VA care.
Our main concern with this bill is that VA, over the past several
years, has received significant new funds targeted to providing better
mental health services to all veterans. VA has been especially
concerned about ensuring services to OIF/OEF veterans, particularly
those who live in rural and remote areas without good access to care.
VA has developed a national mental health strategic plan, to deploy
several new programs within all the normal strictures in which the
system is required to operate. DAV believes VA should rapidly deploy
those plans and exhaust those program possibilities, and then determine
the degree of unmet need in rural areas--rather than being required to
contract out these services before those programs are given a chance to
materialize. Before Congress authorizes a program such as the one
envisioned here for rural veterans, we recommend VA determine the
degree of unmet need after it has done as much as practicable to meet
that need directly. Since Congress recently enacted legislation that
established VA's new Office of Rural Health, we believe that office
should be charged with implementing and managing these matters in
conjunction with VA's Office of Mental Health Services.
S. 2004--A BILL TO AMEND TITLE 38, UNITED STATES CODE, TO ESTABLISH NOT
LESS THAN SIX EPILEPSY CENTERS OF EXCELLENCE IN THE VETERANS HEALTH
ADMINISTRATION OF THE DEPARTMENT OF VETERANS AFFAIRS, AND FOR OTHER
PURPOSES.
These Centers are intended to function as centers of excellence in
research, education, and clinical care activities in the diagnosis and
treatment of epilepsy and include training of medical residents and
other VA providers to ensure better access to state-of-the art
treatments throughout the VA health care system. Provisions in the bill
also include a peer review panel, consisting of experts on epilepsy,
complex multi-trauma associated with combat injuries, including
Post-Traumatic Epilepsy, to assess the scientific and clinical merit of
research and treatment proposals that are submitted to the Centers.
While DAV has no adopted resolution from our membership on this
matter, we have been briefed by professional associations concerned
about the decline of availability of epilepsy services in the VA. Also,
literature is emerging to suggest co-morbid epilepsy in veterans with
Traumatic Brain Injury. Therefore, this is timely legislation to fill a
real need, and DAV would have no objection to its passage.
\1\(1) When VA facilities are incapable of providing necessary care
to a veteran. (2) When VA facilities are geographically inaccessible to
a veteran for necessary care. (3) When medical emergency prevents a
veteran from receiving care in a VA facility. (4) To complete an
episode of VA care. (5) For certain specialty examinations to assist VA
in adjudicating disability claims. (6) For the services in VA facilities
of scarce medical specialists.
S. 2142--THE VETERANS EMERGENCY CARE FAIRNESS ACT OF 2007
The intent of S. 2142 is to amend Sections 1725 and 1728 of title 38,
U.S.C., to require the Secretary of Veterans Affairs to reimburse
veterans receiving emergency treatment in non-VA facilities. In
addition to applying the prudent layperson definition of ``emergency
treatment'' under both Sections, the bill intends to clarify the
current VA practice of denying payment for emergency care provided to a
veteran by a private facility for any period beyond the date on which
VA determines the veteran can be safely transferred. Specifically, it
would amend the definition of reimbursable emergency treatment to
include the time when VA or other Federal facility does not agree to
accept a stabilized veteran who is ready for transfer from a non-VA
facility and the non-VA provider has made reasonable attempts (with
documentation) to make such transfer.
The DAV supports the intent of this bill as outlined above in accord
with the mandate from our membership and with the recommendations in
the Independent Budget for Fiscal Year 2008 to improve the
reimbursement policies for non-VA emergency health care services for
enrolled veterans. Having consulted with the author of this important
measure and with pertinent parties, it is our understanding that the
current language may require additional modification. The DAV thanks
those involved for their efforts to ensure the improvements to this
essential benefit as contemplated by this bill is properly implemented.
S. 2160--THE VETERANS PAIN CARE ACT OF 2007
This measure would amend title 38, U.S.C., to establish a pain care
initiative in all VA health care facilities. Specifically, it would
require the Secretary to ensure that all patients receiving treatment
be assessed for pain at the time of admission or initial treatment and
periodically thereafter, and that pain care management and treatment,
including specialty pain management services, are provided as deemed
clinically appropriate. Pain care initiatives in this measure would be
required to be established by January 2008 for inpatient care and
January 2009 for outpatient care service lines. The bill would also
require the establishment of research centers and training of
healthcare professionals in assessment, diagnosis, treatment and
management of acute and chronic pain.
There is increasing interest by healthcare providers in the
specialized field of pain management, and a number of advances in
medicine and technologies from that interest are benefiting severely
wounded service personnel and veterans. A recent study of OIF/OEF
servicemembers receiving treatment in VA Polytrauma Centers found that
pain is highly prevalent among this group. It also noted in its
clinical implications that pain should be consistently assessed,
treated, and regularly documented. The report concluded that polytrauma
patients are at potential risk for development of chronic pain, and
that aggressive and multidisciplinary pain management (including
medical and behavioral specialists) is necessary. The report suggested
the phenomenon of pain is a new opportunity for VA research in
evaluating long term outcomes; developing and evaluating valid pain
assessment measures for the cognitively impaired; and, developing and
evaluating education or policy initiatives designed to improve the
consistency of assessment and treatment across the VA continuum of
care.
VA has been a leader in assessment and treatment of pain management;
having issued a National Pain Management Strategy in 1998 (its current
iteration is VHA Directive 2003-021). We understand that the overall
objective of VA's national strategy is to develop a comprehensive,
multicultural, integrated, system-wide approach to pain management that
reduces pain and suffering for veterans experiencing acute and chronic
pain associated with a wide range of illnesses, including terminal
illness. However, we are concerned that implementation of pain
management programs has not been consistent throughout VA's nationwide
health care system.
DAV does not have a specific resolution adopted in support of
establishing a legislated system-wide pain initiative at all VA medical
facilities, but we believe the goals of the bill are in accord with
providing high quality, comprehensive health care services to sick and
disabled veterans and thus, would be strongly supported by our
membership; therefore; we have no objection to this measure and look
forward to its enactment.
S. 2162--THE MENTAL HEALTH IMPROVEMENTS ACT OF 2007
This measure would establish new program requirements and new
emphases on programs for treatment of Post-Traumatic Stress Disorder
(PTSD) and substance use disorder--with special regard for the treatment
of veterans who suffer from comorbid associations of these disorders.
Sections 102�104 of the bill would require VA to offer a complete
package of continuous services for substance use disorders, including:
counseling; intensive outpatient care; relapse prevention services;
aftercare; opiate substitution and other pharmaceutical therapies and
treatments; detoxification and stabilization services; and any other
services the Secretary deemed necessary, at all VA medical centers and
community-based outpatient clinics unless specifically exempted. The
measure would require that treatment is provided concurrently for such
disorders by a team of providers with appropriate expertise. This
section describes allocation funding to facilities for these new
programs, as well as how facilities would apply for such funding.
Sections 105 and 106 would require establishment of not less than six
new National Centers of Excellence on Post-Traumatic Stress Disorder
and Substance Use Disorder, that provide comprehensive inpatient
treatment and recovery services for veterans newly diagnosed with both
PTSD and a substance use disorder. The bill would require the
Secretary to establish a process of referral to step-down
rehabilitation programs at other VA locations from a center of
excellence, and to conduct a review and report on all of VA's
residential mental health care facilities, with guidance on required
data elements in the report.
Title II--Section 201 of the measure seeks to make mental health
accessibility enhancements. This provision would require the
establishment of a pilot program of peer outreach, peer support,
readjustment counseling and other mental health services for OIF/OEF
veterans who reside in rural areas and do not have adequate access
through VA. Services would be provided using community mental health
centers (grantee organizations of the Substance Abuse and Mental Health
Services Administration, Department of Health and Human Services), and
facilities of the Indian Health Service, through cooperative agreements
or contracts. This pilot program would be carried out in a minimum of
two Veterans Integrated Service Networks (VISNs) for a 3-year period.
Provisions would require the Secretary to carry out a training program
for contracted mental health personnel and peer counselors charged to
carry out these services for OIF/OEF veterans. All contractors would be
required to comply with applicable protocols of the Department and
provide, on an annual basis, specified clinical and demographic
information including the number of veterans served.
Title III--Section 301 of the bill would establish a new, targeted
research program in co-morbid PTSD and substance use disorders, and
would authorize $2 million annually to carry out this program, through
VA's National Center for PTSD.
Title IV--Sections 401 and 402 of the measure seek to clarify
authority for VA to provide mental health services to families of
veterans coping with readjustment issues. The bill would establish a
ten-site pilot program for providing specialized transition assistance
in Vet Centers to veterans and their families, and would authorize $3
million to be used for this purpose. The bill would require a number of
reports on all these new authorities.
Current research highlights that OEF/OIF combat veterans are at
higher risk for PTSD and other mental health problems, including
substance use disorder, as a result of their military experiences. Mr.
Chairman, like you, we are concerned that over the past decade VA has
drastically reduced its substance abuse treatment and related
rehabilitation services, and has made little progress in restoring
them--even in the face of increased demand from veterans returning from
these current conflicts. There are multiple indications that PTSD and
readjustment issues, in conjunction with the misuse of substances will
continue to be a significant problem for our newest generation of
combat veterans and therefore; we need to adapt new programs and
services to meet their unique needs. We are especially pleased with the
provisions pertaining to mental health services for family members. The
families of these veterans are suffering too and are the core support
for veterans struggling to rehabilitate and overcome readjustment
issues related to their military service. We hope at the same time
previous generations of veterans and their families can also benefit
from these newly proposed programs and services.
Although DAV has no approved resolution calling for a joint treatment
program for PTSD and substance use disorders from our membership, we
believe the overall goals of the bill are in accord with providing high
quality, comprehensive health care services to sick and disabled
veterans. Thus, with only two exceptions, stated below, we believe
these are very timely provisions, and we fully support them.
It is our understanding that the National Center for PTSD is focused
primarily on research in PTSD, while your intentions for these six new
centers would focus them on direct clinical care, as regional referral
specialty centers in the care of these co-morbid conditions. Should
this bill be enacted, we hope that the seven facilities would work in
tandem to advance both the clinical and research fields associated with
PTSD and substance use disorders. An additional concern relates to
Title II Section 201 of the bill�while we support the peer counseling
concept we continue to have concerns about contracting with non-VA
providers for specialized PTSD treatment. While we appreciate the
Chairman's efforts to address unmet needs in underserved areas we refer
you to the comments we provided on S. 38, the Veterans' Mental Health
Outreach and Access Act of 2007. We would value the opportunity to work
with the Committee staff to make further adjustments to the provisions
in this section of the bill so that we can fully support this
well-intended measure.
Mr. Chairman, again, DAV appreciates the opportunity to appear before
you today and present our views these bills. I will be pleased to
respond to any questions you or other Committee Members may have.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY JOY ILEM, ASSISTANT,
NATIONAL LEGISLATIVE DIRECTOR OF THE DISABLED AMERICAN VETERANS TO
THE COMMITTEE ON VETERANS� AFFAIRS
Question. During our hearing DAV expressed concern about section 201
of S. 2162, related to a proposed pilot program to develop peer support
and outreach for OEF/OIF veterans living in rural areas and for
readjustment counseling at community mental health centers and the
Indian Health Service. You indicated in your statement that DAV is not
opposed to contracting for mental health services when such services
are not available from VA, and that VA already has sufficient authority
to contract for care. You also expressed concern about maintaining the
quality of care that would be provided by non-VA providers under this
new authority. Our bill includes a provision to ensure VA would provide
training to qualify contractors to address this challenge.
Given these provisions of the bill, why do you believe that quality of
care would not be protected for these rural veterans?
Response. Mr. Chairman, we appreciate the opportunity to clarify our
position on your bill. First and foremost, DAV believes that veterans
deserve the highest quality health care available to them--whether
provided by VA, purchased on a fee basis, or through contractors under
VA auspices. Because of its long history in providing effective
readjustment counseling services that are culturally sensitive to
veterans and their unique military combat experiences, unquestionably
VA is the optimum source for readjustment services for our newest
veterans. However, when VA is not able to meet demand for services for
legitimate reasons, it is clear that VA must use other options. As DAV
testified, VA already has ample authority to provide services through
fee basis and contract care programs. The question is how VA should
provide that contract care.
There have been disturbing reports that some private mental health
providers are not only insensitive to the veteran culture but have
attempted to assign blame to veterans for having been a part of the
military establishment, and thus are culpable for their own mental
health problems induced by combat exposure during that service. The
Committee bill would require that participating community mental health
clinics (CMHC) and the Indian Health Service (IHS) receive VA provided
culturally sensitive, relevant clinical training in order to deliver
effective post deployment readjustment counseling and treatment for
Post Traumatic Stress Disorder (PTSD); thus, we believe the Committee
is acknowledging there may be deficits in the private mental health
community and the IHS in treating veterans for military-related
readjustment disorders.
As stated in our testimony, DAV wants to ensure that all veterans
receiving care from VA or through its fee basis or contract programs
are treated in accordance with VA's standards. In its 2001 report,
``Crossing the Quality Chasm: A New Health Care System for the 21st
Century,'' the Institute of Medicine (IOM) put forward six aims that
now underpin the standard of care for U.S. providers. The IOM aims are
that health care will be safe (avoiding errors and injury), effective
(based on the best scientific knowledge), patient-centered (respectful
of, and responsive to patient preferences, needs and values), timely
(reduced waiting time and harmful delay), efficient (avoiding waste),
and equitable (unvarying, based on race, ethnicity, gender, geography,
or socioeconomic status). VA embraces the IOM aims and therefore should
manage rural veterans' health care issues in a way that addresses all
of the aims collectively.
DAV believes that while section 201 of S. 2162 would address
timeliness and equity of mental health services, two important IOM
aims, it would do so to the potential detriment of the others. In fact,
without evidence that CMHCs have relevant capacity, it is questionable
whether even the timeliness or access goals of this legislation can be
achieved. DAV understands that several years ago VA tried to explore a
partnership with these clinics, but it appeared that most CMHCs had no
excess capacity. In addition, it is unclear if these clinics would be
able to provide the range of post-deployment mental health services
that new veterans may require. Specifically, these veterans may need
services for depression; stress and anxiety reactions, including PTSD;
individual or group counseling; specialized intensive outpatient
treatment for severe PTSD--including cognitive behavioral best
practices; services for relationship problems (including marital and
family counseling); psychopharmacology services; and, substance-use
disorder interventions and treatment, including initial assessment and
referral, brief intervention and/or motivational counseling,
traditional outpatient counseling and intensive outpatient
substance-use disorder care. DAV is not confident they will be able to
rise to such a formidable challenge, given the small population that
would be assigned to each CMHC and the amount of training and other
resources that would be required to prepare them for this patient care
workload.
VA holds itself out to veterans to be their health care system, a
direct provider of care. DAV observes, like the Committee, that VA
currently lacks an integrated approach to address the unique health
care challenges of OEF/OIF veterans living in rural, remote and
frontier areas. To remedy this gap, VA should identify an effective and
creative approach to make health care�including mental health
care--available to our newest generation of wartime veterans
irrespective of their locations of residence. Many of these veterans
have co-morbid physical and mental health conditions related to
military service therefore; we want VA to address the veteran's needs
in a holistic manner. Additionally, VA needs to develop performance
measures and quality standards to assess the care that is provided
through contract or fee-basis arrangements. VA should also be held
accountable by Congress to provide a continuum of services for these
veterans whether provided directly or through contracts.
DAV believes that reform in rural, remote and frontier VA care can be
achieved with the same overarching principles that have accompanied the
transformation of the Veterans Health Administration (VHA) over the
past decade. Necessary actions to achieve this reform would include:
Issuance of clear VHA policy that local facilities and
Networks, through their mental health leadership, are responsible for
creating a VHA-sponsored system that provides a stipulated array of
services reasonably accessible to as many OEF/OIF veterans as possible
who need these services.
Provision of direct services wherever VHA has a large enough
concentration of veterans needing such services, and has an existing
VHA site of care. This would require VA to upgrade access to marital
counseling and develop brief interventions for substance
abuse--services that VHA does not make easily accessible in even some
of its largest facilities.
Contracting for care where there is not a large enough
concentration of veterans needing readjustment counseling services,
after local and Network leadership assess the availability and quality
of alternative service providers (e.g. Vet Centers, State veterans
services), including the availability and quality of services which
could be purchased in the community, and assuring that a full array of
services is made readily available.
Oversight by Congress of this policy, with evidence that it is
coordinated with the VHA Office of Mental Health Services and the newly
established Office of Rural Health.
A critical aspect of health care quality is patient-centered care
that is respectful of veterans' preferences, values and culture but is
also holistic and provides care coordination. Coordination of the full
range of services for every enrolled veteran should be a key
characteristic of VA care. This will not occur unless VA remains
integrally involved in the veterans overall health care.
Additionally, VA should make available to all its health care
contractors gateways to VA's computerized patient record system (CPRS)
so that they can provide clinical information on the care of patients
assigned to them and so that they are aware of the veterans' entire
medical history, diagnoses, and prescribed medications. VA must
develop a strategic plan to achieve true continuity of care for its
contract care patients.
Any organization that wants to partner or contract with VA in
providing health services, including mental health services, should be
willing to provide performance measurement data on each IOM quality aim
and other requirements that VA may need to validate quality. They would
need to develop the ability to collect, track and submit data on the
technical quality process and outcome measures, patient satisfaction,
and wait times, as well as clinical data. This information should be
collected and reported publicly on a quarterly basis.
Finally, Mr. Chairman, we appreciate the Committee�s efforts in
attempting to address this difficult issue, and this opportunity to
further expand on our thoughts regarding mental health care options for
rural, remote and frontier veterans. During your hearing on October
24th one Member suggested by his question that DAV and others would
prefer veterans to remain unserved rather than having care provided by
private contractors. To the contrary, DAV members--all service-disabled
veterans--are the prime users of VA�s fee-basis and contract health
care programs. We want for our members, and for our newest generation
of combat wounded veterans, the very best care VA can provide or obtain
whether from another Federal agency or grantee, or from private
providers through contracts. We believe our policy, and our thoughts
expressed here, are consistent with that goal.
Chairman AKAKA. Thank you very much.
Ms. MURDOUGH?
STATEMENT OF BRENDA MURDOUGH, MSN, RN-C, MILITARY/VETERANS
INITIATIVE COORDINATOR, AMERICAN PAIN FOUNDATION
Ms. MURDOUGH. Good morning. My name is Brenda Murdough.
Mr. Chairman, Ranking Member Burr, Members of the Committee on
Veterans Affairs, I am here to provide testimony to support the
Veterans Pain Care Act of 2007, S. 2160, on behalf of the American Pain
Foundation and our Military/Veterans Pain Initiative.
I would like to thank Chairman Daniel Akaka and his dedicated staff
for their leadership in introducing this important legislation.
I am the Coordinator of this initiative for the American Pain
Foundation, and I am a certified nurse specialist in pain management.
I am also a member of the American Society for Pain Management
Nursing, having worked in the field of pain management for the last
71/2 years.
I am also here on behalf of the more than one million families
who have members currently serving or who have served in the Armed
Forces on active duty or in the National Guard and Reserve. My husband
retired from active duty in the Army after 23 years of active service.
His father is a World War II veteran. We have had family members serve
in almost every armed conflict in the United States back to the
Revolution, with the most recent being our son, who served 15 months in
the Army in Iraq, returning last December. He is still on active duty.
My sister's two daughters serve on active duty in the Army, with one
currently serving in Afghanistan, the other scheduled for deployment to
Iraq most likely in February with her husband of 4 months, who also
serves. My oldest brother's son is also currently serving in the Army
in Iraq. My brother served for 30 years on active duty and retired last
year, after having served in the First Gulf War. My younger brother
served in the Army in the early 1980's, and my husband�s brother is on
active duty in the Air Force. I could go on, but I think my point is
clear.
Military service has been an important and influential part of my
life and I care deeply for the members of the Armed Services and their
families, particularly those who have suffered the horrors of
battlefield injury. I am proud of their service and I am honored to
know so many individuals personally.
But it is for all military personnel, active and retired, and all
veterans from all armed conflicts that this important legislation for
effective pain management must be enacted. The Veterans Pain Care Act
of 2007 is designed to ensure improvement in pain care services,
research, education, and training for the benefit of the veteran
population. It is the least we can do for those who have given so much
for the service of their country.
Founded in 1997, the American Pain Foundation is the Nation's leading
independent nonprofit organization serving people with pain. Several
years ago, with support from the Disabled American Veterans Charitable
Service Trust, APF began reaching out to veterans with pain. The goal
of APF's Military/Veterans Pain Initiative is to improve the quality of
life of military veterans who suffer from pain by collaboratively
working with other organizations to provide resources, information, and
support to veterans with pain, their loved ones and caregivers, and to
advocate for quality acute chronic pain care and increased research.
I know firsthand the importance of early and effective pain
management in acute pain care to prevent the development of chronic
painful conditions. Newsweek recently had an article highlighting this.
Our men and women serving in Iraq and Afghanistan are surviving
battlefield injuries that previously would have been fatal, thanks to
improvements in battlefield medicine and evacuation. The most recent
complete study of soldiers enrolled in VA polytrauma centers show that
more than 90 percent have chronic pain. Most have pain from more than
one part of the body, and that pain is the most common symptom in
returning soldiers.
Advances in neuroscience, such as neuroimaging, now demonstrate that
unrelieved pain, regardless of its initial cause, can be an aggressive
disease that damages the nervous system, causing permanent pathological
changes in sensory neurons and in the tissues of the spinal cord and
brain. We need to be sure these painful shrapnel wounds, traumatic
amputations, closed head traumas, and other battlefield injuries are
receiving the most immediate and effective pain management at the time
of acute injury to prevent chronic painful conditions from developing,
and we need to make sure that all veterans that have developed chronic
pain are receiving proper comprehensive, multi-modal pain care.
Perhaps more than any other Federal agency, the VA has been a leader
in focusing institutional resources on the assessment and treatment of
pain. The Veterans Health Administration has made pain management a
national priority. However, although many of our military and veterans'
treatment facilities offer the highest level of skilled expertise in
treating these painful conditions suffered by our wounded Armed
Servicemen and women, we need to ensure that all of our veterans'
facilities are consistently providing the highest level of
comprehensive pain management to prevent long-term suffering and
disability.
We know the high multi-dimensional costs of untreated or undertreated
pain on individuals and on families. Chronic pain conditions, such as
those that can come from Traumatic Brain Injury, multiple fractures,
traumatic amputation, crush injuries, and other battlefield injuries
can be devastating to individuals and their families as they try to
cope with the impact physically, mentally, socially, psychologically,
and economically.
Pain can be acute and effectively treated by short-term
interventions, or it can be chronic, often without effective cures, and
sometimes without consistent and effective means of alleviation.
Chronic pain symptoms and Post-Traumatic Stress Disorder frequently
co-occur and may intensify individuals� experience of both conditions.
Those who suffer severe chronic pain see their daily lives disrupted,
sometimes forever. Their pain and their constant search for relief
affects their function, their relationships, and those they love, their
ability to do their work effectively, and often their self-esteem.
Chronic pain is often accompanied by or leads to sleep disorders,
emotional distress, anxiety, depression, and even suicide. We need to
provide our Armed Servicemen and women with the resources necessary to
provide effective pain relief within the Veterans Administration Health
Care System.
The APF has recently developed ��Treatment Options: A Guide for
Living With Pain�� for people living with pain, written and reviewed by
leading pain specialists. Our guide provides credible, comprehensive
information about many options for care. Pain is complex and unique to
each individual and is usually best managed by a combination of
treatments, such as medication, psychological assistance, physical
rehabilitation, injection infusion therapies, implanted devices, such
as spinal cord stimulators, or continuous infusion catheters and
complementary alternative medicines.
I recently had the privilege and honor of meeting and speaking with
soldiers at Walter Reed Medical Center on the regional anesthesia acute
pain care team rounds and words cannot do justice to the courage and
determination I witnessed. All were amputees. All were injured in the
conflicts in Iraq and Afghanistan. And all will be veterans with
painful, lifelong consequences of their battlefield injuries. They
fought for others. Now it is our time to fight for them. They deserve
freedom from pain.
With this in mind, I ask you to pass the Veterans Pain Care Act of
2007, S. 2160, so that all--
Chairman AKAKA. Ms. Murdough, will you please summarize your
statement?
Ms. MURDOUGH. Thank you. All veterans, all of our men and women who
have served, past, present, and future, who have suffered wounds of
battle deserve consistent, high-quality pain management, deserve
freedom from pain, and it is our obligation to provide it to them. It
is the least we can do.
Thank you. I apologize.
[The prepared statement of Ms. Murdough follows:]
PREPARED STATEMENT OF BRENDA MURDOUGH, MSN RN-C, MILITARY/VETERANS
INITIATIVE COORDINATOR, AMERICAN PAIN FOUNDATION
Mr. Chairman and Members of the Committee on Veteran's Affairs, my
name is Brenda Murdough, MSN RN�C. I am here to provide testimony to
support the Veterans Pain Care Act of 2007, on behalf of the American
Pain Foundation and our Military/Veterans Pain Initiative. I am the
Coordinator of this Initiative for the American Pain Foundation and I
am a certified nurse specialist in pain management. I am also a member
of the American Society for Pain Management Nursing, having worked in
the field of pain management for the last seven and a half years.
I am also here on behalf of the more than one million families who
have members currently serving or who have served in the armed forces
on active duty or in the National Guard and Reserve. My husband retired
from active duty in the Army after 23 years of service. His father is a
WWII veteran. We have had family members serve in almost every armed
conflict in the United States back to the Revolution, with the most
recent being our son, who served 15 months in the Army in Iraq,
returning last December. He is still on active duty. My sister's two
daughters serve on active duty in the Army with one currently in
Afghanistan and the other scheduled for deployment to Iraq most likely
in February with her husband of 4 months, who also serves. My oldest
brother's son is also currently serving in the Army in Iraq. My brother
served for 30 years on active duty and retired last year after having
served in the first Gulf War. My younger brother served in the Army in
the early 80's and my husbands' brother is on active duty in the Air
Force. I could go on, but I think my point is clear. Military service
has been an important and influential part of my life and I care deeply
for the members of our armed services and their families, particularly
those who have suffered the horrors of battlefield injury. I am proud
of their service and honored to know so many individuals personally.
But it is for all military personnel, active and retired, and all
veterans from all armed conflicts that this important legislation for
effective pain management must be enacted. The Veterans Pain Care Act
of 2007 is designed to ensure improvement in pain care services,
research, education, and training for the benefit of the veteran
population. It's the least we can do for those who have given so much
in the service of their country.
Founded in 1997, the American Pain Foundation (APF) is the Nation's
leading independent nonprofit organization serving people with pain.
Three years ago, with support from the Disabled American Veterans
Charitable Service Trust, APF began reaching out to veterans with pain.
The goal of APF's Military/Veterans Pain Initiative is to improve the
quality of life of military/veterans who suffer from pain by
collaboratively working with other organizations to provide resources,
information and support to veterans with pain, their loved ones and
caregivers; and to advocate for quality acute and chronic pain care and
increased research.
I know first hand the importance of early and effective pain
management in acute pain care to prevent the development of chronic
pain conditions. Our men and women serving in Iraq and Afghanistan are
surviving battlefield injuries that previously would have been fatal,
thanks to improvements in battlefield medicine and evacuation. The most
recent complete study of soldiers enrolled in VA Polytrauma Centers
show that more than 90 percent have chronic pain, that most have pain
from more than one part of the body, and that pain is the most common
symptom in returning soldiers. Advances in neuroscience, such as
neuroimaging, now demonstrate that unrelieved pain, regardless of its
initial cause, can be an aggressive disease that damages the nervous
system, causing permanent pathological changes in sensory neurons and
in the tissues of the spinal cord and brain. We need to be sure that
these painful shrapnel wounds, traumatic amputations, closed head
traumas and other battlefield injuries are receiving the most immediate
and effective pain management at the time of acute injury to prevent
chronic painful conditions from developing. And we need to make sure
that all veterans that have developed chronic pain are receiving
proper, comprehensive, multi-modal pain care.
Perhaps more than any other Federal agency, the VA has been a leader
in focusing institutional resources on the assessment and treatment of
pain. The Veterans Health Administration has made pain management a
national priority. However, although many of our military and veterans
treatment facilities offer the highest level of skill and expertise in
treating these painful conditions suffered by our wounded armed service
men and women, we need to ensure that all of our veterans' facilities
are consistently providing the highest level of effective,
comprehensive pain management to prevent long term suffering and
disability.
We also know the high, multidimensional costs of untreated or under
treated pain on individuals and their families. Chronic pain conditions
such as those that can come from Traumatic Brain Injury, multiple
fractures, traumatic amputation, crush injuries and other battlefield
injuries can be devastating to individuals and their families as they
try to cope with the impact physically, mentally, socially,
psychologically and economically. Pain can be acute and effectively
treated by short term interventions, or it can be chronic, often
without effective ��cures�� and sometimes without consistent and
effective means of alleviation. Chronic pain symptoms and Post
Traumatic Stress Disorder frequently co-occur and may intensify an
individual's experience of both conditions. Those who suffer severe
chronic pain see their daily lives disrupted�sometimes forever. Their
pain and their constant search for relief affects their function, their
relationships with those they love, their ability to do their work
effectively, and often their self esteem. Chronic pain is often
accompanied by or leads to sleep disorders, emotional distress,
anxiety, depression, and even suicide. We need to provide our armed
service men and women with the resources necessary to provide effective
pain relief within the Veterans Administration Health Care system.
The APF has recently developed Treatment Options: A Guide for People
Living with Pain. Written and reviewed by leading pain specialists, our
guide provides credible, comprehensive information about many options
for care. Pain is complex and unique to each individual and is usually
best managed using a combination of treatments such as medication,
psychological assistance, physical rehabilitation, injection and
infusion therapies, implantable devices such as spinal cord stimulators
or continuous infusion catheters, and complementary and alternative
medicine.
I recently had the privilege and honor of meeting and speaking with
soldiers at Walter Reed Medical Center on the Regional Anesthesia Acute
Pain Care team rounds and words cannot do justice to the courage and
determination I witnessed. All were amputees, all were injured in the
conflicts in Iraq and Afghanistan and all will be veterans with
painful, lifelong consequences of their battlefield injuries. They
fought for others rights and now it's our time to fight for theirs.
Freedom from pain is their right.
It is with this in mind that I ask you to pass the Veterans Pain Care
Act of 2007. This bill requires that all facilities within the
Department of Veterans Affairs are held accountable for the adequacy
and consistency of pain treatment across programs and geographic
regions; that pain assessment, diagnosis and treatment be prompt and
integral to veterans health care; and that the VA increase its research
into the areas of acute and chronic pain. Our veterans, all of our men
and women who have served, past, present and future, who have suffered
the wounds of battle, have earned the right to consistent high quality
pain management--have earned the right to freedom from pain--and it is
our obligation to them to provide it. It is the least we can do.
Additional information is available at American Pain Foundation, 201
N. Charles Street, Suite 710 Baltimore, MD 21201-4111 P: 410-783-7292
www.painfoundation.org
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO
BRENDA MURDOUGH, MSN, RN-C, MILITARY/VETERANS INITIATIVE COORDINATOR,
AMERICAN PAIN FOUNDATION
1. In your testimony, you raised concerns over the implementation of
VA's pain management program, in that it has not been consistent across
the entire system.
Can you comment further on this, and discuss the areas most urgently
in need of improvement?
There are VA facilities that have excellent pain care programs--an
example is the Tampa Florida center, which was recently highlighted in
the news. Unfortunately, this high quality, multidiscipline,
comprehensive approach to pain management is not available to those who
must travel long distances, only to find that the person treating them
has had no training in Pain Management, is not educated in prescribing
the medications necessary to manage pain effectively, or that the
resources necessary are not available in the area. Consequently, the
areas most urgently in need of attention are ensuring available,
consistent, high quality, multimodal pain care treatment and an
increase in individuals who are appropriately educated and trained in
the specialty of Pain Management. We hear from Veterans often about the
disparity of Pain Management across the VA system.
2. As you have testified, pain is complex and unique to each
individual. How can VA most effectively prioritize their research to
address the array of acute and chronic pain conditions veterans face?
How much focus should there be upon treatment versus other priorities?
Research opportunities should focus on two main categories: improved
acute pain management either in the battlefield or at the time of
injury to prevent the possible development of chronic pain conditions,
and the improvement in treatment options for chronic pain conditions,
including the pain specific to Traumatic Brain Injury, traumatic
amputation, shrapnel wounds, and other concussive injuries which may
have long term pain associated with them. Research should focus on the
most effective means of decreasing pain and improving quality of life,
including the most effective multi modal approaches for accomplishing
these goals. Research should also explore the high co-prevalence of
psychiatric disorders (such as PTSD and depression) with pain.
Chairman AKAKA. Thank you.
Dr. SMITH?
STATEMENT OF BRIEN J. SMITH, M.D., MEDICAL DIRECTOR,
COMPREHENSIVE EPILEPSY PROGRAM, HENRY FORD HOSPITAL
Dr. SMITH. Mr. Chairman and distinguished Members of the Committee,
thank you very much for the opportunity to be here today. My name is
Brien Smith and I am the Medical Director of the Comprehensive Epilepsy
Program at Henry Ford Hospital in Detroit, Michigan. I am pleased to
speak today in support of S. 2004, the VA Epilepsy Centers of
Excellence Act of 2007.
Epilepsy is a medical condition that produces seizures affecting a
variety of mental and physical functions. The seizure happens when a
brief strong surge of electrical activity affects part or all of the
brain. When a person has two or more seizures, the condition is then
considered epilepsy. Epilepsy affects 1 percent of the U.S. population,
or three million people.
One of my first experiences with Post-Traumatic Epilepsy as a
clinician is when I met George Bussell in 1994. Mr. Bussell's Traumatic
Brain Injury occurred in 1944 while he served as a combat engineer
during World War II and he was taking up a mine field between France
and Germany. A fragment from a shell struck him in the frontal region,
blowing off his helmet and leading to hospitalization. He seemed to
recover fully, but subsequently developed seizures 16 years later
arising from the area of injury. Despite multiple attempts to control
his seizures, his life was dramatically altered by daily seizures until
he was presented to my clinic in 1994, 34 years later, for surgical
evaluation. Fortunately, we were able to help him with surgery and he
gained a new sense of independence for the last 10 years of his life.
Mr. Bussell is one of many similar stories. We know that trauma to
the brain, whether mild or severe, is clearly a defined risk factor for
epilepsy. Studies from the Vietnam War and from the Iran-Iraq War show
that 32 to 50 percent or more of service-related TBI victims develop
epilepsy within 1 to 15 years Post-Trauma. Let me clarify that this
statistic is for penetrating injuries which occur when a foreign object
or piece of fractured skull enters the brain.
Today's story is a bit different. The common head trauma in Iraq is
the result of the shockwave effect of high pressure that reverberates
through the body and head from an explosion like those from an
improvised explosive device, or IED. Researchers fear that incidence of
Post-Traumatic Epilepsy could increase exponentially given this
mechanism of injury. The 2003 data from Walter Reed Army Medical Center
found evidence of brain injury in 61 percent of returning soldiers who
had been exposed to IED blasts according to the Defense and Veterans
Brain Injury Center, a partnership between the VA and Department of
Defense. It is because of such alarming statistics that the Epilepsy
Foundation and epileptologists like me believe that S. 2004 is
critically needed.
We have to make sure that VA is prepared for the influx of
Post-Traumatic Epilepsy. In essence, that is what S. 2004 is all about.
The VA currently lacks a national program for epilepsy with clear
guidelines on when to refer patients for further assessment and
treatment of epilepsy. What the VA does have is a great model. Centers
of Excellence have been developed over the years to address other
disabling and chronic diseases in the veteran population such as
Parkinson's disease and multiple sclerosis. Through such Centers of
Excellence, the VA has been able to address many of the other common
consequences of TBI, such as psychological changes and vision problems,
but not Post-Traumatic Epilepsy.
The VA did establish epilepsy centers in the 1970's, but they have
languished with few staff and no national budget, leaving veterans with
Post-Traumatic Epilepsy, like Mr. Bussell, at the mercy of an
inadequate system. Many veterans are denied services in locations
without the necessary epilepsy facilities and the centers are not
linked together. Sadly, the potential of these centers to be the
backbone of a national epilepsy program never materialized.
The new centers created by S. 2004 would be linked with prestigious
medical schools and research centers, thus attracting outstanding
clinicians and scientists capable of driving innovation in the
prevention and treatment of Post-Traumatic Epilepsy. A highlight of
this legislation is that it contains a telemedicine component whereby
the review of neurologic diagnostic tests, such as EEGs and MRIs, will
be able to take place through transmission of the tests from the
veteran's local care facility to one of the six centers. Thus, the
centers would provide a nationwide monitoring program to improve the
quality of life for veterans who live in rural areas that are far from
a center.
Mr. Chairman, I strongly believe that we must strike while the iron
is hot. As a Nation, we became more aware of TBI as a consequence of
war when news anchor Bob Woodruff shared his personal story with the
Nation. But while we now have people understanding that TBI is
occurring at high rates, most people do not understand the high
probability of epilepsy as a consequence of TBI or that epilepsy may
manifest many years later.
Congress has the opportunity right now to make a difference for our
veterans and for their future. Without proper diagnosis and care, their
lives and livelihoods are affected forever. By enacting S. 2004, we
will be finally putting into place a national network of centers to
address the effects of TBI and epilepsy for the war heroes of today who
will be citizens living in your towns tomorrow.
Thank you for this opportunity today.
[The prepared statement of Dr. Smith follows:]
PREPARED STATEMENT OF BRIEN J. SMITH, MD, MEDICAL DIRECTOR,
COMPREHENSIVE EPILEPSY PROGRAM HENRY FORD HOSPITAL
Mr. Chairman and Distinguished Members of the Committee:
Thank you very much for the opportunity to be here today. My name is
Brien Smith and I am Medical Director of the Comprehensive Epilepsy
Program at the Henry Ford Hospital in Detroit, Michigan. I am pleased
to speak in support of S. 2004, the VA Epilepsy Centers of Excellence
Act of 2007 and to share with you some thoughts about why these Centers
are critically needed.
Epilepsy is a medical condition that produces seizures affecting a
variety of mental and physical functions. A seizure happens when a
brief, strong surge of electrical activity affects part or all of the
brain. When a person has two or more seizures the condition is then
considered epilepsy. Epilepsy affects about 1 percent of the U.S.
population or 3 million people.
Nearly half a million people are involved in some kind of accidental
brain injury each year--typically through a car accident or a fall--and
80,000 of them require hospitalization due to moderate or severe
Traumatic Brain Injury. Mortality and morbidity as a consequence of TBI
are a major public health problem and Post-Traumatic Epilepsy is linked
to psychosocial disability and is probably a contributing factor to
premature death after penetrating head injury.
One of my first experiences with Post-Traumatic Epilepsy as a
clinician is when I met George Bussell in 1994. Mr. Bussell�s Traumatic
Brain Injury occurred in 1944 when he served as a combat engineer
during World War II and he was taking up a mine field between France
and Germany. A fragment from a shell struck him in the frontal region
blowing off his helmet and leading to hospitalization. He seemed to
recover fully, but subsequently developed seizures 16 years later
arising from the area of injury. His wife recalls witnessing the first
event with him screaming out, becoming confused, strange movements of
his arms and legs, clicking of his tongue and undressing himself.
Despite multiple attempts to control his seizures his life was altered
by these recurrent, almost daily events until he presented to our
clinic in 1994 for surgical evaluation. With good fortune, surgical
intervention at age 69 provided him with a new sense of independence
for the last 10 years of his life.
Mr. Bussell is one of many similar stories. We know that the risk for
our service men and women is very real--even if we cannot predict the
exact number of soldiers who will be harmed, we know that trauma to the
brain, whether mild or severe, is a clearly defined risk factor for
epilepsy. Past studies from the Vietnam War referenced in my written
testimony, show that more than 50 percent of service related TBI
becomes epilepsy within 1-15 years Post Trauma. This statistic is for
penetrating injuries which occur when a foreign object or piece of
fractured skull enters the brain. Another study conducted between 1980
and 1988 in Iran looking at soldiers in the Iran-Iraq war showed 32
percent of penetrating head injury TBI became epilepsy within 6 months
to 2 years.
Today's story is a bit different. The common head trauma in Iraq is
the result of a ``shock wave'' effect of high pressure that
reverberates through the body and head from an explosion like those
from the Improvised Explosive Devices or IEDs. Researchers fear that
incidence of Post-Traumatic Epilepsy could increase exponentially given
the shock wave effect from IEDs.
2003 data from Walter Reed Army Medical Center found evidence of
brain injury in 61 percent of returning soldiers who had been exposed
to blasts according to the Defense and Veterans Brain Injury Center
(DVBIC), a partnership between the VA and Department of Defense. It is
because of such alarming statistics that the Epilepsy Foundation and
epileptologists like me believe that S. 2004 is critically needed.
The legislation has three major goals:
1. (re)Establish 6 Centers to specialize in Post Traumatic Epilepsy
and make them part of a national network of Centers that can serve
veterans;
2. Conduct research that will lead to an ability to prevent epilepsy
as an outcome of TBI as well as research for better seizure control and
an eventual cure for all epilepsy;
3. Allow veterans living in rural communities or far from VA
hospitals access to the care they need.
Given the high rate of Post-Traumatic Epilepsy that veterans with TBI
are likely to endure, the Epilepsy Foundation and the American Academy
of Neurology believes that Congress should take a strong role in
veterans' health care by authorizing this bill that would direct the VA
to establish a strong national epilepsy program with research,
education, and clinical centers that will provide state-of-the-art care
for our brave soldiers.
As this Committee heard in May from Dr. John Booss, a former national
director of neurology for the VA, the VA lacks a national program for
epilepsy with clear guidelines on when to refer patients for further
assessment and treatment of epilepsy. VA Centers of Excellence have
been the model of innovation in the delivery of highly specialized
health care and research for other disabling and chronic diseases in
the veteran population such as Parkinson�s disease and Multiple
Sclerosis. The VA has the infrastructure to address many of the other
common consequences of TBI such as psychosocial changes and vision
problems but not Post-Traumatic Epilepsy.
The VA established Epilepsy Centers as early as 1972, but these
Centers have languished over the years with few staff and no national
budget. The net result of allowing these Centers to fall by the wayside
is that veterans with post TBI epilepsy are at the variable mercy of a
system with markedly uneven distribution of epilepsy services. This
often results in denial of services in locations without the necessary
epilepsy facilities and in which administrators are hard pressed to
meet their budget. Sadly, the potential of these Centers to be the
backbone of a national epilepsy program never materialized.
Under this bill, the VA would designate six new Centers that would be
linked with prestigious medical schools and research centers thus
attracting outstanding clinicians and scientists capable of driving
innovation in the prevention and treatment of Post-Traumatic Epilepsy.
State-of-the-art care is what our veterans deserve. Research is the key
to discovering ways to better predict when TBI victims will develop
epilepsy.
To date, research has been focused primarily on the seizures
themselves and what drugs might control or eliminate them. My colleague
Marc Dichter, M.D., Ph.D. professor of neurology and pharmacology at
the University of Pennsylvania says, ``We basically wait for epilepsy
to happen and then see if we can treat it, which is in stark contrast
to how we tackle other public health problems such as cancer or heart
disease where we identify risk factors and try to prevent disease from
occurring.''
Another grave concern we have is that many returning veterans live in
rural areas or far from a VA Center. S. 2004 contains a component on
telemedicine whereby the review of neurological diagnostic tests such
as EEG's and MRI's will be able to take place through transmission of
such tests from the veteran�s local care facility to one of the 6
ECoEs. Thus, the ECoEs would provide a nationwide monitoring program to
improve the quality of life for veterans with Post-Traumatic Epilepsy
who live in rural areas.
Mr. Chairman, I strongly believe that we must strike while the iron
is hot. As a Nation we became more aware of TBI as a consequence of war
when news anchor Bob Woodruff shared his story of experiencing TBI with
the Nation. But while we now have people understanding that TBI is
occurring at high rates, most people do not understand the high
probability of epilepsy as a consequence of the TBI or that the
epilepsy may manifest many years later. Congress has the opportunity
right now to make a difference for our veterans and for their future.
Without proper diagnosis and care, their lives and livelihoods are
affected forever. By enacting the VA Epilepsy Centers of Excellence Act
of 2007, we will be putting into place a national network of Centers to
address the affects of TBI and epilepsy for the war heroes of today who
will be the citizens living in your towns tomorrow.
Thank you for this opportunity today.
STUDIES REFERENCED:
Epilepsy after penetrating head injury. I. Clinical correlates: A
report of the Vietnam Head Injury Study. Andres M. Salazar, Bahman
Jabbari, Stephen C. Vance, Jordan Grafman, Dina Amin, and J.D. Dillon.
Neurology 1985; 35;1406 Prognostic Factors in the Occurrence of
Post-Traumatic Epilepsy after Penetration Head Injury Suffered During
Military Service. Bizhan Aarabi, M.D., Musa Taghipour, M.D., Ali
Haghnegahdar, M.D., Majidreza Farokhi, M.D., Lloyd Mobley, M.D.,
Division of Neurosurgery, University of Nebraska Medical Center, Omaha,
Nebraska; Division of Neurosurgery, Shiraz University of Medical
Sciences, Shiraz, Iran, Neurosurg Focus 8(1), 2000. Copywrite 2000
American Association of Neurological Surgeons
--------
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO
DR. BRIEN SMITH, M.D., MEDICAL DIRECTOR, COMPREHENSIVE EPILEPSY
PROGRAM, HENRY FORD HOSPITAL
1. Your prepared testimony noted that epilepsy is unlike most other
medical conditions, in that despite known risk factors, a wait-and-see
approach is used in lieu of aggressive preventive care. Recognizing
that there is a large population of veterans who may be at risk for
developing epilepsy, what types of preventive practices can be
implemented?
Presently, there are no preventive practices from a medical
perspective available. Aggressive preventative care would be ideal, if
there was any data to suggest what that is. Completing controlled
trials on acute Traumatic Brain Injury is very difficult and costly in
the civilian population. Unfortunately, combat arenas, like Iraq, is
one of the few scenarios where research trials could be performed to
identify potentially profitable treatments.
A number of compounds have been tested either in animal models and a
few in human civilian studies which were hoped to demonstrate
neuroprotective or antiepileptogenic properties without disturbing the
normal features of the healing process. No agents have been identified
thus far which demonstrate positive results. In fact, a recently
published study on the use of magnesium in humans with head trauma
appeared to actually have a negative effect versus placebo, after
animal studies had suggested potential neuroprotective properties.
Attempts are being made to optimize the care in the acute
Post-Traumatic Period (first 2 weeks), but there has been no data to
suggest that this has had any significant impact in reducing the
subsequent development of epilepsy.
2. What role would the creation of epilepsy centers of excellence
play in the development of preventative medicine and the early
diagnosis of epilepsy?
Epilepsy Centers of Excellence would serve as a model to develop
patient care practices designed to assist in recognizing the
development of Post-Traumatic Epilepsy and rapidly initiate evaluation
and treatment. All soldiers with a history of head trauma, and at risk
for the development of epilepsy, would undergo baseline testing
including EEG, MRI, and Neuropsychological testing. Vigilant outpatient
monitoring followed by scheduled testing with a prolonged follow-up
period would provide significant data to identify soldiers at highest
risk to develop the condition and enable reduction of secondary
morbidity from unrecognized seizures.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO
DR. BRIEN SMITH, MEDICAL DIRECTOR, COMPREHENSIVE EPILEPSY PROGRAM,
HENRY FORD HOSPITAL
Dr. Smith, in your testimony you spoke about a former patient,
Mr. Bussell. He was injured in WWII, and began having seizures 16 years
later, and yet he didn't enter your clinic and get proper care to treat
his seizures until 1994.
Can you please share with us where he was in the interim and whether
he sought medical care from the VA?
Mr. Bussell did seek care from the VA shortly after the onset of his
seizures in 1960. He was informed that the seizures were unrelated to
his previous head trauma, and that his problem was a separate issue.
Due to the limited options offered to him, Mrs. Bussell felt she was
running into a ``dead end'' with the VA and therefore pursued
evaluations at outside centers. Mr. Bussell was evaluated at the
University of Michigan for epilepsy surgery, but since he was
considered a complicated extratemporal case, the surgical option was
not offered, and he was entered into a number of experimental drug
trials. After those attempts failed, he was subsequently seen in my
clinic at Henry Ford Hospital where the surgical treatment option was
offered.
Do you think veterans of this generation will meet the same fate as
Mr. Bussell if we fail to develop a national program for epilepsy care?
Yes. The VA system is presently ill-prepared to handle the numbers of
returning soldiers who are at risk of developing Post-Traumatic
Epilepsy. Not only do they have only a limited number of centers that
have the equipment to manage these patients, the specialty personnel to
complete these evaluations, and provide cutting edge treatment is
lacking. The VA has a very limited perspective on the problem of
Post-Traumatic Epilepsy. When you review their 180 page Traumatic Brain
Injury manual, there is only one-half of a page that addresses
epilepsy, and none of the listed authors are considered epilepsy
specialists.
Chairman AKAKA. Thank you very much, Doctor.
Captain WALKER?
STATEMENT OF CAPT. CONSTANCE A. WALKER, USN (RET.),
NATIONAL ALLIANCE ON MENTAL ILLNESS MEMBER, NAMI
VETERANS COUNCIL; PRESIDENT, NAMI SOUTHERN MARYLAND
Capt. WALKER. Good morning, Chairman Akaka and Members of the
Committee. My name is Connie Walker. Thank you for your invitation to
provide testimony as you consider this very important legislation
related to mental health programs in the Department of Veterans
Affairs.
This is a particularly important session for me, not only as a
veteran and as a member of the National Alliance on Mental Illness, but
as the parent of an Operation Iraqi Freedom 100 percent disabled
veteran. Having said that, sir, I would ask the Committee's indulgence
for two additional minutes, if I may.
My son asked if he could come today, but I said no. Mike is
sixfoot-seven and very handsome and I was afraid that people would
pay more attention to him than to what I have to say.
He enlisted in the Army as a motor transport operator in June
2001, Associate�s Degree in hand, basketball trophies and varsity
letters in the attic, and more impressed by a chance to see the
world and a very large enlistment bonus than by the idea of two
more years of college. He had a good service in the Army and
particularly enjoyed his deployment to Germany.
In January 2003, his unit deployed to Northern Kuwait in support of
the first phase of the war and our advance into Baghdad. They returned
about 7 months later. I was deeply concerned with what I saw on that
homecoming weekend. He would wake up screaming and was very subdued.
The Army assured me he would be seen by a counselor at Fort Eustis, but
in the coming months, his physical and mental decline became even more
apparent.
In December 2003, at my insistence, after an aborted attempt by the
Army to administratively separate him, my son received a full physical
and mental evaluation. In January 2004, Michael was diagnosed with
PTSD, major depression, and schizophrenia. He was hospitalized, and
later that year medically retired. Today, he lives with my husband and
I in rural Southern Maryland. After using every resource available to
us where we live and coordinating with the VA whenever we can, we are
encouraging him to accept residential mental health care at the VA
Medical Center in Perry Point, Maryland. The issue is not that my son
cannot be helped.
The issue is one of availability and quality of care where we live. I
have been and remain my son�s primary advocate and have worked with
military, VA, and civilian mental health care, insurance, and
disability benefits systems. Navigating these waters is always a
difficult job. At times, it is debilitating, even to someone with my
skill sets: a 20-year career in recruitment, accession, retention, and
retiree policy and program management; strong supporters within the VA,
TRICARE, and other Federal and State agencies; and access to a local
resource network that spans three Maryland counties. My experiences, my
advocacy on behalf of OIF and OEF veterans and families in St. Mary's
County and other parts of Maryland, North Carolina, Georgia, and
California's rural areas, and connections to veteran advocates across
the country have led me to this conclusion.
Mr. Chairman, it is impossible to overstate the stressors that rural
and frontier family caregivers are bearing on a daily basis as they
search for limited treatment and rehabilitative services, and work to
support a loved one whose cognitive abilities have been severely and
sometimes permanently impaired by the invisible injuries of PTSD, other
mental health issues, or the aftermath of Traumatic Brain Injury.
From a mental health care perspective, a single bottom line looms
over everything in mental health treatment and rehabilitation for our
veterans in rural areas. The likelihood of obtaining effective services
is slim to none for those who live beyond a reasonable commute from a
VA medical center or do not have access to an appropriately and
consistently staffed VA Community-Based Outpatient Clinic.
This is a painful realization for families of these veterans,
especially in light of this truth about recovery: Early intervention
and regular access to treatment and rehabilitation services are as
vital to a disabled veteran's recovery from serious mental illness as
they are to a physically injured veteran's recovery from serious
physical injury.
Mr. Chairman, you asked me to limit my remarks to your mental health
bill, S. 2162, the Mental Health Care Improvements Act. My formal
statement submitted earlier this week also discusses the other
legislation under your consideration. Your proposed mental health bill
would establish new requirements in the VA for the treatment of PTSD
and substance use disorder, with special procedures to address the
treatment of veterans who suffer from co-occurring disorders. VA
emphasis on concurrent treatment for veterans who have PTSD or other
mental illness and are self-medicating with alcohol or drugs would be a
welcome step forward in these veterans' journey to recovery.
That said, for OIF and OEF veterans who need these services in rural
areas, I think the only practical avenue for VA care for this core of
veterans would be through the CBOCs. The Substance Abuse and Mental
Health Services Administration reports that rural substance abuse is a
large and growing problem in America with insufficient resources in
place to meet that challenge. So to reach rural veterans, rural CBOCs
would need to be fully and consistently staffed, not staffed by
rotating mental health professionals among multiple sites, in order to
offer consistent treatment capabilities when these veterans need
them--not on the day of the week that the physician happens to be
there. I am afraid that even under these circumstances, veterans in
need of mental health treatment who are self-medicating in our frontier
areas are likely to be beyond reach.
To continue, the legislation would require a VA review of its
residential mental health care facilities, including the domiciliaries.
The deliverable would be a report on availability and quality of care
at these sites for this Committee and the House Committee on Veterans
Affairs. Mr. Chairman, this is an extremely important assessment of VA
residential and long-term mental health care facilities and it cannot
wait.
I was an Inspector General in my last Navy assignment. A legislative
mandate is not necessary to initiate a fact-finding review of this
nature. There are inspection and audit agencies that can be tasked to
take this for action right now, for example, the VA's Office of
Inspector General or the GAO.
Mr. Chairman, your legislation would require the VA to establish a
pilot program in two VA networks for peer outreach and support,
readjustment counseling, and other mental health services for OIF and
OEF veterans in partnership with community mental health services and
the Indian Health Service. Sir, this aspect of your legislation
discusses a vital need for families like mine in rural America:
increased access to mental health care programs and rehabilitation
services for veterans who are coming home to places where VA resources
are very limited or do not exist.
There are several issues of concern, not with your legislation's
correct and critically important intent, but with the assumption of a
capability of existing rural resources to achieve that goal, VA
training notwithstanding. The overarching challenge is a national
issue. There are too few mental health care specialists, programs, and
services in rural areas to meet the needs of the existing population.
Sixty percent of rural Americans live in federally designated mental
health professional shortage areas. Sixty-five percent get their mental
health care from their primary care doctor. In Southern Maryland, where
I live, individuals seeking psychiatric care can wait up to 4 months
for their first appointment.
Related concerns go to community mental health centers, where
programs are funded primarily through grants from the Department of
Health and Human Services. There are very few centers in rural areas,
and sustained mental health workforce shortages have reached crisis
levels in many areas of this country. Clinics most often operate at
capacity, and many of their clients have lived with chronic mental
illness for years.
My son received services through our county�s only community-based
residential treatment program after his return to Southern Maryland.
Mike has had an independent full life and although he wanted to come
home, certainly, after his medical retirement--coming home to live with
Mom was not something he was excited about doing...would it be for any
young man or woman? We arranged for residential treatment at the only
agency available and found the gap between slick marketing and reality
to be more than disillusioning.
We know that 56% of OIF and OEF veterans utilizing VA health care are
under 29 years old, just like my son. This demographic, these veterans'
distinct psychiatric treatment and rehabilitation needs, and what they
want and we all hope for, for their futures--will make the requirement
for VA training of community mental health center clinicians, at a
minimum, even more important.
Mr. Chairman, if this legislation will increase mental health
staffing and resources in rural areas, then it can ensure access to
care for OIF and OEF veterans who need it and it must be supported. My
fear is that the current state of our country's rural mental health
infrastructure will keep it from achieving its intent and more precious
time will be lost, and that clock is ticking.
Mr. Chairman, Senior Ranking Member Burr, like you, I believe the
solution is achievable and that a collaboration of care is what it will
take. Local mental and physical health care providers must receive some
VA training in mental and physical health issues for this generation of
combat veterans so they know what to look for. A continuum of partnered
care that keeps an assigned VA case manager informed on a regular
basis, an approach that will take input from family caregivers into
account and give them some training--
Chairman AKAKA. Captain Walker, will you please summarize your
statement?
Capt. WALKER. Sure. VA and Health and Human Services must actively
partner and perhaps even combine resources for a treatment venue in
rural areas that works for this population of veterans and their
families. It cannot be business as usual, and in rural areas, right
now, it is definitely business as usual.
Thank you for considering my views on this legislation, sir.
[The prepared statement of Capt. Walker follows:]
PREPARED STATEMENT OF CONSTANCE A. WALKER, CAPT, USN (RET.)
NATIONAL ALLIANCE ON MENTAL ILLNESS MEMBER, VETERANS'
COUNCIL, PRESIDENT, NAMI SOUTHERN MARYLAND
Chairman Akaka and Members of the Committee--
As a member of the Veterans Council of the National Alliance on
Mental Illness (NAMI), I appreciate your invitation to provide
testimony for your consideration of several legislative proposals
related to mental health programs in the Department of Veterans Affairs
(VA). On behalf of NAMI�s Executive Director, Mr. Michael Fitzpatrick,
and our Veterans Council Chairman, Ms. Sally Miller, of Bozeman,
Montana, please accept our thanks for this opportunity to speak with
you today.
NAMI is the Nation's largest non-profit organization representing and
advocating on behalf of persons living with chronic mental health
challenges. Through our 1,200 chapters and affiliates in all 50 states,
NAMI supports education, outreach, advocacy and biomedical research on
behalf of persons with schizophrenia, bipolar disorder, major
depression, severe anxiety disorders, Post-Traumatic Stress Disorder
(PTSD), and other chronic mental illnesses that affect children and
adults.
NAMI and its Veteran Members established the Veterans Council in 2004
to assure close attention is paid to mental health issues in the VA and
within each Veterans Integrated Service Network (VISN). We advocate for
an improved VA continuum of care for veterans with severe mental
illness. The council includes members from each of VA�s 21 VISNs. These
members serve as NAMI liaisons with their VISNs; provide outreach to
national Veterans Service Organizations; increase Congressional
awareness of the special circumstances and challenges of serious mental
illness in the veteran population; and work closely with NAMI State and
affiliate offices on issues affecting veterans and their families.
Council membership includes veterans who live with serious mental
illness, family members of this population of veterans, and NAMI
supporters with an involvement and interest in the issues that affect
veterans living with mental illness. The Council�s monthly meetings are
conducted via teleconference and often feature guest speakers who
provide updates on developments in treatment, research, program
initiatives, and service delivery for veterans, active duty
servicemembers, and family members with serious mental illness. We also
use these opportunities to stay current on developments in Congress and
the Executive Branch that have the potential to affect mental
healthcare for veterans.
Mr. Chairman, as you indicated in my introduction, my name is
Constance ``Connie'' Walker. I am a retired Navy Captain with over 22
years of active duty service; a member of NAMI�s Veterans Council; and,
the President of a regional, rural NAMI affiliate in southern Maryland.
My son, Michael, is a disabled veteran of Operation Iraqi Freedom
(OIF). He enlisted in the Army as a Motor Transport Operator in June
2001, associate's degree in hand, but Mike was more impressed by an
enlistment bonus and a chance to see the world than the idea of two
more years of college.
In January 2003, Mike�s unit deployed to northern Kuwait in support
of the first phase of OIF and our advance into Baghdad. That deployment
ended in July. In December of that year--at my insistence, after a
season of observable physical and mental decline in him, and an aborted
effort by the Army to administratively separate him--my son received a
full mental and physical evaluation. In January 2004, Mike was
diagnosed with PTSD, major depression, and schizophrenia; he was
hospitalized, and medically retired later that year. Today my son lives
with my husband and me in southern Maryland.
Throughout that period and since my son�s medical retirement, I have
been his primary advocate in working with military, VA, and civilian
mental healthcare, insurance, and disability benefit systems.
Navigating these waters is always challenging and sometimes
debilitating--even to someone like me, with over 20 years of experience
in recruitment, accession, retention, and retiree policy and program
management; having strong supporters within the VA, TRICARE, and other
Federal and State agencies; and professional involvement in a local
resource network that spans three Maryland counties. My family's
experiences; my advocacy work on behalf of OIF and Operation Enduring
Freedom (OEF) veterans and families in rural areas of Maryland, North
Carolina, Georgia, and California; and, connections to veteran
advocates across the country, have led me to this conclusion:
It is impossible to overstate the stressors that rural and frontier
family caregivers are bearing on a daily basis as they search for
limited treatment and rehabilitative services, and work to support a
loved one whose cognitive abilities have been severely and sometimes
permanently impaired by the invisible injuries of PTSD or other serious
mental illness.
There is a looming reality over all discussions about recovery-based
treatment and rehabilitation services for rural OIF and OEF veterans
living with PTSD or other serious mental illness. The likelihood of
obtaining those specialized services on a consistent basis is very
small for veterans living in rural and frontier areas beyond a
reasonable commute to a VA Medical Center (VAMC) or without access to
an appropriately and consistently staffed VA Community Based Outpatient
Clinic (CBOC).
This is a sobering fact, Mr. Chairman. Early intervention and regular
access to appropriate treatment, rehabilitation, and support services
are as vital to a disabled veteran�s prospects for recovery from
serious mental illness as they are for recovery from serious physical
injury.
Mr. Chairman, with that background, I offer the following comments on
the legislation before the Committee today, as requested in your
invitation letter:
S. 2162 MENTAL HEALTH BILL
Title I--PTSD and Substance Use Disorder
This bill would establish new VA requirements and re-emphasize
existing VA programs for the treatment of PTSD and substance use
disorder (SUD), with special procedures for VA to address the treatment
of veterans who suffer from co-morbid association of these disorders.
It would require VA to expand its offering of services for SUD,
including counseling, outpatient care, prevention, aftercare, opiate
substitution and other pharmaceutical treatments, detoxification and
stabilization services, and other services the Secretary deems
necessary, at every VAMC and CBOC. It would create a joint program of
care for veterans with PTSD and a SUD, and authorize VA to spend $50
million a year in FY08, FY09, and FY10 on this program. VA would also
designate six ``National Centers of Excellence on Post-Traumatic Stress
Disorder and Substance Use Disorder.''
Following orthopedic problems, mental health is the second largest
area of illness for which OIF and OEF veterans are seeking treatment at
VA medical centers and clinics, and the demand for mental health
services is increasing at a faster rate than orthopedic care. If this
trend continues, we can expect to see mental health care at the top of
the VA's treatment list in the future. Within the range of mental
health issues that OIF and OEF veterans are experiencing, PTSD tops the
list. PTSD is a special emphasis area for NAMI in its work to support
veterans in the VA health care system.
The requirement in this legislation to emphasize concurrent treatment
for veterans who have PTSD or other mental illness and a SUD is an
important step forward in the treatment and recovery of veterans with
PTSD or other mental illness who self-medicate with alcohol and/or
drugs. Expanded VA efforts to treat co-occurring disorders would be
welcome, and is long overdue. That said, for OIF and OEF veterans who
need these services in rural and frontier areas, the only practical
avenue to VA care for co-occurring disorders would be through VA's
CBOCs. The Substance Abuse and Mental Health Services Administration
(SAMHSA) reports that substance abuse is a large and growing problem in
rural America. There would need to be a sense of urgency in ensuring
CBOCs in rural areas have a fully staffed and consistent treatment
capability for this population of veterans. Even under those
circumstances, veterans who need mental health treatment and are
self-medicating in America's frontier areas are likely to be beyond
reach.
This legislation would also require a review of all VA residential
mental health care facilities, including domiciliary facilities. The
results of the review would produce a report to Senate and House
Committees on Veterans' Affairs that addresses the availability of care
and provides, for each one, an assessment of supervision and support;
staff-to-patient ratio, assessment of rules and procedures for
medication management; description of protocols for handling missed
appointments, and recommendations for improvements to residents' care
and the facilities themselves.
This is an issue of extreme significance but I am personally puzzled
by the need for legislation to conduct this review. Unless there are
legal constraints to doing so, it should be possible to avoid delays
inherent to the legislative process by requesting GAO or any of the
audit or inspection agencies available for tasking by Congress (to
include the VA's Inspector General) to conduct this review and deliver
the report.
TITLE II--MENTAL HEALTH ACCESSIBILITY ENHANCEMENTS
This legislation would require the establishment of a 3-year pilot
program in two VA networks to provide peer outreach, peer support,
readjustment counseling and other mental health services to OIF and OEF
veterans, particularly National Guard and Reserve veterans, who live in
rural areas and are unable to routinely access comprehensive mental
health services through the VA. These services would instead be
provided through community mental health centers or facilities of the
Indian Health Service participating in the pilot as VA�s partners.
Clinicians at these facilities would receive VA training to help them
address mental health concerns unique to the experiences of OIF and OEF
veterans. These facilities would be required to annually report the
following information to the VA: number of veterans served; courses of
treatment provided; and demographic information for services,
diagnoses, and courses of that treatment.
Mr. Chairman, the goal of this legislation is vitally important:
increasing access to mental healthcare programs and rehabilitation
services for veterans returning to rural and frontier areas where VA
resources are limited or do not exist. It is similar in its proposals
to S.38, but downsized. In an effort to address this need using inhouse
resources, the VA recently launched a program at selected test sites to
provide Mental Health Intensive Case Management (MHICM) services in
some rural areas, but this program is in its infancy.
If legislation can increase mental health resources for veterans and
families who live in rural areas, it should be supported. However,
there are concerns that cause NAMI to question whether legislation
alone can achieve this goal.
The lack of availability of mental healthcare specialists, programs
and services in rural areas is a national issue. Most rural areas do
not have the mental health resources in place to meet the needs of the
existing population. More than 60% of rural Americans live in mental
health professional shortage areas. 65% percent get their mental health
care from their primary care physicians. St. Mary's County, Maryland
received its federal designation as a psychiatric services shortage
area in 2005. Individuals seeking psychiatric care often wait 3 or 4
months for their first appointment.
Community Mental Health Center programs are funded primarily through
grants from the Department of Health and Human Services. There are very
few centers in rural areas. Those there are tend to operate at
capacity, and many of their clients have lived with chronic mental
illness for years. These centers would be attempting to assimilate a
very different client population in terms of OIF and OEF veterans'
average age, psychiatric treatment, and rehabilitative needs. Given
these considerations, the legislation's requirement for VA training of
clinical staff takes on even more significance.
These considerations raise a question as to whether legislation alone
will be able to create an acceptable solution for OIF and OEF veterans
in rural areas, who need timely and regular access to recovery-based
mental healthcare treatment and rehabilitative services.
S. 38
This legislation would establish a 3-year program of services for
members of the immediate families of new veterans diagnosed with PTSD
or other serious mental illness. Services would include education,
support, counseling and other programs for families to increase their
understanding of their veteran�s illness, enabling them to more
effectively support their veteran�s journey to recovery. These programs
would also improve the family�s coping skills and ability to more
effectively manage the stressors that family caregivers deal with every
day. VA would have to develop a program based on these
requirements--but these families are in desperate need of help. There
is an equally important subject this bill does not address:
compensation for family caregivers. Their role, in advocating for a
seriously disabled veterans' physical and mental healthcare and
supporting their recoveries, is a fulltime job. My circumstances are
unusual. I draw retired O-6 pay from the United States Navy and have a
supportive spouse who is willing and able to work past retirement
eligibility age. We can support my son. The vast majority of family
caregivers supporting a seriously disabled veteran�s recovery do not
enjoy these luxuries. In many cases, family caregivers have had to quit
their jobs to take on fulltime caregiving responsibilities--placing the
family under even more stress as it struggles to deal with the loss of
income.
S. 2142
This bill would require the Secretary of Veterans Affairs to
reimburse veterans with service-connected disabilities for costs
incurred as a result of emergency treatment in civilian hospitals, for
the period of inpatient care needed before they can be transported to
VA facilities.
It is a fact that a percentage of OIF and OEF veterans with PTSD or
other mental illness, TBI, and other injuries not visible to the eye,
go undiagnosed until symptoms become obvious. A VA facility is not
always within commuting distance when the veteran with a service
connected disability needs emergency inpatient care. NAMI supports
legislation that broadens the entitlement of service-disabled veterans
to emergency inpatient care covered by the VA, certainly until the
veteran can be safely transported to a VA facility. Therefore, since
this bill clarifies that VA responsibility, NAMI supports it.
S. 2004 AND S. 2160
Mr. Chairman, these two bills do not deal with mental illness, so
NAMI takes no position on them.
CONCLUSION
The National Alliance on Mental Illness is committed to supporting VA
efforts to improve and expand mental healthcare programs and services
for veterans living with serious mental illness. Our members directly
see the effects of what the national Veterans Service Organizations
have reported through the Independent Budget for years: chronic
under-funding of veterans� health care has eroded the VA's ability to
quickly and effectively respond to present-day and projected
requirements, even with the infusion of new funds it now is receiving.
Forward motion has been stalled for 3 years on VA's ``National Mental
Health Strategic Plan,'' to reform its mental health programs--a plan
that NAMI helped develop and fully endorses. A Government
Accountability Office (GAO) report released in September 2006 noted
that the VA had failed to spend all of a promised $300 million in 2005
that was allocated towards improved awareness of mental illness
treatment services in the VA; improved access to mental health services
for Veterans returning from Iraq and Afghanistan, as well as others
diagnosed with serious mental illness�all important initiatives within
the VA strategic plan. NAMI hopes the Committee will agree that
oversight of VA's implementation of its National Mental Health
Strategic Plan would be beneficial to ensuring its progress toward full
implementation, to provide help to OIF-OEF veterans and all veterans
who live with mental illness.
Chairman Akaka and Members of the Committee, thank you for your
invitation for NAMI to offer testimony as you consider this
legislation. I would be pleased to respond to any questions you may
have.
Chairman AKAKA. Thank you very much, Captain. I really appreciate
that.
Let me just ask one question and then I will pass it on to other
Members. Ms. Ilem, in your testimony, you raised concerns about
increasing contract care at VA. What safeguards do you feel are
necessary to ensure that veterans get the best care available when they
are treated for mental health issues or other conditions by outside
care providers?
Ms. ILEM. Well, I think the provisions in the bill, in your bill, try
to--attempt to make sure that there is cultural competence. If VA has
to provide that care outside VA, I think that is critical. When they
have to use contracted care, we hope that it would be more consistent
with VA�s care that those folks have access to, evidencebased
treatments that VA had found effective in treating these very unique
PTSD and readjustment issue problems, substance abuse issues, and that
veterans are going to have the full benefit of good quality care. I
mean, that is, I guess, our main issue with that.
We would like to see VA provide as much of that care as possible
in-house, and hopefully through the Office of Rural Care that is just
newly stood up that they have been charged to address these issues, and
we are hoping that they can really get a handle on what the unmet need
is out there and how VA can really help provide that care and not just
contract it out with not having a good handle on who those veterans are
and that they have access to VA evidence-based programs for the
treatment.
Chairman AKAKA. Mr. Blake, you indicated that PVA remains concerned
about the eligibility criteria that determines which veterans are
eligible for reimbursements for certain emergency care. Can you please
expand upon your concerns?
Mr. BLAKE. Well, Mr. Chairman, I think that my statement kind of
speaks for itself. There are a couple of--I guess the 24-month
requirement is something that we didn�t see as being addressed by the
legislation that we feel is a critical component to addressing the
emergent care requirement. And again, our bottom-line point about
allowing for emergent care for any veteran who is currently eligible
for VA health care within the system to be reimbursed if they get that
care outside of the VA or within the VA.
I mean, I don't know that I could expand on any more than that. I
would certainly refer you to our section in the Independent Budget for
fiscal year 2008, but most of that is also addressed by my statement,
as well.
Chairman AKAKA. Thank you. I will yield now to Senator Burr.
Senator BURR. Mr. Chairman, thank you.
Captain Walker, thank you for that very personal testimony that I
think sheds a lot of light on the challenge that Senator Akaka and I
and VA deal with, and that is that, and I quote your numbers and they
were very consistent with the numbers I found, that 60% of rural
Americans live in an area where mental health professionals don't
exist. So it implores me to turn to you, Mr. Blake, and you, Ms. Ilem,
because I went back to read your testimony, Mr. Blake. Let me just read
it. PVA opposes the provisions of this legislation that would authorize
VA to contract with community mental health centers to meet the needs
of veterans dealing with mental health.
I represent North Carolina. Sixty percent of North Carolina is rural.
I think today in the private health care system, finding the
specialists that we need to provide services to the entire population,
much less the challenges it presents within the VA system to find how
to reach some of the rural markets.
Let me give you an opportunity. Are you opposed to contracting under
any condition, or are you opposed to contracting under some conditions?
Mr. BLAKE. Well, Senator Burr, I think our statement speaks for
itself in that we believe that the authority exists within the VA to
contract care, particularly in the rural setting, already. As we have
testified on the broader rural health care issue, which we feel is
probably maybe one of the leading issues that VHA is facing, our
concern has always been that maybe the VA has not applied its fee basis
authority in the appropriate manner anyway and it would also affect
these individuals.
To qualify my statement that you read from a little bit further, our
sense has always been that the VA can provide better care and more
cost-effective care within its own system. That is why we voice our
concerns about broader contract care with this in mind, being
particularly the mental health aspect.
I think the point that Captain Walker made can't be lost, that it is
not just a problem for the VA, it is a problem nationally. I mean, if
the access and the professionals are not there, I can certainly see
where this legislation gets the VA in the door, and we appreciate the
provisions about training--
Senator BURR. All this simply does is create some options where there
are no options today, options that the VA in charge of delivering
health care to veterans�if, in fact, a veteran lives in an area that
there is no VA services because, quite frankly, there are no mental
health professionals, we are challenged. That may mean the only option
for that veteran outside of driving an hour and a half, hoping that
they are on their scheduled appointment, and we know the consistency of
their visits and the access at difficult times is absolutely crucial,
maybe they turn to some company that is specifically designed to cover
rural areas. Would you object to that?
Mr. BLAKE. Absolutely not, Senator. In fact, I would suggest that
the Spinal Cord Injury Service uses a similar method for individuals
that we have, particularly PVA members who live in extremely rural
areas, because they make those choices, as well. And they have fee
basis as an availability.
Senator BURR. My attempt here is to find out exactly, when you say we
oppose any effort, I mean, that is a pretty strong thing.
Ms. Ilem, let me turn to you. In your testimony, you said the VA
should be given time to fully implement and deploy new programs and
strategies that are not yet fully deployed, then we should reassess the
situation and see about the possibility of contracting opportunities.
How do I look at Captain Walker and her son and suggest that she wait
until they complete an assessment of the deployment of new programs and
strategies? Is that fair?
Ms. ILEM. Well, I think my point I was trying to make is that all of
this money and effort has been put into, from Congress, making sure
that VA has the opportunity to provide this care and the new law--
Senator BURR. Should this Committee be focused on process or outcome?
Ms. ILEM. Well, certainly outcome, but it does take time for VA to
get those services in place. But if VA doesn�t have it right now when
that veteran needs it, obviously they have the authority to provide
that care on a contracted basis. But do you want them to provide that
care or authorize that care through somebody who may not fully
understand or have the cultural competence to provide PTSD or
readjustment issue care? I mean, we want that veteran to have, you
know, if they have to drive in to get it because that is the best care
available, you know, what is in the best interest of that veteran?
Obviously, getting it close to their home is important, especially if
it is a situation where they don�t have good transportation to and from
the medical center. But at the same time, we want to make sure there is
the cultural competence out there on behalf of that provider providing
that care. And if VA can't do it, and we would expect them to do it, if
they do not have their services up and running for that veteran, that
should be made available to them.
Senator BURR. How many veterans are you willing to let fall through
the crack while VA completes their assessment of new programs--
Ms. ILEM. We don't want any veterans to fall through the cracks.
Senator BURR. But they are. They are today. We wouldn't be doing this
legislation. Captain Walker wouldn�t be here testifying. And this is no
reflection on the position of both of your groups or a reflection on
the VA.
Dr. Smith, let me just turn to you because the vote has started and I
know the Chairman has been very gracious, but I didn't see any other
Members, so I thought I would take the opportunity.
[Laughter.]
Senator BURR. You clearly drew a distinction between Shockwaves and
Direct Blows, not penetrations but blows. Can you sort it out for me?
Is epilepsy, Post-Traumatic Epilepsy, more likely in Shockwave Injuries
versus Direct Blow Injuries, or do we know?
Dr. SMITH. Senator, we don�t know exactly the answer to that question
right now. Most of the data that we have from in the past, for example,
in Vietnam, you have missile injuries that penetrate the brain and
create blood. Blood is something that is very irritative to the brain.
But remember that a lot of head injuries that we see are closed head
injuries where you have acceleration-deceleration injuries and it is a
diffuse process where there can be the development of partial epilepsy
which has nothing to do with penetration.
This is a whole new world we are looking at with these IEDs and the
type of injury. In talking to a couple neurologists who have actually
been there, when they talk about the type of injuries they are seeing,
a bullet injury is directly in and can be directly out where these IEDs
are smashing areas and there is debris in a number of areas that is
creating a completely different picture that we are not used to seeing.
Senator BURR. Thank you for that, and there is a reason I went in the
order that I did. You are dealing with it today, Captain. I know you
guys have to take the position that you do. You bring a new element
that we don�t talk about enough. It is the servicemen and women today
who are coming back with injuries that we haven't experienced, that if
we are not focused on the technological progressions in prosthetics, if
we are not focused on how we treat the mental health issues that arise
from this current operation, if, in fact, we don�t transition Traumatic
Brain Injury from one of penetration to one of shockwaves and possibly
some direct blows, then we have done an injustice to the personnel that
we have asked to serve.
Part of our ability to address these is that we have to act quickly,
and it doesn�t mean that we always have all the information. It doesn't
mean that we have all the programs out. Clearly, I think we could all
find consensus that there are areas of the country that even in the
private sector, it is very difficult to find the services that cover
the scope that are needed and that it shouldn�t be unusual for VA to
have a problem there like the private sector does, and when we hit
those, that we ought not wait for programs to be fully vetted, that we
ought to contract with somebody if, in fact, there is somebody that is
qualified to deliver that service.
Right now, the single most important thing we have to do is to drop
the concerns we have with process. We will sort out process and focus
on outcome, and that is how many of these men and women that go into
the system for whatever need come out as quickly as they can, but with
a life in front of them that is as productive as we can possibly make
it and they can possibly enjoy.
I thank you for letting me ask you some very pointed questions.
Again, I thank all of you for your testimony, and Mr. Chairman, I
thank you for your indulgence.
Chairman AKAKA. Thank you very much, Senator Burr.
A vote has been called. I want to thank our panelists here. We have
questions that we will submit for your responses.
I also want to thank Dr. Kussman, who has remained here to listen to
the testimony of our second panel. I want you to know I appreciate
that, Dr. Kussman.
Again, I appreciate all of you and your testimonies as well as your
responses. The reason I am going to adjourn is that we have a series of
votes, and instead of keeping you here waiting until we are done, I
want you to know that we appreciate your coming. We have heard from you
and this will, without question, help us in dealing with these issues
in the Department of Veterans Affairs. This is all for the sake of
trying to find the best ways of helping our veterans, and I thank you
for contributing to that.
Captain Blake, I had questions about families and your family, as
well, but we will hear from you on that in your responses.
I want to thank all of you again for appearing here and wish you well
in all that you do.
This hearing is adjourned.
[Whereupon, at 11:12 a.m., the Committee was adjourned.]