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Wednesday,
April 25, 2012. Chaos and violence continue, tensions continue to rise
between Iraq and Turkey, the US Veterans Affairs Committee has been
caught lying about wait time for veterans seeking health care, a witness
calls for a cultural change at VA, and more.
Larry
Abramson: Over the past five years, the Department of Veterans Affairs
says the number of former service members seeking mental health services
has climbed by a third. In response, the agency has boosted funding,
and tightened standards. Now, any vet asking for help is supposed to be
evaluated within 24 hours and start treatment within two weeks. The VA
has claimed that happens in the vast majority of cases. But a new
investigation by the agency's inspector general says the VA statistics
are skewed to make wait times appear shorter. [. . ] The inspector
general's report says rather than starting the clock from the moment a
vet asks for mental health care, the VA has been counting from whenever
the first appointment came available. That could add weeks or months to
the wait time. So while the VA has been saying 95 percent of vets were
seen as quickly as they were supposed to be, actually, nearly 100,000
patients had to wait much longer.
"Today's
hearing builds upon two hearings held last year," declared Senator
Patty Murray this morning as she brought the Senate Veterans Affairs
Committee hearing to order. "At each of the previous hearings, the
Committee heard from the VA how accessible mental health care services
were. This was inconsistent with what we heard from veterans and the VA
mental health care providers. So last year, following the July
hearing, I asked the Department to survey its own health care providers
to get a better assessment of the situation. The results as we all now
know were less than satisfactory. Among the findings, we learned that
nearly 40% of the providers surveyed could not schedule an appointment
in their own clinic for a new patient within the 14 days. Over 40% could
not schedule an established patient within 14 days of their desired
appointment. And 70% reported inadequate staffing or space to meet the
mental health care needs. The second hearing, held in November,
looked at the discrepancy between what the VA was telling us and what
the providers were saying. We heard from a VA provider and other
experts about the critical importance of access to the right type of
care delivered timely by qualified mental health professionals. At last
November's hearing, I announced that I would be asking VA's Office of
Inspector General to investigate the true availability of mental health
care services at VA facilities. I want to thank the IG for their
tremendous efforts in addressing such an enormous request. The findings
of this first phase of the investigation are at once substantial and
troubling. We have heard frequently about how long it takes for
veterans to get into treatment and I'm glad the IG has brought those
concerns to light."
There was one panel.
William Schoenhard and Mary Schohn were among those present representing
the Dept of Veterans Affairs, Iraq War veteran Nick Tolentino was
present as a former VA employee who had an understanding of how the VA
worked (and didn't work), Outdoor Odyssey's retired Major General Thomas
Jones shared his thoughts and observations, and the VA's Office of
Inspector General was represented by Linda Halliday and John Daigh.
We'll jump to this exchange where Committee Chair Patty Murray questioned the VA.
Chair
Patty Murray: First, let me say that I'm very happy that the VA is
finally acknowledging the problem. When the Department is saying
there's near perfect compliance but every other indication is that there
are major problems, I think it is an incredible failure of leadership
that no one was looking into this. In fact, when you sit at that table
before this Committee, we expect you to take seriously the issues that
are raised here. It should not take multiple hearings and surveys and
letters and ultimately an IG investigation to get you to act. I also
would like to suggest that if the reality on the ground could be so far
off from what central office thought was happening as it relates to
mental health, then you better take a very hard look at some of the
other areas of care for similar disconnects. Now what we have heard from
the IG is very, very troubling. For months now, we have been
questioning whether Central Office had a full understanding of the
situation out in the field and I believe the IG report has very clearly
shown that you do not. So I want to start by asking you today, after
hearing from this Committee, from veterans, from providers and from
outside experts, why you were not proactive about this problem months
ago.
William
Schoenhard: Chairman Murray, we have been looking at mental health
for, uh, many years, as you know. With the support of the Congress, we
increased our capacity and hired about 8,000 new providers between 2007
and 201. We relied primarily on a uniform mental health handbook that
would be the source of the way in which we would deliver care to our
nation's veterans. That has been the focus of the department to ensure
that we're getting evidence-based therapies and a staffing model that is
largely based on the handbook put out in 2009. I think what we have
learned in this journey -- and we have been wanting to work with our
providers -- is a number of things. As I mentioned in my opening
statement, the way in which we measure these performance measures is not
a good measure of wait time. We want to work very closely with the IG
and with, uh, any resources that are available to assist us in ensuring
that we provide veteran centered performance measures --
Chair
Patty Murray: Mr. Shoenfield, with all due respect, I think back in
2005 the IG said this information was there. So that's a long time with
a lot of veterans in between. So my question is how are you going to
address that growing gap that we've seen --
William Schoenhard: Well I --
Chair Patty Murray: -- between what Central Office believes and what's actually happening out there.
William
Schoenhard: As Dr. Daigh described in our response to the IG report, we
have a number of things going on. One is first we have a working group
that will report this summer on a new set of performance measures that
includes providers on the ground assisting us with ensuring us that we
develop measures in conjunction with support from the IG that are really
veteran-centered -- that are centered on a veteran's individual
condition and one in which we can revamp and go forward. We fully
embrace that our performance measurement system needs to be revised and
we will be doing that with the work of people on the front lines to
assist us. We have the benefit of, uh, these mental health site visits
that are assisting us. We're learning as we go on other issues to do
with scheduling and all of this effort is assisting us in not just
having people at Central Office develop proposed solutions but to engage
the field the way that we need to in order to ensure that we're
veteran-centered and we're able to support our providers in delivering
this care.
Chair
Patty Murray: I-I appreciate that but it is very troubling to me that
this didn't happen five, ten years ago. That we're just now, after
months of this, years of this, that that disconnect is there. But we'll
go back to that because I want to ask Mr. Tolentino and I really
appreciate your willingness to come forward today and I believe your
testimony is going to be very helpful to addressing many of the changes
that are needed in a timely fashion. In your testimony, you suggested
that VA institute more extensive oversight into how mental health care
is actually delivered and funds are spent. Given how adept many of the
facility administrators are at getting around the current system without
being caught, how do you think the VA can most effectively perform that
oversight?
Nick
Tolentino: Madam Chairman, to be perfectly honest, I don't have a very
good answer for you because of the fact that the gaming is so
prevalent. As soon as something is put out, it is torn apart to look to
see what the work-around is. I-I feel that the reports -- the
reporting is -- It's very redundant reporting that feels like it goes
nowhere, there's no feedback loop. It's one way. We're telling you
exactly what -- and most of the times you want to hear -- we did at the
facilities and even at the network. But there's no coming back
and rechecking or coming back with feedback to say, 'Well you said you
spent the money on these services but there's no workload to verify it.
There's nothing concrete to speak to what you say you've done.' I'm
remembering in the short time that I -- that I worked there, many times
we got vast amounts of financial monies for different programs but very,
very seldomly did we get requests to verify what we've done with work
load, with any kind of feedback reports or anything like that. So I
think opening the lines of communication and development of feedback
loop would be very helpful -- and a very transparent feedback loop at
that.
Chair
Patty Murray: Mr. Shcoenhard, my time is out and I want to turn it
over to Senator Brown. But I do want to address an important issue
here. The Department has announced 1600 new mental health care
providers and I appreciate that step, I think it's really needed but I
am concerned that VA hospitals all across the country are going to run
into the same hurdles that Spokane VA has been in not being able to hire
health staff and I hope that medical centers are doing everything
including using all available hiring incentives to fill those
vacancies. And I assure you, that is the next question this Committee
is going to look at. But I want to ask you specifically, how are you
going to make sure the 1600 new health care providers that you announced
don't become 1600 new vacancies?
William
Schoenhard: Chairman Murray, that's a very important question. And we
have stood up in our human resources group and our VHA workforce two
task forces to assist us with this. One is the Recruitment and
Retention of mental health providers with particular focus on
psychiatry. That's where our greatest need and problem is in retaining
and recruiting mental health providers. The second task force is a
Hiring Task Force. That is what can we be doing to expedite and make
sure that we are having the process of recruitment as speedily as
possible. The group has put together a number of good recommendations
that we will be implementing. Part of what Dr. Daigh spoke of earlier in
terms of our four-part mission, one of our great assests -- having been
in the private sector for many years before coming to VA -- is that
many mental health providers including hundreds of trainees today get
part of their training in VA and have the opportunity to experience us
going forward. We need to better link with these trainees and ensure
that we have a warm hand-off for employment when they finish this.
Chair Patty Murray: Okay, that's one issue but then how you arrived at your staffing plan is really unclear to me.
William Schoenhard: Oh, I'm sorry.
Chair
Patty Murray: The new 1600 mental health providers that you allocated,
the information that we got from the department yesterday on where that
was going to go isn't supported by any concrete evidence or facts. In
fact, the VISN 20 director told Senator [Mark] Begich and I that she
learned about the new positions only a couple of days ago, didn't know
if it was sufficient and didn't know how the department even reached
those numbers. So I want to ask you how did you arrive at that number
1600 and what makes you confident that it's going to be effectively
placed across the country? What is the plan -- staffing plan -- that
you used to do that?
William
Schoenhard: Thank you. Uh, I'm sorry, I misunderstood the question
and I'm going to ask Dr. Schohn who may want to embellish on that. We
used a model that looks at the volume of services and I wonder if Dr.
Schoen might speak to this? We are piloting this in 3 VISINs. I would
be happy to answer further.
Mary
Schohn: Thank you. Yes, as part of our response to the Committee in
November, we planned to develop a staffing model. The staffing model --
Chair Patty Murray: I'm sorry. You planned to -- planned to develop a staffing plan? It's not yet in place?
Mary
Schohn: No, no. We did develop the staffing model. But we submitted
to you that that was part of our action plan in November. We developed
the staffing model. We're in the process of implementing it in VISNs 1, 4
and 22 to -- to understand how to implement it so we don't want to
simply say, 'Here's the number of staff,' without actually a plan for
how this rolled out. Is this really the right number of staff to really
evaluate how well and how effective this methodology is? Our plan,
however, also is not to wait until we get a full evaluation of this plan
but basically to staff up so that we'll be fully ready to implement
this plan throughout the country by the end of the fiscal year. So we
will have -- we are planning -- the plan itself is based idnetification
of existing staff at facilities, the veteran population, the range of
services offered and the demand for services. And our plan is to be
able to use this to project the need so that we will have a standard so
that we will have a standard model in the future that is empirically
validated, that we will all know how many staff is needed.
Murray
then passed to Senator Scott Brown who was serving as Ranking Member on
the Committee in Senator Richard Burr's absence. Ava will be covering Scott Brown at Trina's site tonight. Kat will offer her impressions on the hearing at her own site tonight and Wally will be reporting on the hearing at Rebecca's
site tonight (and probably covering Scott Brown as well -- in terms of
money issues). We'll move over to some of Jon Tester's questions.
Only four Senators were present for this hearing: Chair Murray, acting
Ranking Member Scott Brown, Senator Jon Tester and Senator Jerry
Moran. Both Moran and Tester have rural concers due to their states
(Moran represents Kansas, Tester represents Montana).
Senator
Jon Tester: Just from a rural persepctive, I will tell you that one of
the reasons the VA can't contract out in a rural state like Montana is
because the private sector doesn't have anymore mental health
professionals than the VA has. And I just want to point that out
because it's -- it's mental health professionals -- whether it's in the
private sector or the VA -- getting these folks is a big problem. And I
very much appreciate Mr. Tolentino's statements about nobody's going to
go to work for a year or two years in the VA when, in fact, in the
private sector, they have much more predictability in their jobs. So we
need to take that into consideration when we start allocating dollars
for the VA to make sure that they have the advantage to compete. And I
very much appreciate that perspective. Along those same lines, I just
want to ask -- Senator Brown was right in the area of 1500 positions
open and an additional 1900 so there is about 3400 positions. They
may not all be psychiatrists, they may not all be clinicians. But how
you're going to fill those in an area where the private sector's sucking
folks up because this is a big issue there too. And the VA, it's
interesting to me. Do you have an allocation by VISN of these 1600
folks? And if you do -- Do you? Could we get a list of those?
William Schoenhard: Yes, sir.
Senator Jon Tester: And how they're going to be allocated?
William Schoenhard: Yes, sir.
Senator
Jon Tester: And the metrics. I know you talked about metrics --
number of veterans and that kind of stuff. Could you give me a list of
metrics on why the number are there? How many are going to be
psychiatrists, how many of them are going to be nurses, clinicians? Are
any of them going to be psychologists?
William Schoenhard: Uh, sir, we are leaving to VISN in discussion with the facilities, they could be psychologists --
Senator Jon Tester: Okay.
William Schoenhard: -- they could be family therapists -- a variety of different health care providers.
Senator
Jon Tester: Okay, thank you. And when it comes to contracting out, do
you guys typically only use psychiatrists? Or can you use psychologists
too?
William Schoenhard: No, we can contract with others.
Senator
Jon Tester: Super. That's good. Because there are some -- there are
some accessibility to those folks in place. I like Montana. I want to
put two things that Mr. Tolentino said along with Major General Jones
said. Major General Jones, I want to thank you for what you're doing. I
very much appreciate it. Mr. Tolentino said when he was there it was
fairly common if someone came in with a problem, don't ask if there's
another issue. There are all sorts of correlations here that are wrong
but I just want to tell you that, okay, if that's done -- and I believe
he's probably right because then we can have a problem. But if you
combine that with what Maj Jones said, that the folks that he's working
with, the major stressor is unknown. We've got a problem in our system
here. Because the only way you're going to find out how to get to the
real root of the problem when it comes to mental health -- and I'm not
a mental health professional -- is that you've got to find out what
that stressor is, you've got to find out what created that problem.
Does that kind of -- Well let me just ask you. If you had a VA
professional in one of the CBOCs [Community-Based Outpatient Clinics] or
in one of the hospitals, do you tell their people: Don't ask any
questions because we don't want to know? I'm hoping to hell that
doesn't come from your end. And why would they do that?
William Schoenhard: Sir, if that is being done, that is totally unacceptable.
If
it's being done, it's unacceptable? That's a rather interesting
comment. If the VA hadn't lied about wait time, the hearing wouldn't
have been called. Had Schoenhard been asked if the VA was lying about
wait time a month ago, he most likely would have replied, "If that is
being done, that is totally unacceptable." What's totally unacceptable
is that the supervision level of the VA doesn't appear able to do their
job. They're in supervision for a reason and that is, yes, to
supervise. So all these things that are going wrong -- these things
they allegedly know nothing about and certainly didn't encourage --
these fall on them. Training apparently needs to be done at extremely
high levels of the VA to explain review what job duties are and what
these duties entail. There is no oversight at the VA. That's been
clear for some time now.
Again, the VA's
Office of Inspector General was represented by Linda Halliday and John
Daigh. We'll note this exchange near the end of the hearing.
Chair
Patty Murray: Dr. Daigh, let me turn to you. As you well know, it's
hard enough to get veterans in the VA system to receive mental health
care. Once a veteran does take a step to reach out for help, we need to
knock down every potential barrier to care. Clearly the report your team
produced shows a huge gap between the time that the VA says it takes to
get veterans mental health care and the reality of how long it actually
takes them to get seen at facilities across our country. Now VA has
concurred with all of your recommendations but I think it's clear we all
have some real concerns because some of these issues have been problems
for years. So can you address a question of what you think it would
take the VA to get this right this time?
Dr.
John Daigh: I think, uhm, to begin with the veteran population is
dispersed across the country and the VA is not evenly dispersed across
the country so those veterans that go to fixed facilities to receive
their care, the VA -- I'm guessing -- is probably trying to address in
this current plan for 1600 people. I haven't come across any details of
the plans. So I think the first issue is to realize you have a problem
where you have facilities and where you don't have facilities. Then I
think the second problem is that, as has been stated here, there simply
are not enough mental health providers to hire off the street in a
timely fashion, I believe. I mean we looked at it the other day.
There's something like 1200 psychiatry graduates a year in this country
from our medical schools so there is a limited pool and there's a great
deal of demand for mental health providers. In our discussions with
private sector, they said that because of the downturn of the economy
and other factors that the non-VA, non-military demand had also gone up
in their experience, ten and twenty percent in the last couple of years.
So I think when I look -- We were asked several years ago to go look at
access to mental health care in Montana. And it was a very interesting
review for me in that Montana VA had linked up with the community
health centers in Montana and I believe -- I may be -- I may be out of
date by a couple of years since we did it a couple of years ago but they
were, there was an organization of community health centers and by
allowing veterans to go to those community health centers which were
usually staffed by psychologists and social workers, usually not by
physicians, they were able to dramatically improve the access time to
get folks to talk to competent people in their neighborhood, in their
city, to get some care. I think in order to make that care cohesive,
as Mr. Tolentino said, you've got to be able to get medical records back
and forth so that there's a coordination of care. So I think the all
hands on deck idea is one that I fully endorse and one where if I look
at some of the cases -- tragic cases -- we've looked at, in the past it
was not infrequent for veterans to show up at a mental health center in
their town and because they were veterans, they were sent to the VA and
there was not a link, they were not accepted or there was no payment
mechanism or there was no authority. So I think that would be a useful
step. Secondly, I think you really have to sit down and, as bad as
metrics are, you do have to sit down and model what you do and figure
out what demand is and try to lay out a business case for what you're
doing.
Chair Patty Murray: Is that in place at the VA today?
Dr.
John Daigh: Um, I don't believe that they have for mental health the
level of business plan that I think they should have. Nor do I think
they have it for most specializations.
Daigh's
suggestions resulted in a number of people nodding their heads and, as
Chair Murray noted, the VA had agreed with the recommendation in the
report from Daigh's office. His responses were common sense ones. So
why did the brain trust of the VA need someone from the IG office to
make these very basic and obvious recommendations for them?
Linda
Halliday would note her opinion that the lying about wait time meant
that there was a need for "a culture change" at VA. She's right. She
also called for holding "the facility directors accountable for how well
the data is actually being captured." There needs to be
accountability, there needs to be a cultural change. Nothing in today's
hearing provided any indication that there would be. Senator Murray
was very clear in her closing marks which included, ". . . I want to
make it very clear, this is not something we're going to have a hearing
on and leave and go do something else tomorrow. This has to be taken
care of. We owe it to these men and women." She was very clear. But
the VA's attitude didn't seem overly concerned and that was only more
true as the hearing concluded and three of them ambled towards the door
laughing and joking and clearly not bothered by the warnings, by the
reprimands, by anything. Repeating, I don't doubt that Murray means
it. I don't doubt that Scott Brown is fed up with it. Tester tries to
word things more nicely but it was clear he was irritated. But that
hearing had no visible effect on the VA staff that should have walked
out of that hearing feeling something other than good humor.
In Iraq, the political crisis continues; however, it may be overshadowed by the regional crisis Nouri has created. Tariq Alhomayed (Al Arabiya) offers this assessment: With
regards to Iraq, al-Maliki is profoundly at odds with the Sunnis, and
wants to imprison his deputy, Tareq al-Hashemi. He has also clashed with
the Kurds, as well as the Sadrists loyal to Iran, and even with
[Abdulaziz] al-Hakim. He is also got involved in an intense dispute with
the Iraqiya bloc, led by Dr. Iyad Allawi. So what left for Mr.
al-Maliki after all this? Regionally, and in terms of the Arab world,
al-Maliki does not have any normal relations with the influential Arab
countries of the region, or any countries in the region for that matter,
with the exception of Iran. Al-Maliki has launched attacks on Saudi
Arabia in language not worthy of a diplomat, let alone a Prime
Minister, and he has done the same with Qatar, and now with Turkey! This
is not all of course, as al-Maliki is also the one who said: "the
[al-Assad] regime did not fall, and it will not fall, and why should it
fall?", despite all that the Baathist tyrant of Damascus has done to the
Syrian people. Iraq is now creating passageways to help the al-Assad
regime by transferring weapons and money and smuggling oil. So what left
after all this? How can al-Maliki say that Turkey is a hostile country,
inciting sectarianism in Iraq, while Tehran launches an attack on
[Massoud] Barzani, on the eve of al-Maliki's visit to Iran, and also
accuses al-Hashemi of wanting to restore Sunni rule in Iraq with the
support of Saudi Arabia?And Nouri's stepped in it again
prompting State of Law (his political slate) surrogates to rush to the
media to play another round of When Nouri Said ____, He Meant ___.
Nouri's called for a federation of Iraq and Iran. No surprise, that
call has alarmed many Iraqis. Al Rafidayn quotes
a State of Law-er insisting Nouri was using a metaphor. (Ask Nouri to
define "metaphor" and, if he can do that, I might believe it.) Iraq
has good relations with Iran, insists Nouri's surrogates, but they do
not want to jeopardize their relationship with others. Alsumaria also carries
the we-don't-really-want-a-federation-despite-what-Nouri-said story.
Nouri just wrapped up a visit to Tehran, one would assume he could
speak plainly. To listen to State of Law, that's not the case. The World Bulletin notes
Ahmet Davutoglu, Foreign Minister of Turkey, has rejected Nouri
al-Maliki's accusations that Turkey is interfering in Iraq's internal
affairs and quotes Davutoglu stating, "Turkey's Iraq policy is quite
clear and we have been a direct part of any controversy in Iraq. We
want that all our Iraqi brothers, Shiites, Sunnis, Turkmens, Arabs and
Kurds live in peace and in prosperity." Turkey's one of Iraq's largest
regional trading partners. Joe Parkinson (Wall St. Journal) observes,
"The two countries have in recent years enjoyed a fast-expanding trade
relationship. Iraq is now Turkey's second-largest trading partner after
Germany, with trade swelling 40% to reach $12 billion last year,
according to Turkey's government. However, more than half of that
volume is between Turkey and Iraq's semiautonomous Kurdish region."
This war he's declared on Turkey really doesn't help Iraq nor does it
improve relations with the Arabic states (Saudi Arabia, Qatar, etc) that
Nouri's already on shaky ground with. Tony Karon (Time) notes:
And
these days, it's not only Iraqi politicians that are courting the
Kurds. Turkey last week feted Barzani in Ankara, rolling out the red
carpet and affording him a meeting with Turkey's President Abdullah Gul
and Foreign Minister Ahmet Davutoglu, and he recently returned from a
visit to Washington D.C. where he met with senior Administration
officials. Those visits seemed to amplify Barzani's defiance of Baghdad
in a dispute over oil revenues, with the KRG prime minister accusing
Maliki of paving the way for a return to dictatorship, and warning that
absent "radical solutions and a specific time-frame to resolve the
present crisis … we will resort to other decisions" -- a not-so-veiled
threat to declare independence from Iraq.Independence, of
course, remains the historical goal of Kurdish Iraqis, and a referendum
on the issue staged in 2005 saw some 98% vote to break away from Iraq.
Geopolitical realities, however, has required a curbing of that popular
sentiment. Iraqi Kurdistan is small and landlocked, and while it
possesses significant oil reserves, it would require the cooperation
of one of its powerful neighbors --Turkey, Iran or Iraq -- to pipe that
oil to market. Also, the KRG was carved out in large part because the
U.S., which had just overthrown Saddam Hussein, helped ensure its
emergence, but made clear it was not ready to support a breakup of Iraq.
Al Rafidayn reports
that it's been decided to open up 50% of Baghdad's main streets over
the next 45 days due to traffic congestion and other issues. Dar Addustour notes
there is some concern that barriers that have protected various
political party offices may also be lifted. Their fears may be
justified and AFP reports that today saw "the offices of two of Iraq's top four Shiite clerics in the central city of Najaf [attacked] with sound bombs".
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