Apr112013
Hearing Transcript on Implementing the Wounded Warrior Provisions of the National Defense Authorization Act for Fiscal Year 2008.
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IMPLEMENTING THE WOUNDED WARRIOR PROVISIONS OF THE NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2008 HEARING BEFORE THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION JUNE 11, 2008 SERIAL No. 110-91 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking
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Malcom A. Shorter, Staff Director Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. |
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C O N T E N T S
June 11, 2008
Implementing the Wounded Warrior Provisions of the National Defense Authorization Act for Fiscal Year 2008
OPENING STATEMENTS
Chairman Bob Filner
Prepared statement of Chairman Filner
Hon. Steve Buyer, Ranking Republican Member
Hon. Steve Scalise
Prepared statement of Congressman Scalise
Hon. Donald J. Cazayoux
Hon. Cliff Stearns
Hon. Stephanie Herseth Sandlin, prepared statement of
Hon. Harry E. Mitchell, prepared statement of
WITNESSES
U.S. Department of Veterans Affairs, Hon. Patrick W. Dunne, RADM, USN (Ret.), Acting Under Secretary for Benefits, and Assistant Secretary for Policy and Planning, Veterans Benefits Administration
Prepared statement of Admiral Dunne
U.S. Department of Defense, Hon. Michael L. Dominguez, Principal Deputy Under Secretary of Defense for Personnel and Readiness
Prepared statement of Mr. Dominguez
Jaycox, Lisa H., Ph.D., Senior Behavioral Scientist/Clinical Psychologist, and Study Co-Director, Invisible Wounds of War Study Team, RAND Corporation
Prepared statement of Dr. Jacox
Tanielian, Terri L., MA, Co-Director, Center for Military Health Policy Research, and Study Co-Director, Invisible Wounds of War Study Team, RAND Corporation
Prepared statement of Ms. Tanielian
SUBMISSION FOR THE RECORD
Disabled American Veterans, Kerry Baker, Associate National Legislative Director
MATERIAL SUBMITTED FOR THE RECORD
Background Letter and Departmental Report:
Hon. David S. C. Chu, Under Secretary of Defense, Personnel and Readiness, U.S. Department of Defense, to Hon. Ike Skelton, Chairman, Committee on Armed Services, letter dated June 9, 2008, transmitting the Department's report on "Administrative Separations Based on Personality Disorder," as required by Section 597 of the National Defense Authorization Act for Fiscal Year 2008 (A similar letter was sent to the Chairman and Ranking Member of Senate Armed Services Committee.)
Post-Hearing Questions and Responses for the Record:
Additional Post-Hearing Letters and Departmental Follow-up Information:
IMPLEMENTING THE WOUNDED WARRIOR PROVISIONS OF THE NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2008
Wednesday, June 11, 2008
U. S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:21 a.m., in Room 334, Cannon House Office Building, Hon. Bob Filner [Chairman of the Committee] presiding.
Present: Representatives Filner, Brown of Florida, Snyder, Michaud, Herseth Sandlin, Mitchell, Hall, Hare, Salazar, Rodriguez, Donnelly, Space, Walz, Cazayoux, Buyer, Stearns, Moran, Brown of South Carolina, Boozman, Brown-Waite, Lamborn, Bilirakis, Buchanan, Scalise.
OPENING STATEMENT OF CHAIRMAN FILNER
The CHAIRMAN. We are going to open our hearing on Implementing the Wounded Warrior Provisions of the National Defense Authorization Act (NDAA) for Fiscal Year 2008. The Committee will come to order.
Mr. Scalise, it is customary for the new members to be granted this opportunity to say a few words if you would like. We welcome you to our Committee and look forward to your participation.
OPENING STATEMENT OF HON. STEVE SCALISE
Mr. SCALISE. Well, thank you, Chairman Filner and Ranking Member Buyer. I appreciate the honor to serve on the Veterans' Affairs Committee and as well as my colleague, Mr. Cazayoux, who I served on the Legislature with, specifically in the New Orleans region.
All the parishes in my district were adversely affected by Hurricane Katrina, but our veterans hospital has been closed because of the damage that it took on from Hurricane Katrina. And so there are a number of issues I want to work on that involve all veterans across the country, but specifically the veterans in our region have been dealing with a number of extra problems because of the closure of that hospital.
And looking forward to working through those issues with you and the rest of the Members of this Committee. Thank you.
[The statement of Congressman Scalise appears in the Appendix.]
The CHAIRMAN. Thank you.
Mr. Cazayoux?
OPENING STATEMENT OF HON. DONALD J. CAZAYOUX, JR.
Mr. CAZAYOUX. Thank you, Mr. Chairman, Members, Ranking Member Buyer. I, too, am delighted and honored to be on this Committee and look forward to working with each of you to make sure that we take care of our veterans in an honorable way and make sure that we take responsibility for our men and women as they come back from fighting our wars.
And thank you very much, Mr. Chairman.
The CHAIRMAN. We thank you and we welcome you to the Committee.
I thank the witnesses for being in this hearing. Officially, we count that over 33,000 servicemembers have been wounded in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). I think we all know that due to the improvement in both battlefield medicine and incredible evacuation procedures and transportation, those who might have died in past conflicts are now surviving, many with multiple serious injuries such as amputations, traumatic brain injury, (TBI) and, of course, post traumatic stress disorder (PTSD).
We have seen a lot of publicity on this and our apparent inability to predict all of this and have the resources in place to deal with it. We are trying to catch up and do that.
The Wounded Warrior provisions of the 2008 National Defense Authorization Act were intended to do just that. Many of them require the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) to collaborate to improve the care and management and transition of recovering servicemembers. The hearing today will explore the progress that the two Departments have made in implementing these provisions.
Thirty-two warrior transition units have been established in the Army to try to improve care management. Injured soldiers are now assigned a primary care manager, nurse case manager, and a squad leader to guide them to their recovery.
The rapid creation of these units appears to be a success. However, according to the U.S. Government Accountability Office (GAO), several challenges remain including hiring sufficient medical staff in a very competitive market, replacing temporarily borrowed personnel with permanent staff, and getting eligible servicemembers into those units.
In December of last year, the VA, in cooperation with DoD and the U.S. Department of Health and Human Services (HHS), established the Federal Recovery Coordinator (FRC) Program to coordinate clinical and nonclinical care for severely injured and ill servicemembers.
As of May of this year, there were only six field staff members working with the 85 patients at three sites. I want to look today at how effective this program has been and how it will be expanded to benefit more of our veterans.
As these veterans transition from the military health system to the VA system, they face the difficulty of navigating through two different and cumbersome disability evaluation systems. The current system is a source of stress and frustration for many veterans.
Last November, both DoD and VA jointly initiated a one-year pilot program to evaluate a streamlined evaluation system. I hope they will be able to expand this program and today we will hear how that is going.
We all know that PTSD and TBI are considered to be the Doctor, signature injuries of this war.
According to a RAND Corporation report that came out in April nearly 300,000 veterans of Afghanistan and Iraq are suffering from PTSD or major depression. Nearly 20 percent, according to the RAND figures and which, I think is a low number, reported a probable traumatic brain injury during deployment.
By the way, compare the 300,000 estimate, which again I think is low, with the official casualty number of 33,000 and there is not just a minor discrepancy between the two figures. I think we are going to ask the Pentagon to deal with these casualty figures in far more realistic terms, and we want to get your thoughts on that.
As we will hear, many veterans are not getting the care they need and deserve. Only 43 percent of those reporting probable TBI have been evaluated by a physician for brain injury. And only half of those who meet the criteria for PTSD or major depression sought help from a physician or mental health provider. This is simply not acceptable and we have to do better.
Again, last year, the Department of Defense established a Center of Excellence for psychological health and traumatic brain injury and I want to see how the VA and DoD are working together to conduct research in these areas and develop best practices.
Certainly an important component to improve continuity of care is development of an interoperable electronic health record, which would allow for the seamless transfer of medical information between the two Departments.
I think we have made some significant progress toward improving care and transition, but a lot of work needs to be done and that is what this hearing is about today. We look forward to an informative hearing.
Our first panel is from the RAND Corporation. Terri Tanielian and Lisa Jaycox will begin the discussion and then we will hear from the Department of Defense and Department of Veterans Affairs.
I want to say, before we start our hearing, that no matter where we stand on the war, we are united in saying that every man or woman that comes back from the war should get all the healthcare—the seamless healthcare—that they need and the benefits they have earned.
I will yield to Mr. Buyer, the Ranking Member, for his opening statement and any quick comments from the rest of our Members.
[The statement of Chairman Filner appears in the Appendix.]
OPENING STATEMENT OF HON. STEVE BUYER
Mr. BUYER. Mr. Chairman, I want to thank the witnesses for being here today to discuss the implementation of the Wounded Warrior provisions of the 2008 Defense Bill.
As you recall, these provisions, many of which were adopted in the Defense bill I drafted, received good input from Mr. Stearns and Mr. Miller, Mr. Brown, Dr. Boozman, along with Mr. Michaud, Stephanie Herseth Sandlin, and, once again, we leaned on Dr. Snyder for his good work with the Defense Bill.
And, Mr. Chairman, you were also very supportive and spoke in support of them at the conference last year. So I want to thank you for your assistance.
I also am very cognizant. One thing I have learned about you, Mr. Chairman, and myself is that sometimes we are not very patient and we are eager to get out there and be aggressive. And I want to thank you. That is what you are trying to do here. But when we put these together, we put in progress reports for a reason.
I almost cannot help but sense we are a month early with the hearing. I know that you are really eager to move out here, but there are eight DoD progress reports that were set forth in the Defense Bill.
Section 16 of the Bill required GAO to provide an assessment of the implementation of the Wounded Warrior provisions six months after enactment. Since that deadline is next month, the GAO is unable to provide this assessment because it has only recently begun its review of the implementation provisions and it would not have been able to provide an in-depth analysis for the Committee.
GAO did indicate that based on the initial assessment, VA and DoD have not finalized a policy nor have they begun implementation of many aspects of the Defense Bill's mandates.
While this is of concern, I feel that it is really premature at this point to criticize the Departments' progress based on incomplete information submitted before the benchmark requirement.
Therefore, my counsel during this hearing will be that the Wounded Warrior provisions must be implemented with a sense of urgency.
Sixteen months have passed since the Washington Post news story revealed some of the instances of inadequate housing of soldiers at the Walter Reed Army Medical Center. While that moment was infamy for some, this Committee has had a long-standing concern that the current DoD and VA disability systems fail to provide a seamless transition, especially for those enduring the military's discharge process.
Over the past 15 years, one commission and a task force report after another has called for measures to streamline the transition process, but such changes have not been implemented.
Therefore, I was pleased that this year's Defense Bill contained these provisions that we had worked on together. That amendment in particular we were able to focus on the use of the uniform separation exam, an evaluation that VA could use for rating decisions.
The electronic DD-214 is something we had talked about for years and I am glad they are finally moving toward that, the real-time access to the veteran's medical history by requiring electronic exchange of critical medical information between DoD and VA. The need for this electronic exchange of medical records was amplified during my many visits. And I am sure, Mr. Chairman, as you too are around, you see that necessity.
While at Landstuhl, I had witnessed patients being transferred from the battlefield with the paper medical files taped to their chests and I was appalled that was being done.
Now, obviously things were being done in transition of air medivac, but, you know, we talk about getting to the electronic medical record. We still have a long way to go.
So, Mr. Chairman, I think what we are going to have to do is perhaps we are going to do this hearing and we are going to have to come back again in maybe September and have another one of these hearings keeping the pressure on, I guess, is what I am going to ask of you. And I think that is what you have done here by moving out here today. But we are going to need to come back and hold them to the time lines on their progress reports would be my counsel to you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Buyer.
I will say that we are in the sixth year of the second longest war in American history and we are way too late on these things—not too early.
Does anybody want to add any comments before we begin?
Mr. Stearns?
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. STEARNS. Mr. Chairman, thank you.
As a Member from Florida with my other colleagues, we have a lot of veterans coming back from the war into Florida. It is one of the largest and fastest-growing veterans populations in the country.
And I think, Mr. Chairman, as you pointed out, it is traumatic brain injury, if a veteran suffers from that, that in turn could create a high incidence of post traumatic stress disorder. So obviously Members want to know what is being done.
I understand Title 17 of the "Wounded Warriors Act" specifically requires the Secretary of the VA to develop an individualized plan to help rehabilitate and reintegrate back into our community servicemembers who have received care at the VA for TBI.
The Act also requires the VA to assign a case member for each veteran suffering from TBI while also explicitly stating the family members of the veteran with TBI should be involved in the development of this individualized plan. This is good. I would like to obviously hear how that is progressing.
Just as a side note, Mr. Chairman, if, in fact, a person suffers from traumatic brain injury and this causes post traumatic stress, if we could, through a blood test immediately administered on the field of battle or after the veteran comes back, through a blood test determine if there is this traumatic brain injury, that would indeed give us insight immediately on how to care for these individuals.
There is a company in my Congressional district called Banyon Biomarkers that we have helped fund for many years to develop this blood test, and they are on the cusp now of making this into a product that the military could carry into battle and actually test the blood samples of an individual to see if they have traumatic brain injury. And that in turn would give us a head start on post traumatic stress.
And I say that. I am obviously bragging about this company. We have funded it over the last six, seven years. And there are real possibilities, Mr. Chairman and my colleagues, that this will be made into a quantitative case and not into a qualitative case where we are trying to understand the veteran who comes back to fill out forms and things like that.
But we need this urgently to be able to help the veteran even though perhaps he feels there is no problem. But this blood test is on the cusp of being made into a device that can be manufactured.
So I look forward to the hearing. And I think as I pointed out in Title 17, the VA has a heavy responsibility to reintegrate these individuals and to help the family members develop this individual plan. So I look forward to the hearing.
And thank you, Mr. Chairman.
The CHAIRMAN. Thank you.
We will start with the first panel. Lisa Jaycox is a Senior Behavioral Scientist and Terri Tanielian is a Senior Social Research Analyst with the RAND Corporation. They will discuss their recent report called "The Invisible Wounds of War," which I think is an important contribution to our understanding of the issues.
Ms. Jaycox will focus on the key findings on psychological cognitive injuries and Ms. Tanielian will focus on the recommendations for addressing these injuries.
You are welcome to start. Thank you.
STATEMENTS OF LISA H. JAYCOX, PH.D., SENIOR BEHAVIORAL SCIENTIST/CLINICAL PSYCHOLOGIST, AND STUDY CO-DIRECTOR, INVISIBLE WOUNDS OF WAR STUDY TEAM, RAND CORPORATION; AND TERRI L. TANIELIAN, MA, CO-DIRECTOR, CENTER FOR MILITARY HEALTH POLICY RESEARCH, AND STUDY CO-DIRECTOR, INVISIBLE WOUNDS OF WAR STUDY TEAM, RAND CORPORATION
STATEMENT OF LISA H. JAYCOX, PH.D.
Dr. JACOX. Thank you, Chairman Filner, Representative Buyer, and distinguished Members of the Committee, thank you for inviting us here today to present on the RAND study, Invisible Wounds of War. It is an honor to be here.
My testimony will present the results of the study which was conducted independently of the DoD and VA and takes a broad perspective on three consequences of war: post traumatic stress disorder or PTSD; depression; and traumatic brain injury or TBI among servicemembers returning from Iraq and Afghanistan.
My colleague, Terri Tanielian, will follow with recommendations for addressing these conditions.
Since October of 2001, approximately 1.6 million U.S. troops have deployed to these theaters at a pace unprecedented in the history of the all volunteer force.
Advances in both medical technology and body armor mean that more servicemembers are surviving their combat experience. However, casualties of a different kind are beginning to emerge, invisible wounds such as mental health and cognitive impairments resulting from deployment experiences.
First, I will discuss our findings relative to PTSD and depression. Our telephone survey representing all previously deployed individuals found substantial rates of mental health problems in the past 30 days with 14 percent screening positive for PTSD and 14 percent for major depression.
Some specific groups previously under-studied including the Reserve components and those who have left military service may be at higher risk of suffering from these conditions, but the single best predictor of PTSD and depression is the number of combat traumas experienced while deployed.
Only about half of those with current PTSD or major depression had sought help for a mental health problem in the past year and only about half of those that sought care received minimally adequate treatment. The number who received quality care would be even smaller.
Many barriers inhibit veterans from getting help for their mental health problems including concerns about treatment leading to negative career repercussions and also concern that treatment might not be effective.
Unless treated, both PTSD and depression have wide-ranging and negative implications that affect work, family, and social functioning including substance abuse, homelessness, and suicide. Thus, early intervention is needed to help stem this cascade of negative consequences.
In dollar terms, the cost associated with PTSD and depression are substantial. We estimated costs incurred within the first two years after servicemembers return home to range from $4 to $6 billion.
Our cost model assumes the status quo in which the minority of individuals with PTSD and depression actually get treatment and the minority of that care is acceptable quality of care. If we assume high-quality care goes to every person with PTSD or depression, we see that by increasing treatment costs, the societal costs are reduced by as much as $2 billion in just two years.
For active-duty personnel in particular, personal and cultural factors impede the use of services as do structural aspects of services such as wait times and availability of providers.
We identified gaps in organizational tools and incentives that would support the delivery of high-quality mental healthcare to the active-duty population and to retired military who use TRICARE.
The VA provides a promising model for the DoD in quality improvement in mental healthcare. However, it faces challenges in providing access to veterans, many of whom have difficulty securing appointments, particularly in facilities that have been resourced primarily to meet the needs of older veterans.
Improving access to mental healthcare for veterans will require reaching beyond the DoD and VA healthcare systems, but it will be essential to ensure quality care in these systems.
I am now going to turn to our results regarding TBI or traumatic brain injury. In our survey, we found 19 percent reported a probable TBI during deployment, although we do not know the severity of that injury or whether the injury caused functional impairment. Of those reporting probable TBI while deployed, 57 percent had not been evaluated by a physician for brain injury.
In dollar terms, we estimate one year cost for mild TBI or concussion to be about $30,000 largely due to productivity losses. In contrast, for moderate to severe cases, costs are about ten times higher and are due mostly to mortality costs.
The medical science for treating combat-related TBI is in its infancy. Research is urgently needed to develop effective screening tools as well as to document what treatment and rehabilitation will be most effective.
In terms of the service systems for mild TBI, we found gaps in access to services stemming from poor documentation of blast exposures and failure to identify individuals with probable TBI. Servicemembers with more severe injuries face a different kind of access gap, lack of coordination across the continuum of care.
Thank you for the opportunity to testify today and share our results. Additional research results are available in my written testimony and also available at veterans.rand.org. Thank you.
[The statement of Ms. Jaycox appears in the Appendix.]
The CHAIRMAN. Thank you very much.
Ms. Tanielian?
STATEMENT OF TERRI L. TANIELIAN, MA
Ms. TANIELIAN. Chairman Filner, Representative Buyer, and distinguished Members of the Committee. Thank you for inviting me to testify today. It is an honor and pleasure to be here.
My testimony will briefly discuss several recommendations for addressing the psychological and cognitive injuries among servicemembers returning from Afghanistan and Iraq.
The purpose of these recommendations is to close the gaps in access and quality for our Nation's veterans that Dr. Jaycox described.
Our report offers four recommendations that would improve the understanding and treatment of PTSD, depression, and TBI among combat veterans.
First, our report recommends an increase in the number of providers who are trained and certified to deliver proven or what we call evidence-based care. There is a substantial unmet need for treatment of PTSD and depression among military servicemembers following deployment.
Both DoD and the VA have had difficulty in recruiting and retaining appropriately trained mental health professionals to fill existing or new slots. With the possibility of more than 300,000 new cases of mental health conditions among Iraq and Afghanistan vets, a commensurate increase in treatment capacity is needed.
Since there is already an increased need for services, the expansion of trained providers is already several years overdue. With an existing shortage of mental health professionals in the U.S. healthcare system more broadly, this has become a critical pipeline issue.
Such investment could be facilitated by several strategies including adjusting financial reimbursement for providers to offer appropriate compensation and incentives, developing certification processes to document the qualifications of providers, and establishing regional training centers for joint training of DoD, VA, and civilian providers in evidence-based care for PTSD and depression.
Our second recommendation is to change policies that would encourage active-duty personnel and veterans to seek needed care. Many servicemembers are reluctant to seek services for fear of negative career repercussions. Policies must be changed so that there are no perceived or real adverse career consequences for individuals who seek treatment except when functional impairment compromises fitness for duty.
Such policies will require creating new ways for servicemembers and veterans to obtain treatments that are confidential, off the record, off base, and during off-duty hours. Currently information about being in treatment is available to command staff even though treatment itself is not a sign of dysfunction or poor job performance, providing an option for confidential treatment has the potential to increase total force readiness by encouraging individuals to seek healthcare before problems accrue to a critical level.
Third, to close the gap in quality, our study recommends delivering evidence-based care to servicemembers and veterans wherever and whenever they are served. Treatments for PTSD and depression vary substantially in their effectiveness and while the most effective treatments are being delivered in some sectors of the care system for military personnel and veterans, system-wide implementation remains a problem.
Delivery of evidence-based care to all veterans with PTSD or depression would pay for itself or even save money by improving productivity and reducing medical and mortality costs within only two years.
The VA is at the forefront of trying to ensure that evidence-based care is delivered to all of its patients, but it has yet to evaluate its success at these efforts across the entire system nor will the VA serve all veterans.
Transformations are required to achieve the needed improvement in quality of care for our veterans. For example, providers delivering treatments to veterans must be held accountable for the services they are providing.
TRICARE and the VA could require that all patients be treated by therapists who are certified to handle the diagnosed disorders of that patient and use varying payment systems to incentivize the delivery of evidence-based care. Monitoring systems should also be used to ensure quality and coordination of care.
Our final recommendation calls for investing in research to close information gaps and plan effectively for the future. Better understanding is needed of the full range of problems that confront individuals with post-combat PTSD, depression, and TBI. Greater knowledge is also needed to understand who is at risk for developing mental health problems and who is most vulnerable to relapse.
At the same time, policymakers need to be able to accurately measure the costs and benefits of different treatment options so that fiscally responsible investments in care can be made. A coordinated Federal research agenda on these issues within the veterans population is sorely needed.
Such a program would likely require resources in excess of that currently devoted to PTSD and TBI through DoD and the VA and could extend to the National Institutes of Health (NIH), the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality.
Addressing PTSD and depression as well as TBI among those deployed to Afghanistan and Iraq should be a national priority, but it is not an easy undertaking. The prevalence of these injuries is relatively high and may grow as these conflicts continue. And the long-term consequences associated with these injuries if left untreated without evidence-based care can be severe.
The systems of care available to address these conditions have been improved significantly, but critical gaps remain. System-level changes across the entire U.S. healthcare system are essential if the Nation is to meet not only its responsibility to recruit, prepare, and sustain a military force but also its responsibility to address service-connected injuries and disabilities.
Thank you again for the opportunity to testify today and to share our research findings and recommendations.
[The statement of Ms. Tanielian appears in the Appendix.]
The CHAIRMAN. Thank you both very much.
Mr. Snyder, if you have any questions, you are recognized.
Mr. SNYDER. Is it Tanielian? Am I saying that right? The issue of training, you are very clear multiple times in here talking about evidence-based treatment and that people need to be trained in that.
If I today decided to quit this job and I wanted to become that kind of a trainer, where would I go and how long would it take me?
Ms. TANIELIAN. That is an excellent question. And we recommend actually that regional training centers be developed that would offer this type of training in evidence-based care. Currently, availability of such training is sparse in different locations around the country and we would need additional training centers.
I would also ask Dr. Jaycox who is trained in some of these evidence-based therapies to comment.
Dr. JACOX. I think one part of your question is who can be trained. And normally some degree of clinical training be before you get training in evidence-based treatments is required.
But that does not necessarily mean just psychiatrists and psychologists. Social workers, marriage and family therapists, etc., there are many different people with degrees who would be ready to take up this kind of training.
And the DoD is rolling out a number of training programs among and providers within their systems. So there is, you know, a number of different efforts to bring these kinds of treatments into both the DoD settings and the VA.
Mr. SNYDER. Is not one of the problems there, I mean, my impression is we have a lack of general mental health providers in this country anyway already, right? Do you agree with that?
Dr. JACOX. Yes.
Mr. SNYDER. And so if what we are talking about is trying to take this pool that we think is inadequate for the country and get some of them to take additional training at these regional training centers and these specific treatment modalities for PTSD and the depression and the kind of thing you are talking about, we are still going to have the same shortage of providers; are we not?
Ms. TANIELIAN. We have a current shortage of providers in the U.S. mental healthcare system. That is why we identified this as a pipeline issue. We do need to think about the pipeline of individuals going into mental health professions as well as those paraprofessionals that Dr. Jaycox described and how they could be trained as well in these particular types of approaches.
We need to think broadly because we need a large investment to get the required expansion as soon as possible.
Mr. SNYDER. One of the issues that comes up sometimes is that there is an interest to meet this need and having probably people with quite limited mental health treatment background, you know, but who may be veterans themselves or have been in combat themselves.
I do not see anywhere in your writing that you are suggesting that we omit step one which is some basic background and education and clinical experience in providing treatment to patients and folks with mental health issues.
Would you elaborate on that?
Ms. TANIELIAN. Yes, I agree that there needs to be some baseline clinical training, but there are also roles for other types of people in the treatment process. We know that support and help with transitions is extremely important for reducing PTSD and depression symptoms.
So, for instance, in the Vet Centers, that role of helping people work out their financial problems, their employment problems, their family problems is important as well.
And in addition, there are some new models that integrate care, for instance in primary care, where the primary care physician can serve as sort of the point of contact that then would help decide, which patients need to go into the more intensive psychotherapy approaches, for instance.
And the primary care physicians can be trained to deliver the medications with psychiatric consult so that individuals would not have to see a psychiatrist directly, but could also work with their primary care physician.
Mr. SNYDER. One of the things that happens, it seems to me, in mental health services is a person goes to see, and you talked about this, I think, Ms. Tanielian, a person goes to see their mental health provider. They spend time with them. Then they come out with their slip that says counseling or just something, and I think it is deliberate, you do not know what happened in the room.
The problem is, it seems, is that part of the issue that makes it difficult to evaluate what has been effective or not effective or if the person is being paid, Federal dollars is providing the kind of what you call evidence-based therapy.
Would you comment on that?
Ms. TANIELIAN. Absolutely. Our healthcare system is designed on a reimbursement system that only asks providers to record the number of minutes that they saw the patients.
Our analyses suggests that we need to break down the black box of what is happening in these sessions and require accountability so it would be more informative for both evaluating the types of care that are being delivered as well as incentivizing the delivery of evidence-based care, to understand what types of therapies or treatments are being delivered in that 30, 45, or 90 minute session.
Mr. SNYDER. Thank you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Snyder.
Mr. Stearns?
Mr. STEARNS. Thank you, Mr. Chairman.
Just to put this in perspective, how many, and this is a question each of you can answer separately, how many, if any, of your recommendations were already addressed in the Wounded Warrior provisions of Public Law 110-181? Start with you.
Dr. JACOX. You know, our report is complementary to the Wounded Warrior provisions in that we are focusing on depression, PTSD, and—
Mr. STEARNS. No. But that is not the question. The question is, how many of the Wounded Warrior provisions of these recommendations are already being done?
Dr. JACOX. Those really focus on the severely wounded individuals so that it is a different system of care that we are looking at, by and large, except for in terms of moderate to severe TBI. So I do not have an exact answer for you.
Mr. STEARNS. Do you?
Ms. TANIELIAN. It is an excellent question. I think that we could look a little bit more closely at the specific provisions in the legislation and provide you with a more detailed response about the exact overlap.
We are suggesting that the issues for raising the level of quality of care that is provided really extend beyond the DoD and the VA and go across the entire U.S. healthcare system in terms of the pipeline issues for providers who are going into these professions as well as the systems that would need to be in place to ensure appropriate quality in terms of the evidence-based care that is being delivered to the veterans.
Mr. STEARNS. So you are also talking about the private sector too?
Ms. TANIELIAN. Absolutely. A number of veterans will be seeking care outside of the DoD and the VA healthcare systems in the private sector as well as the publicly-funded healthcare sector.
Mr. STEARNS. Maybe it is difficult for you to answer. But if you took the VA, the DoD, and the private sector and if you could rank them into a professional opinion in terms of the quality of mental healthcare and traumatic brain injury care provided services, is the private sector way ahead of the DoD? I mean, if you took VA and DoD and the private sector, could you give me sort of a ranking here or just a feel for this?
Dr. JACOX. I will give you my opinion on that.
Mr. STEARNS. Yes. Just your personal opinion after you have done this.
Dr. JACOX. Yes.
Mr. STEARNS. You are the analyst and you are the experts.
Dr. JACOX. As we said earlier, the VA is really at the forefront for monitoring quality and rolling out—
Mr. STEARNS. The VA is ahead of the private sector?
Dr. JACOX. Yes.
Mr. STEARNS. And ahead of DoD?
Dr. JACOX. Yes, in that it is both conscientiously monitoring and trying to enhance quality both for PTSD and depression. The DoD is rolling out a lot of programs, but is not yet monitoring the quality of those programs. And the civilian sector, I would say, is behind both of them.
Mr. STEARNS. Is that your opinion also that the Veterans Administration is way ahead of the private sector as well as DoD?
Ms. TANIELIAN. Yes. The VA has a number of tools in place that they are using already, as Dr. Jaycox described, to increase the level of evidence-based care that is delivered to its patients as well as to monitor and incentivize the delivery of that type of care.
The DoD also has similar tools that they are now able to roll out. The civilian sector, while there are some models out there, for decades, the veterans healthcare systems as well as the military health systems have led the field, particularly around the treatment of PTSD.
Mr. STEARNS. You probably heard my opening statement in which Banyan Biomarkers, which is affiliated with the University of Florida, which I represent, has done research to identify in the battlefield from a blood test whether there is traumatic brain injury.
Have you ever heard of that or have you been aware of that kind of advancement?
Dr. JACOX. I am not aware of that, but we really focused on post-deployment PTSD, TBI and depression, so not during deployment.
Mr. STEARNS. What does RAND define as minimally adequate care for mental health conditions? Do the different policies and procedures among the services and the VA impact the delivery of mental healthcare and TBI care? If so, in what way? And does Public Law 110-181 address any of these issues?
Dr. JACOX. We talked about the definition of minimally adequate care. First, we defined it in a way that is similar to the way researchers are doing so in the civilian sector and that is that if people reported having counseling or psychotherapy that they have at least eight sessions of psychotherapy that lasted at least 30 minutes each in the last year.
So really it is just talking about an amount of time in therapy. And for medication that you visited a doctor at least four times and stayed on the medication as long as your doctor wanted you to.
So, again, it is sort of a dose of therapy rather than just talking about the specific type of therapy or the type of medication provided.
Mr. STEARNS. Anything you would like to add?
Ms. TANIELIAN. No, thank you.
Mr. STEARNS. Okay. Thank you, Mr. Chairman.
The CHAIRMAN. Thank you, Mr. Stearns.
We will now hear from the Chairman of our Health Subcommittee, Mr. Michaud.
Mr. MICHAUD. Thank you very much, Mr. Chairman.
Doctor, you had mentioned, I believe at the beginning of your remarks that societal costs actually could go down by as much as $2 billion if they received treatment earlier.
Is that for the veteran themselves or does that include their families, the cost to society because of the families affected as well?
Dr. JACOX. Thank you for letting me elaborate a little bit on that.
The costs in our model included lost productivity at work, so both presenteeism and absenteeism, being able to function less well on the job, lives lost to suicide, and treatment costs, that is direct treatment costs.
We were not able to factor in things that we know exist like difficulty with family members, divorce, substance use because there are not good dollar figures to attach to those and in order to be able to put them as assumptions into the model.
So really the gains with treatment have to do with increased productivity at work and fewer suicides. Productivity is the biggest cost driver for both PTSD and depression.
Mr. MICHAUD. Do those figures include, for example, if someone comes back who has PTSD, which ultimately might lead to alcoholism or drug abuse and incarceration, is the cost of incarceration put onto the county or State?
Is the cost of incarceration incorporated in that as well?
Dr. JACOX. No. So that kind of cost is not incorporated, just work productivity, suicide, and treatment costs. And they are very conservative estimates because, as you point out, there are many other costs that we are aware of.
Mr. MICHAUD. Okay. You mentioned that the VA does a better job compared to the DoD as well as in the private sector.
What do you attribute that to? Do you attribute it to the VA does not have to worry about cost reimbursement and they can do a better job?
Ms. TANIELIAN. It is not necessarily that it is about reimbursement, rather it is that there has been an investment in research as well as in training and rolling out evidence-based practice guidelines to train providers in the delivery of evidence-based care as well as the use of tools that they have within the system, such as the electronic medical record that would enable them to kind of monitor care.
Mr. MICHAUD. You had mentioned that there were actually regional training teams, facilities where you can actually train.
Where are those located? And the second part of that question is, if you look at the demographics of our military today, I believe 40 percent are from rural areas, and do you see a disparity between urban versus rural in getting the help that individual military or veterans need?
Ms. TANIELIAN. Sure. We recommend the establishment of regional training centers to train providers in this type of care. It is not that they exist already.
And there is a lot of variation in accessibility of care between urban and rural areas. Those that may be further away from military installations and VA healthcare facilities will have greater difficulty in getting services in those types of settings and will turn to their community-based setting and sector for care.
And that is why civilian providers would also need to be trained in delivering evidence-based therapy as well as be trained in the military culture and being sensitive to the special issues in treating military servicemembers and veterans.
Mr. MICHAUD. And where would you suggest that these facilities be located when you look at the demographics of our veterans?
Dr. JACOX. That is a great question. We are hoping to do some further work on that. And I think there is some work underway also to actually map out where servicemembers and veterans are and where the facilities are and figure out the areas of need. But we did not analyze that in this report.
Mr. MICHAUD. And my last question is, when you look at the Department of Defense and you look at the VA system and what is happening out there in the private sector, there definitely is a shortage of healthcare professionals.
Have you looked at, and it would probably be hard to judge, but right now when you look at the war as it continues on, there is definitely a need in DoD for those type of healthcare professionals as well as in the VA system, but as the war winds down, there will probably be less need in DoD but more need actually in the VA system? Have you looked how those two can kind of meld together to work more cooperatively?
Ms. TANIELIAN. That is a critical kind of study that would need to be done. We were not able to examine the data that would be required to look at that and project demand over time and to look at the capacity that would be required in five, ten years and where that capacity would be best placed.
We have heard anecdotally that there is a shifting of providers from our community-based mental health sectors to either the DoD or VA now because they are hiring. And so we are taking providers from what is a shortage area already. And so that is why we identify this as a major pipeline issue for the entire U.S. healthcare system.
Mr. MICHAUD. Thank you very much. Appreciate it.
The CHAIRMAN. Thank you.
Dr. Boozman, you are recognized.
Mr. BOOZMAN. Thank you very much.
I was wondering. You talked about evidence-based care as in contrast to what? Will you discuss, you know, some of the things that are going on that you are concerned about versus the evidence-based care?
Dr. JACOX. Well, we contrast it with the usual care, which is not necessarily a bad thing, but does not have the higher recovery rates that we find with evidence-based care. And to be frank, we do not know exactly what is going on in usual care. There have been some studies of it, but it is more diffuse supportive type of therapy without using the specific techniques that we know to be effective.
We have a whole section in our report that discusses the evidence-based care for PTSD, depression, and TBI and compares it with—gives a level of evidence for the DoD and VA guidelines for healthcare for those conditions.
And so really when we talk about evidence-based care, we are talking about offering the best that we know is available which offers higher recovery rates, but is not perfect either.
Mr. BOOZMAN. You mentioned, I think, 18 and a half percent PTSD and depression. How is that in contrast to just the general service, the people that have not deployed or do you have any figures as far as what that represents?
Dr. JACOX. We used similar measures to what have been used in other studies, but we do not have good estimates for the nondeployed population.
I can tell you in our sample, everyone had been deployed, but we had a group of people who had not been exposed to any combat exposures while deployed, so no experiences of loss or traumatic events.
And we found very low rates of PTSD and depression there. One percent for PTSD and three percent for depression. So that gives you an idea.
Mr. BOOZMAN. Okay. I guess I think it probably is important to find that out and then, too, just the general population, you know, what kind of depression.
Ms. TANIELIAN. Sure. In the general civilian population, about seven percent will experience depression in a year and only about three and a half percent will experience PTSD in a year.
Mr. BOOZMAN. The other problem that you mentioned was, you know, people not reporting, you know, the fact that they were having a problem.
Can you talk to us about specific things that you feel like we can do a better job of?
Dr. JACOX. Sure. We asked servicemembers what would get in the way of getting treatment and, as we mentioned, three of the top five barriers had to do with concerns about negative repercussions on career, security clearance—
Mr. BOOZMAN. And, yet, I think you also said that the rate of reporting was about the same as the general population.
Dr. JACOX. The rate of reporting, that service use was about the same as in the general population?
Mr. BOOZMAN. Yes.
Dr. JACOX. Yes. That is true. We do have difficulty getting individuals with mental health problems in the civilian sector into care as well.
Here, though, the types of barriers are very different. In the civilian population, it really has to do more with access and here everybody has access to some type of care. And it is really about concern around negative career repercussions. So that was a striking difference.
Mr. BOOZMAN. Good. Thank you very much, Mr. Chairman. I yield back.
Thank you for your testimony.
The CHAIRMAN. Thank you.
Mr. SNYDER. Mr. Chairman, that report, we do not have that.
The CHAIRMAN. Mr. Snyder would like to look at that book if you would not mind passing it around. And if he does not pay for it, we will get him for it. Thank you.
Mr. Mitchell? Mr. Hare?
Mr. HARE. Thank you, Mr. Chairman.
I just have two questions. Ms. Tanielian, you mentioned in your testimony that slightly more than half of those that are suffering from PTSD and depression are receiving minimally adequate care.
Can you describe what you mean by that and also what are the long-term effects of the inadequate care? What might they be and what are we looking at here?
Ms. TANIELIAN. Sure. Only about half of those who had sought care from a professional in the past year received what we define as minimally adequate care, which really was about the amount of time they spent in either therapy or the number of times that they visited the doctor.
So if they were getting medications, it was four visits to a physician in the past year and taking the medication as long as they were recommended to. If they were in therapy or counseling, it was visiting a therapist for at least eight visits of 30 minutes in duration.
So this is really just a minimum dose of therapy. Without treatment or with under-treatment, we know that there are long-term negative consequences associated with having PTSD, depression, and TBI including impairments in relationship, homelessness, increased risk for suicide, problems with employment, et cetera.
Mr. HARE. So what kind of care? I mean, okay, we know what minimum care here is, minimally. So what would you advocate for that?
Ms. TANIELIAN. We are recommending that veterans and servicemembers, wherever they are treated, wherever, in whichever sector, they be offered the latest evidence-based therapies, treatments that have been demonstrated through research to yield higher recovery rates. So faster recovery as well as more time without symptoms.
Mr. HARE. Okay. And, Dr. Jaycox, just a quick question for you. How could both the VA and the DoD improve the methods for identifying and bringing in soldiers who may be suffering from PTSD, major depression, or TBI to improve their care?
Dr. JACOX. That is a really good question. There are a number of screening efforts underway. Unfortunately, you know, there is some concern that servicemembers and veterans do not want a PTSD or depression diagnosis on the record in their personnel file.
And so it is tricky to figure out a way to screen them in a way that will benefit them and get them into care without the concerns about negative career repercussions.
I think the more that the military can do to encourage care, to make it acceptable and seen as a sign of strength to receive mental health treatment post deployment, the more servicemembers would be willing to seek out those services and admit to symptoms when they are screened.
Mr. HARE. The Chairman has advocated for a long time, and I completely agree with him, that we ought to be screening everybody so that that person does not have to identify themselves as having a problem and then there is the whether or not it is going to affect whether or not they are going to be able to advance in rank or whether it is going to affect them in their jobs.
So would you concur that what we should be looking at doing is screening everybody that comes back with no exceptions and also then monitoring them for a longer period of time because a lot of times, as I understand it, and I have a Vet Center close to my Congressional district office, a lot of this does not just happen in a matter of weeks or months? It could be down the road. Plus, you know these are things that affect not just the service person but their entire family.
Dr. JACOX. There are mandatory screenings post deployment and now three to six months after return, but those, again, are imperfect in that servicemembers might not be willing to admit to symptoms when screened.
But I agree that long-term follow-up is necessary. Research is necessary to follow individuals over time and track and see how they are doing and particularly around traumatic brain injury where we know so little about the functional impairment, the long-term course, and the types of treatments that are needed, that there really is a strong need to identify and follow individuals over time.
Mr. HARE.&n
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