Submission For The Record of Wounded Warrior Project
Chairman Benishek, Ranking Member Brownley, and Members of the Subcommittee:
Thank you for inviting Wounded Warrior Project (WWP) to offer views today on legislation under consideration by the Subcommittee. Working closely with warriors who have sustained wounds, injuries, and illnesses in service since 9/11, WWP brings an important perspective to your deliberations regarding the VA health care system and the statutory framework under which it operates. Several bills on your agenda address issues of importance to our warriors, though we also want to alert the Subcommittee to concerns raised by other measures. For the record, however, we are concerned that today’s agenda does not include either legislation or draft legislation to extend the VA’s Assisted Living Pilot Program. That program has been an important resource for warriors who have sustained traumatic brain injuries and have required specialized residential rehabilitation. With veterans who need this level of care now “locked out” of the program and others at risk of being discharged prematurely, we renew our request that this Subcommittee move legislation at the earliest opportunity to lift the program’s “sunset.”
Expanding Access to Care for MST-Related Conditions
WWP welcomes the Subcommittee’s consideration of legislation to remove barriers to care and treatment for MST-related conditions. The importance of early access to counseling and treatment as well as assuring the quality and effectiveness of treatments for health problems associated with MST cannot be overstated. Researchers report that MST is an even stronger predictor of PTSD than combat and victims’ reluctance to report these traumatic incidents can also result in delaying treatment for conditions relating to that experience. In-service sexual assaults have long-term health implications, including PTSD, increased suicide risk, major depression and alcohol or drug abuse and without outreach to engage victims of MST on needed care, the long-term impact may be intensified. With the VA reporting that some 1 in 5 women and 1 in 100 men seen in its medical system responded "yes" when screened for MST and the Department of Defense reporting that 26,000 active duty service members experienced a sexual assault in 2012, it is clear that there is a great need for resources, support, and effective treatment for those who are coping with health issues as a result of an in-service assault. While researchers cite the importance of screening for MST and associated referral for mental health care, many victims do not currently seek VA care. Indeed, researchers have noted frequent lack of knowledge on the part of women veterans regarding eligibility for and access to VA care, with many mistakenly believing eligibility is linked to establishing service-connection for a condition. A recent survey of WWP Alumni further demonstrates the great challenges in getting needed treatment for warriors affected by MST. Almost half of the respondents indicated accessing care through VA for MST related conditions was ‘Very difficult’. And of those who did not seek VA care, 41% did not know they were eligible for such care. In our view, there is still a lot of work to do to improve care and treatment for veterans with MST related conditions.
With these challenges in mind, WWP offers our strong support for H.R. 2527 and H.R. 2974, which, respectively, would expand eligibility to counseling and treatment for MST-related conditions for veterans whose sexual trauma occurred during inactive duty training and provide eligibility for beneficiary travel for veterans seeking treatment or care for MST through VA. As the Subcommittee’s important oversight work has documented, however, the scope of the problem is not limited to access to care. Testimony at a recent Subcommittee hearing provided strong evidence that both the Department of Defense and the VA are failing to provide adequate mental health services for veterans who had been assaulted by fellow service members. Veterans at that hearing detailed troubling, yet similar experiences relating not only to access to VA care, but to inadequate screening, providers who were either insensitive or lacked needed expertise, and facilities ill-equipped to appropriately care for MST survivors.
We commend the VA for taking significant steps (described at the Subcommittee’s February 26th oversight hearing) to improve veterans’ screening and care for MST- related conditions. To date, however, too many warriors still have not received timely, effective treatment. In short, wide gaps remain between well-intentioned policies and on-the-ground practice. With those concerns, we urge the Committee to continue to pursue these issues through oversight, to include conducting a searching inquiry as to whether VA has yet achieved the level of mental health staffing needed to meet the mental health needs of our veterans. Further, we urge that such oversight focus on improving access to MST-related care and training providers, as needed, to provide effective screening and appropriate, sensitive care for those seeking treatment for MST-related conditions.
Legislation to Address Operational Challenges: H.R. 2661 and H.R. 4198
We are unable to support two other bills, in particular, H.R. 2661 and H.R. 4198, that propose to address operational challenges inherent in the administration of a health care system. H.R. 2661 would direct VA to implement a policy “to ensure” that a veteran enrolled in VA’s health care system is able to schedule an appointment, within seven days in the case of primary care and within 14 days in the case of a specialty care, of the date that the veteran or provider requests. The bill sets additional expectations VA is to achieve to further that policy.
In testifying before the Subcommittee in the past at hearings examining VA mental health care, WWP expressed deep concerns with the long waits warriors have encountered at many facilities with regard to both initial and follow-up mental health care visits. Those concerns have not vanished. But while there are certainly systemic problems with VA scheduling practices and with the reliability of VA’s mechanisms for reporting wait times, scheduling cannot be altogether divorced from an array of other, often complex issues. To focus solely on implementation of a scheduling policy, as proposed in H.R. 2661, is to fall short of remedying deeper problems and to risk compounding those that already exist.
Repairing flaws in how VA accomplishes appointment-scheduling is unlikely by itself to ensure that veterans actually receive timely, needed treatment. To illustrate, sustained congressional oversight into severe timeliness problems in VA’s provision of mental health care finally led to the Secretary’s acknowledging in April 2012 a need for 1900 additional mental health staff. Just as it is important to take account of the link between adequate staffing and timeliness, we urge the Subcommittee to work toward ensuring that VA care is not only timely, but effective. The establishment of rigid standards of timeliness (not goals, but requirements) – without regard to staffing levels or other limitations -- can create (and has in recent experience in VHA led to) perverse incentives to “game” the system and even to institute practices that compromise care quality. Well-intentioned VA performance requirements too often lead to inappropriate practices. We offer the following relatively recent examples arising from VA efforts to set policy for mental health care:
- a VA facility at which practitioners were directed not to ask veterans about their mental health problems lest it become necessary to provide them treatment (as required by performance measures) for which there was not adequate staff;
- VA facilities that have shifted staff to ensure that veterans are “seen” within 14 days (to meet a metric) but that, as a result, cannot begin real treatment until many weeks later;
- A VA facility that has instructed staff to substitute a diagnosis other than PTSD in instances where PTSD is a patient’s primary diagnosis to avoid having to meet performance requirements relating to provision of evidence-based treatments for PTSD.
- VA facilities that have prematurely placed veterans who need individual therapy into group therapy that is being “counted” inappropriately as meeting a performance metric.
While we certainly acknowledge the importance of improving both VA’s timeliness and systems for effective scheduling of appointments, we have real concern with setting rigid requirements that ignore not only patient acuity and differences between elective and necessary care, but overarching fiscal and other resource constraints. We do not in any way seek to minimize the importance of the issues raised by the General Accountability Office in its report on the Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight. But we believe the well-intentioned prescription set in H.R. 2661 is not the “best medicine” to cure the problem, and do not support its enactment.
H.R. 4198 proposes to reinstitute a statutory reporting requirement established in 1996 that was aimed at preventing downsizing or even termination of certain specialized programs dedicated to the specialized needs of veterans with particular disabilities. A careful review of the impact of that well-intentioned law, and subsequent amendments to it, would likely call its effectiveness into question. The law employed 1996 as a baseline against which to gauge whether VA “maintained” then-existing programs. While this bill does implicitly raise highly important issues, there has been too much change in the VA health care system to employ a 17-year old benchmark as the framework for judging whether VA programs and services are meeting some of our veterans’ most critical needs. We are more than sympathetic to the concerns underlying the bill, but urge the Subcommittee to avoid missing this important mark by simply reinstating a reporting requirement that for a number of the programs it aims to protect is substantially outdated.
Mental Health Care
H.R. 3387, the Classified Veterans Access to Care Act, would direct VA to establish standards and procedures to accommodate veterans’ access to care without “improperly disclos[ing] classified information.” It is our understanding that this legislation was developed as a response to a disturbing instance of a patient (with knowledge of classified information) being prematurely placed in group therapy. We share a concern that veterans needing mental health care should be afforded that care in an appropriate and timely manner and, particularly, without being made to attend group therapy before they are offered needed individual treatment. That concern is not limited to situations where a patient feels unable to discuss mental health problems in a group setting because of an obligation not to disclose classified information. Congressional testimony that many VA medical centers have routinely placed patients in group-therapy settings rather than provide needed individual therapy highlights a broader problem than the bill addresses. As such, we recommend that the Subcommittee consider a more comprehensive solution than H.R. 3387 proposes. Providing effective care requires building a relationship of trust between provider and patient – a bond that is not necessarily easily established and setting the foundation for such trust should generally begin in individual treatment. We also urge more focus on the soundness and effectiveness of the VA’s mental health performance measures, which currently track adherence to process requirements, but fail to assess whether veterans are actually improving.
A second measure, H.R. 183, would direct VA to carry out a five-year pilot program to assess training service dogs as a therapeutic medium to treat mental health and posttraumatic stress disorder symptoms. In our work with Wounded Warriors, we hear from many individuals who have benefitted greatly from the use of a service dog for a mental health condition. We are also aware of reports suggesting incarcerated inmates have derived benefits from participating in programs in which they train service dogs. WWP is not able to assess the strength or existence of evidence that might suggest that training dogs offers promise as a mode of therapy for veterans with mental health conditions. More importantly, however, H.R. 183 is in the nature of a directed research program. Given many other competing claims on VA’s budget, we believe that decisions to fund research initiatives, however appealing they may appear, should be based on a peer-review evaluation process. However meritorious this proposal may be, we would urge the Subcommittee to discourage the direction of VA research. While we do not support H.R. 183, WWP is certainly not opposed to innovation. To the contrary, we are supportive of finding innovative ways to engage more veterans in needed mental health care. In that regard, we have specifically supported approaches that would integrate complementary medicine into traditional practices as well as using complementary practices as a gateway to evidence-based services to engage veterans who, for example, might otherwise be reluctant to seek or accept mental health treatment.
With WWP’s most recent annual survey of our wounded warriors showing that nearly 18% of our survey respondents report having severe hearing loss, evaluation, care and services for hearing-impaired veterans is certainly a concern. As such, we welcome the Subcommittee’s consideration of hearing-related issues. In that regard, H.R. 3508 would set standards for, and authorize appointment under title 38 to, hearing aid specialists, and require VA to report annually on timely access to hearing health services and contracting policies with respect to providing those services.
As discussed above, wait times for treatment and needed VA services is an overarching issue. And as discussed above, and in a recent IG audit report on VA’s Hearing Aid Services, the adequacy of VA staffing is an important dimension of providing timely service.
As with other VA services, there appears to be variability in the timeliness of VA hearing-related services. WWP field staff who reported very recently on their experience in several regions of the country advised that “warriors still have general complaints with wait times for appointments, [but] not any more so for hearing assistance than any other service,” and even that “many [WWP staff and warriors] reported that hearing evaluations and administering of services (aids, battery replacements, etc.) are one of the more expedited facets of the VAMC.” Another, however, cited “lag[s in service] universally around my region.” Such delays could certainly continue to grow as earlier generations of veterans age, and hearing impairments worsen.
While WWP has no position on H.R. 3508, we do believe VA has much more work to do – across a broad range of health care services – to address the adequacy of health care staffing and the timeliness (as well as the effectiveness) of its provision of services. We would encourage the Subcommittee to continue to press VA on these important issues.
Finally, we applaud the Subcommittee’s efforts to resolve the longstanding difficulty associated with authorizing major medical facility leases, and welcome the draft authorization bill being considered today.
Thank you for your consideration of our views.
 D. Yaeger, et al." DSM-IV Diagnosed Posttraumatic Stress Disorder in Women Veterans With and Without Military Sexual Trauma," 21(S3) J Gen Internal Medicine S65–S69 (2006)
 Rachel Kimerling, et al., “Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq,” 100(8) Am. J. Public Health, 1409-1412 (2010).
 M. Murdoch, et al., “Women and War: What Physicians Should Know,” 21(S3) J. of Gen. Internal Medicine S5-S10 (2006).
 U.S. Dept. of Veterans' Affairs and the National Center for PTSD Fact Sheet, “Military Sexual Trauma,” available at http://www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp.
 See Donna Washington, et al., “Women Veterans’ Perceptions and Decision-Making about Veterans Affairs Health Care,” 172(8) Military Medicine 812-817 (2007).
 VA Mental Health Care: Evaluating Access and Assessing Care: Hearing Before the S. Comm. on Veterans’ Affairs, 112th Cong. (Apr. 25, 2012) (Testimony of Nicholas Tolentino, OIF Veteran and former VA medical center administrative officer).
 VA Mental Health Care Staffing: Ensuring Quality and Quantity: Hearing Before the Subcomm, on Health of the H. Comm. on Veterans' Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole Sawyer, PsyD, Licensed Clinical Psychologist).
 VA Mental Health Care Staffing: Ensuring Quality and Quantity: Hearing Before the Subcommittee on Health of the H. Comm. on Veterans' Affairs, 112th Cong. (2012) (Testimony of Ralph Ibson), supra note 21.
 VA Office of Inspector General, “Audit of VA’s Hearing Aid Services,” 12-02910-80 (Feb. 20, 2014).