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Witness Testimony of Gerald M. Cross, M.D., FAAFP, Veterans Health Administration, Principal Deputy Under Secretary for Health, U.S. Department of Veterans Affairs

Good Morning Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me here today to present the Administration’s views on eight bills that would affect Department of Veterans Affairs (VA) programs that provide veteran health care benefits and services.  With me today is Walter Hall, Assistant General Counsel. 

H. R. 3819     Veterans Emergency Care Fairness Act of 2007

Mr. Chairman, the first bill I will discuss is H.R. 3819.  VA strongly supports this measure, which would amend sections 1725 and 1728 of title 38 to make mandatory, standardize, and enhance our authority to pay expenses incurred when a covered veteran receives previously unauthorized emergency treatment in a non-VA facility.  Those sections are currently discretionary (the Secretary “may reimburse” as opposed to “shall reimburse”), cover different veteran populations, and use different definitions of “medical emergency.”

Currently, the Secretary may reimburse or directly pay the reasonable value of non-VA emergency treatment of a service-connected disability, a non-service-connected disability aggravating a service-connected disability, any disability of a veteran with a permanent and total disability, or for a covered vocational rehabilitation purpose.  When such claims are filed, VA medical professionals must determine whether there existed an actual emergency of such nature that delay in obtaining treatment would have been hazardous to life or health.  Expenses incurred once the veteran had been stabilized and could have been transferred safely to VA or another Federal facility may not be reimbursed or paid.

The Secretary may also reimburse or pay for the reasonable value of expenses incurred by a covered veteran for non-VA emergency treatment where the treatment is sought for a non-service connected disability.  The statutory standard for determining whether the treatment was emergent is whether a prudent-layperson would have thought it reasonable to seek immediate medical attention.  This prudent-layperson standard means that if it turns out that the veteran’s condition was not an actual medical emergency, VA can still reimburse or pay the expenses.  This happens, for instance, when a veteran goes to the nearest emergency room believing a heart attack is underway but a severe case of heartburn is actually diagnosed.  As with claims for service-connected conditions, the Secretary is only authorized to reimburse or pay for the reasonable value of the emergency treatment, and the emergency is considered ended at the point the veteran could have been transferred safely to a VA facility or other Federal facility. 

H.R. 3819 would make it mandatory for the Secretary to reimburse or pay for the reasonable value of treatment for any veteran who meets eligibility criteria and would standardize the programs by applying the prudent-layperson definition of “emergency treatment” in both situations.  Most importantly, it would define “emergency treatment” as continuing until (1) the veteran could have been transferred safely to a VA or other Federal facility, or (2) a VA or other Federal facility agrees to accept such transfer if, at the time the veteran could have been transferred safely, the non-VA provider makes and documents reasonable attempts to transfer the veteran to a VA facility or other Federal facility.  While VA facilities work aggressively to accept the transfers once an emergency is stabilized, there have been cases where VA has been unable to find a facility that had the resources needed to furnish the care required.  In those rare cases, the veteran may ultimately be liable for post-emergency costs, imposing a serious monetary hardship.  The bill would appropriately foreclose this result.

Effective reimbursement or payment of emergency treatment has been an issue of concern to the Department.  HR 3819 appropriately resolves important billing issues, properly placing the financial onus on the Department to provide appropriate care either in the VA or Federal system or at a non-VA facility. 

VA determined funds were available within the FY2008 President's Budget level for this expanded benefit. 

As a technical matter, I would like to clarify that if a veteran currently meets the eligibility criteria on which the reimbursement or direct payment claim is based, VA invariably pays the claim.  Thus, changing the Secretary’s authority from “may” to “shall” for purposes of both types of claims would have no practical effect.   Nevertheless, we do not object to such a change. 

H.R. 4146      Emergency Medical Care for Veterans in Non-VA Facilities

H.R. 4146 would also amend section 1725 of title 38 to make clear that the determination as to whether a veteran can be transferred safely to a VA or other Federal facility is to be based both on the condition of the veteran and on the availability of a bed in a Department facility that is not geographically inaccessible to the veteran. 

We favor the approach in H.R. 3819, which would make the same definition of “emergency treatment” apply to claims filed pursuant to both section 1725 and 1728.  H.R. 4146 would amend only section 1725.  As a result, a greater benefit (i.e., VA reimbursement or payment of non-VA emergency treatment up until the point in time a VA bed is available for the eligible veteran) would be provided to veterans with non-service connected disabilities than is available to veterans under section 1728 for service-connected disabilities, a discrepancy that cannot be justified.  We therefore prefer the standardization of terms, and increased consistency in application, that H.R. 3819 would provide. 

H.R. 4053      Mental Health Improvements Act of 2007

Title I.  Substance Use Disorders and Mental Health Care

H.R. 4053 is the companion bill to S. 2162, on which the Department testified before the Senate Committee on Veterans’ Affairs this past October.  While we appreciate the attention given to the critical issues addressed in this bill, we cannot support its prescriptive approach of mandating forms of treatment, treatment settings, and composition of treatment teams. 

Section 102 would require the Secretary to ensure that, at each VA medical center and community based out-patient clinic (CBOC), available services would include, at minimum:  short term motivational counseling, intensive outpatient care, detoxification and stabilization, relapse prevention, ongoing aftercare and outpatient counseling, opiate substitution therapy, and pharmacological treatments aimed at reducing cravings for drugs and alcohol.  The Secretary could, however, exempt an individual medical center or CBOC from providing any of the otherwise required services, but the Secretary would have to report annually to Congress on the facilities receiving an exemption, including reasons for the exemption. 

Section 103 would require the Secretary to ensure concurrent VA treatment for a veteran’s substance use disorder and co-morbid mental health disorder by a team of clinicians and health professionals with expertise treating substance use and mental health disorders, in conjunction with other professionals as considered appropriate by the Secretary. 

Section 104 would mandate that the Secretary carry out a program to enhance VA’s treatment of veterans suffering from substance use disorders and PTSD through a competitive allocation of funds to VA facilities.  Funding awarded to a facility would be used for purposes specified in the bill, such as peer outreach programs through VA’s Vet Centers to re-engage veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) who miss multiple appointments for post-traumatic stress disorder (PTSD) or a substance use disorder.  These peer outreach programs would need to be done in tandem with efforts of CBOCs and PTSD and substance use disorder treatment teams in VA’s medical centers.  Funds would also be used for collaboration between VA’s urgent care clinicians and substance use disorder and PTSD professionals to ensure expedited referrals and for other specified purposes. 

Section 104 would further require the Secretary to allocate $50 million from appropriated funds available for medical care for each of fiscal years 2008, 2009, and 2010 to fund these programs; the Secretary would be required to submit a report to Congress within the first year regarding the program and the facilities for which funding had been allocated.  The bill would require the total expenditure for PTSD and substance use disorder programs to not be less than $50 million in excess of a specified baseline amount.  (The bill would define the baseline as the amount of the total expenditures on VA’s treatment programs for PTSD and substance use disorders for the most recent fiscal year for which final expenditure amounts are known, as adjusted to reflect any subsequent increase in applicable costs to deliver those programs.)

Section 105 would require the Secretary to establish not less than six national centers of excellence on PTSD and substance use disorders, to provide comprehensive inpatient treatment and recovery services to veterans newly diagnosed with these disorders.  Candidate sites would be restricted to VA medical centers capable of treating concurrent PTSD and substance abuse disorders and of providing inpatient care, and located in a geographical area with a high number of veterans diagnosed with both PTSD and substance use disorders.  This provision would also require the Secretary to establish a process to refer and aid the transition of veterans from these national centers to programs providing step down rehabilitation treatment. 

Section 106 would require the Secretary, acting through the Office of the Medical Inspector (OMI), to review all of VA’s residential mental health care facilities, including domiciliary facilities.  The OMI report must include a description of the care available in residential mental health care facilities in each Veterans Integrated Service Network; an assessment of the supervision and support provided in the VHA residential mental health care facilities; the ratio of staff members at each residential mental health care facility to patients at such facility; an assessment of the appropriateness of rules and procedures for the prescription and administration of medications to patients in such residential mental health care facilities; a description of the protocols at each residential mental health care facility for handling missed appointments; and any recommendations the Secretary considers appropriate for improvements to residential mental health care facilities.  The bill requires OMT to submit to Congress a detailed report with these specified findings.

Section 107 would provide for title I of this bill to be enacted in tribute to Justin Bailey, an OIF veteran who died while under VA treatment for PTSD and a substance use disorder. 

VA does not support enactment of this title.  Title I is overly prescriptive and would attempt to mandate the type of treatments to be provided to covered veterans, the treatment settings, and the composition of treatment teams.  Treatment decisions should be based on professional medical judgments in light of an individual patient’s needs, and experienced health care clinicians and managers are in the best position to decide how best to deliver needed health care services at the local level.  It is more consistent with the principles of patient-centered medicine, as well as more efficient, to focus on making these services available to patients who require them, as opposed to requiring every VA facility to provide these services.

We are also concerned that section 104 would require all the competitively funded peer outreach services to be furnished through VA’s Vet Centers.  This would make Vet Centers reliant on the medical centers to provide funding needed to meet the peer outreach requirements of this program.  Vet Centers generally receive their funding apart from the medical centers.  And we do not support section 105.  VA has previously expressed its difficulties with the concept of centers of excellence as opposed to the achievement of an overall standard of delivery of excellent care on a national basis; this provision is also overly restrictive and prescriptive.  I refer you to the concerns VA has previously expressed regarding disease-specific treatment centers and models.  Finally, section 106 would impose extremely onerous and time-consuming requirements on the OMI, which would overwhelm that office’s capacity to meet its responsibility to oversee and investigate the quality of care furnished in all lines of service throughout the VA system—an absolutely vital function within the Veterans Health Administration.  To meet the mandate, the Department would have to expand that office significantly.  The OMI should be focused on its general mission, not on the narrowly focused duties set forth in section 106.

Title II.  Mental Health Accessibility Enhancements

Section 201 of H.R. 4053 would require that, within six months after enactment of the bill, the Secretary establish a three-year pilot program to assess the feasibility and advisability of providing eligible OIF/OEF veterans, particularly those from the National Guard or Reserve, with services including peer outreach and support, specified readjustment counseling, and other mental health services.  Eligible veterans would include those who are enrolled in VA’s health care system and who, for purposes of the pilot program, receive a referral from a VHA health professional to a community mental health center or to a facility of the Indian Health Service (IHS).

In providing readjustment counseling services and other mental health services to rural veterans lacking access to comprehensive VA mental health services, section 201 would require the Secretary, acting through the Office of Rural Health, to contract for those services with community mental health centers (as defined in 42 CFR §410.2) and/or IHS facilities.   

Sites for the pilot must include at least two Veterans Integrated Service Networks selected by the Secretary (VISNs).  At least two of the sites would have to be located in rural areas that lack access to comprehensive VA mental health services.  A participating community mental health center or IHS facility would be required, to the extent practicable, to provide readjustment counseling and other mental health services through the use of telehealth services.  It would also need to utilize best practices and technologies and to meet any other requirements established by the Secretary and would have to comply with applicable VA protocols before incurring any liability on behalf of the Department.  It would further be required to provide clinical information on each veteran treated, as required by the Secretary. 

The Secretary would be required to carry out a national program of training for (1) veterans to provide peer outreach and peer support services under the pilot program; and required training for (2) clinicians at community mental health centers or IHS facilities to ensure they could furnish covered services in a manner accounting for factors unique to OEF/OIF veterans’ experiences, including combat and military training experiences.  This provision would also establish detailed annual reporting requirements for participating centers and facilities. 

Mr. Chairman, all of these services are already available to OEF/OIF veterans, including those who served in the National Guard or the Reserves.  No demonstrated need exists for the pilot program or these additional authorities, which are duplicative of currently existing authorities.  It is also unclear to us how the peer outreach services to be provided under section 201 relate to the peer outreach program that would be established by section 104.

As to the requirement to contract with a community mental health center or IHS facility, VA has previously expressed a concern that imposition of such a requirement may inadvertently reduce the opportunity for a veteran to receive care from the most highly qualified contractor.  Additionally, it is most often the case that when VA lacks capacity to provide mental health services in a certain rural area, the same situation exists for the community mental health centers and IHS facilities.  IHS facilities, staff, and other resources should be focused on American Indians and Alaska Natives.  VA and IHS have a Memorandum of Understanding (MOU) that provides the appropriate framework for cooperative ventures within the capacities of each of our two agencies, using that MOU and our current flexibilities to contract with the most appropriate provider when VA is not able to provide necessary services is the most effective way of assuring that rural veterans get the care they need.  

Title III.  Research

Section 301 of H.R. 4053 would require the Secretary, through the National Center for PTSD, to carry out a program of research into co-morbid PTSD and substance use disorder, including coordination of research and data collection and dissemination.  The bill prescribes that the research address: co-morbid PTSD and substance use disorder; systematic integration of treatment for the disorders; and development of protocols to evaluate care of veterans with co-morbid disorders and to facilitate the cumulative clinical progress of such veterans.   Section 301 would authorize $2 million to be appropriated for each fiscal year 2008 through 2011 to carry out this program and specifically require the funds be allocated to the National PTSD Center in addition to any other amounts made available to it under any other provision of law.

Section 302 would continue the Special Committee on PTSD (which is established within VHA) through 2012; otherwise the Committee’s mandate would terminate after 2008.  VA strongly supports continuing the Special Committee.

With the exception of the extension of the Special Committee, VA does not support the provisions in title III.  VA is a world-recognized leader in the care of PTSD and substance use disorders, particularly when these conditions co-exist.  Please note that the recent scientific literature review by the Institute of Medicine did not find that VA’s treatments for PTSD other than Cognitive Processing Therapy (CP Therapy) and Prolonged Exposure Therapy (EP Therapy) were not efficacious; rather, the IOM concluded that the scientific literature did not show that the other therapies used by VA met its standard for unequivocally and conclusively demonstrating their efficacy in the treatment of PTSD.  The activities required by title III are also redundant of VHA’s on-going efforts, particularly of the research efforts being carried out by VA’s National PTSD Center.  We would welcome the opportunity to brief the Committee on VA’s achievements and efforts in this area, along with the role of the Office of Mental Health in overseeing the PTSD and substance abuse programs.

Title IV.  Assistance for Families of Veterans

In connection with the family support services authorized in chapter 17 of title 38, United States Code (i.e., mental health services, consultation, professional counseling, and training), section 401 would amend the statutory definition of “professional counseling” to expressly include “marriage and family counseling.”  This provision would also ease eligibility requirements for such services by authorizing their provision when “appropriate” (as opposed to “essential”) for a veteran’s effective treatment and rehabilitation.  Section 401 provides for that these services to be available to family members in VA medical centers, Vet Centers, CBOCs, or in other facilities the Secretary considers necessary.  Currently, these family support services are restricted to care provided in inpatient care settings.

Section 402 would require the Secretary to carry out, through a non-VA entity, a three-year pilot program to assess the feasibility and advisability of providing “readjustment and transition assistance” to veterans and their families in cooperation with Vet Centers.  Readjustment and transition assistance would be defined as preemptive, proactive, and principle-centered, and would include assistance and training for veterans and their families in coping with the challenges associated with making the transition from military to civilian life.  This provision would require the pilot program be furnished pursuant to an agreement between the Secretary and any for-profit or non-profit organization the Secretary selects as having demonstrated expertise and experience providing the designated services.  The pilot program would be carried out in cooperation with 10 geographically-distributed Vet Centers, which would be responsible for promoting awareness of the assistance available to veterans and their families through the Vet Centers, the entity selected to conduct the pilot, and other appropriate mechanisms.  Section 402 would establish detailed reporting requirements and authorize $1 million to be appropriated for each of fiscal years 2008 through 2010 to carry out the pilot program.  Such amounts would remain available until expended.

VA does not support title IV.  It is unclear how these “readjustment and transition assistance” services are intended to differ from, or interact with, the readjustment counseling services and related mental health services already available to veterans and their families through our Vet Centers.  The provision conflicts in many respects with VA’s existing authorities to provide readjustment counseling and related mental health services and creates confusion, especially regarding client outreach, in what is currently a highly successful program.  (Indeed, the 98 percent rate of client satisfaction with the Vet Centers is the highest of all VA’s programs.) 

We also do not understand the implied need for use of a non-VA organization for provision of these services.  Vet Centers already provide marriage and counseling services to family members as necessary to further the veteran’s readjustment.  Let me assure you that, when necessary, our Vet Centers readily contract with appropriate organizations and providers to ensure veterans and their families receive covered family support services.  In sum, this provision would not effectively enhance current authorities or Vet Center activities; rather, we see that it has serious potential to create confusion and disruption for both VA and our beneficiaries.  

If the purpose of section 402 is to authorize readjustment and transition assistance services for family members that are other than those required for the veteran’s successful readjustment, we would object.  In contrast to the situation with veterans, if during the provision of readjustment counseling services, Vet Center staff identify a family member’s need for more complex mental health care services or other medical care that is not in furtherance of the veteran’s recovery or readjustment, VA can neither refer the family member to a VA facility for such care nor refer that family member to a non-VA provider. Consequently, both our Vet Center staff and the affected family member would be placed in an untenable position.

H. R. 4231     Rural Veterans Health Care Access Act of 2007

Mr. Chairman, VA strongly opposes H.R. 4231, which would require the Secretary to implement a five-year pilot program using a voucher system to pay for mental health counseling at non-VA facilities for eligible OEF/OIF veterans.  Those eligible for this benefit are veterans eligible to receive hospital care and medical services under section 1710 of title 38, United States Code, who also:  served on active duty in support of a contingency operation (as defined in section 101(13) of title 10, United States Code); are diagnosed with a mental health condition for which a certified mental health provider recommends mental health counseling; and reside at least 30 miles from a VA medical facility employing a full-time mental health professional. 

Under the pilot program, the Secretary would compile and maintain a list of mental health providers, including family counseling providers, who agree to accept a voucher as payment in full for counseling services furnished to the veteran bearing the voucher and to accept VA payment at the rates specified in the bill.  Providers would be required to comply with all applicable VA protocols.  H.R. 4231 would also permit an eligible veteran to use these vouchers as payment in full for visits to a family counseling provider (on the list) if a certified mental health provider or the Secretary recommends that the veteran and the veteran’s family receive family counseling. 

Once requested by an eligible veteran, the Secretary would be required to issue a six-month supply of vouchers within 30 days.  An additional six-month supply of vouchers could be provided.  To receive payment under a voucher, following provision of mental health or family counseling services, the provider would submit a voucher bearing the signatures of the provider and the veteran. 

Prior to the pilot program’s expiration, the Secretary would be required to conduct a study of its effectiveness and, based on that study, recommend whether the program should be extended or expanded.  If the Secretary determines it should be extended or expanded, H.R. 4231 would authorize the Secretary to take such action.

VA strongly objects that as now drafted the bill would permit a veteran with a diagnosed mental health condition to be eligible for individual and family counseling services under the program based on a non-VA provider’s recommendation.  Without exception, a recommendation for a veteran’s receipt of mental health counseling services by a non-VA provider should be made only by the appropriate Department mental health professional.  This is necessary to ensure a continuum of care for the veteran as well as appropriate coordination and oversight of all the medical services furnished to the veteran.  This would also lessen any potential for self-referrals and conflicts of interest by participating providers.  

Second, this bill would result in fragmentation of care. Vouchers would be available only for some types of care (mental health counseling) but the bill does not address their possible need for biomedically-based mental health services and evidence-based psychotherapy.  H.R. 4231 could also lead to further barriers in integrating mental health services with other components of care and to the delivery of evidence-based interventions for mental health conditions. 

The Office of Rural Health (ORH) is currently collaborating across VHA to develop policies and practices that expand and adapt current initiatives, and to develop new models of care delivery that may be most appropriate for rural veterans. 

More importantly, ORH will leverage the VHA’s capabilities to develop partnerships with governmental and non-governmental entities to provide the best solutions to the challenges that rural veterans face and enhance the delivery of care by creating greater access, engaging in research, promulgating best practices and developing sound and effective policies to support the unique needs of enrolled veterans residing in geographically rural areas. 

Lastly, we note the bill does not provide any criteria for determining the need or scope for family counseling services, whereas, it limits a veteran’s eligibility to counseling services needed to treat the diagnosed mental health condition. 

We further note the distance requirement would not limit this benefit to veterans residing in rural areas because those in many urban settings would likewise meet this requirement.   

H.R. 2790      Director of Physician Assistant Services

H.R. 2790 would re-title the position of VHA’s “Advisor on Physician Assistants” to “Director of Physician Assistant Services.”  This change in position title would appear to raise the incumbent and this discipline to the same level as VHA’s other directors and lines of service.  The bill would also expand the statutory duties of the position to require the incumbent to report to the Under Secretary for Health on all matters relating to the education and training, employment, appropriate utilization, and optimal participation of physician assistants within VA programs and initiatives.  Finally, it would also require the incumbent to serve full-time and be located with the VA Central Office. 

The current field-based Advisor position was established in 2000 and is successfully meeting the bill’s objectives.  Nonetheless, we do not object to the change in position title, although we note that Physician Assistant services do not constitute an actual service line.  We do object to the provision in the bill that would restrict the locus of the position to VA Central Office.  VA derives significant benefits from having the flexibility to use field-based clinicians in this and similar positions.  Often the best candidates for such positions do not wish to give up their clinical duties entirely and relocate to Washington.  It is also valuable for us to keep this position as a dual, as opposed to a full-time, role to enhance the incumbent’s effectiveness by maintaining a “hands-on” approach and front-line perspective.  We estimate the cost of converting this position to one that is full-time would be $34,252 for fiscal year 2008 and $413,151 over a ten-year period.

H.R. 4204      Veterans Suicide Study Act

H.R. 4204 would require the Secretary to conduct a study to determine the number of veterans who have committed suicide between January 1, 1997, and the date of the bill’s enactment.  The study would have to be carried out in coordination with the Secretary of Defense, Veterans Service Organizations, and State public health offices and veterans agencies.  The bill would require the Secretary to submit a report to Congress on his findings within 180 days of the bill’s enactment. 

We do not believe the study required by this bill would generate information that would further our understanding of how to effectively screen and treat veterans who may be at risk of suicide.  It would merely provide us with the rates for this cohort of veterans.  VA has studied suicide rates for multiple cohorts of veterans and, through such efforts, has already identified the major clinical risk factors for suicide.  (In fact, we recently completed such a study for OEF/OIF veterans that we discussed at a recent hearing before the full House Committee on Veterans’ Affairs.  Using the data generated from those studies, we have developed protocols and processes to mitigate those risk-factors.  For these reasons, we do not support section 103. 

Further, certain requirements mandated by the bill make itsimplementation notfeasible.  As now drafted, it would not afford VAthe flexibility needed to develop a thorough and useful study.  To design and carry out a study that is best designed to provide usable information to address the issue of veteran suicide rates, we believe the Secretary (not Congress) should determine the organization(s) with which the Department should coordinate the study.  For instance, CDC currently studies suicide rates among the general population, while VA’s role has been to validate the information compiled by CDC.

Additionally the 180-day timeframe is not realistic, as there is currently a two-year time lag in the information released by CDC on suicide rates.  We would be glad to brief the Committee on study designs we believe would be more feasible and would better serve its ends.  We estimate the cost of this bill to be $1,580,006 in fiscal year 2008 and $2,078,667 over a ten-year period.

H.R. 3458      Pilot Program on Traumatic Brain Injury Care in Rural Areas

Mr. Chairman, H.R. 3458 would require VA to carry out a five-year pilot program to enhance care to veterans with traumatic brain injury (TBI) in five rural states (selected by the Secretary) in consultation with VA’s Office of Rural Health.  VA would be required to assign a VA case manager to each VA patient diagnosed with TBI.  The bill would further direct the Secretary to take specific actions in the pilot program states, including:

  • providing training to the assigned case managers, including coordinating with non-Department medical facilities, as appropriate, for such training;
  • determining an appropriate ratio of patients with TBI per case manager to ensure proper and efficient treatment;
  • seeking contracts with private health care providers in any area where no VA medical facility is easily accessible to TBI-diagnosed residents, with the independent contractors to be reimbursed by VA; and
  • providing updated information on the treatment of TBI to such private healthcare providers as have contracted with VA under the bill.

We do not support H.R. 3458 because it is not necessary.  A number of TBI initiatives have been developed and implemented by VA under current authorities, including programs that address the issue of case management.  In determining to provide care directly or by contract, VA considers not only local capacity and staffing issues but also the needs of the individual veteran and his or her family.  

In our view, the bill would also establish a troubling precedent by establishing contract authority separate from our fee-basis contracting authority in chapter 17 of title 38, United States Code, for the treatment of a single condition/type of injury.  These typically are very complex medical cases involving co-morbidities.  Treatment of TBI and TBI related conditions cannot easily be singled out from other conditions requiring simultaneous medical attention.  That is, TBI cannot be treated in a vacuum.  For that reason the bill has potential to fragment care for the veteran population that most needs to receive its VA health care in a well-coordinated manner with continuous monitoring and oversight.  We also note the number of eligible veterans covered by the bill is potentially great, because this bill is not limited to TBI due to injuries sustained during service in combat operations. 

Since the time this bill was introduced on August 4, 2007, each VA facility has put into place an OEF/OIF case management program for severely injured OEF/OIF members.  In October of 2007, VA established the Care Management and Social Work Service to ensure that each VA facility has an appropriate treatment team caring for these veterans (to include a program manager, clinical case manager(s), transition patient advocate, and a VBA OIF/OEF liaison).  All enrolled severely injured service members receive screening for TBI, and any OEF/OIF veteran who requests case management services may receive them. 

H.R. 4107      Women Veterans Health Care Improvement Act

Title I.  Studies and Assessments of Department of Veterans Affairs Health Services for Women Veterans

In general, title I of H.R. 4107 would require VA to conduct a number of studies related to health care benefits for women veterans.  More specifically, section 101 would require VA, in collaboration with VHA’s War-Related Injury and Illness Study Centers, to contract with one or more qualified entities or organizations to conduct an epidemiologic cohort (longitudinal) study on the health consequences of combat service of women veterans who served in OEF/OIF.  The study would need to include information on their general, mental, and reproductive health and mortality.  The bill would require VA to use a sufficiently large cohort of women veterans and require a minimum follow-up period of ten years.   The bill also would require VA to enter into arrangements with the Department of Defense (DoD) for purposes of carrying out this study.  For its part, DoD would be required to provide VA with relevant health care data, including pre-deployment health and health risk assessments, and to provide VA access to the cohort while they are serving in the Armed Forces. 

Section 102 of the bill would require VA to contract with a qualified independent entity or organization to carry out a comprehensive assessment of barriers encountered by women veterans seeking comprehensive VA health care, especially for those who served in OEF/OIF.  In carrying out this study, the bill recommends VA survey women veterans who seek or receive VA health care services as well as those who do not.  Section 102 would also set forth specific elements to be researched as part of the study.  They include the following:

  • Perceived stigma with respect to seeking mental health care services.
  • Driving distance or availability of alternate transportation to the nearest appropriate VA facility on access to care.
  • Availability of child care.
  • Acceptability of integrated primary care, or with women’s health clinics, or both.
  • Comprehension of eligibility requirements for, and the scope of services available under, such health care.
  • The quality and nature of the reception by providers of such health care and their staff of the veteran.
  • The perception of personal safety and comfort of women veterans in inpatient, outpatient, and behavioral health facilities of the Department.
  • Cultural sensitivity of health care providers and staff to issues that particularly affect women.
  • Effectiveness of outreach for health care services available to women veterans.
  • Other significant barriers identified by the VA Secretary.

Once the assessment is completed, the Secretary would be required to ensure the head of the Center for Women Veterans and the Advisory Committee on Women Veterans (as well as any other pertinent VA program offices) review the results of the study and submit their own findings with respect to it.  The Secretary would need to include these findings in the Congressional report required under this section.  

Section 103 would require VA to conduct a comprehensive assessment of all VA health care services and programs for women veterans.  In particular, the assessment would need to address specialized programs for women with PTSD, homeless women, women requiring care for substance abuse or mental illnesses, and those requiring pregnancy care.  In conducting this study, VA would be required to determine whether effective health care services, including evidenced-based health care services, are readily available to and easily accessed by women veterans in areas of health promotion, disease prevention and health care.  The determination would need to be based on the following factors:  frequency with which such services are available and provided; demographics of the women veterans population; sites where such services are available and provided; and whether, and to what extent, waiting lists, geographic distance, and other factors obstruct the receipt of any of such services at any such site. 

In response to the comprehensive assessment, section 103 would further require VA to develop a program to improve the provision of health care services to women veterans and to project their future health care needs (including mental health care) and, particularly, those of women serving in the OEF/OIF combat theaters.  In so doing, VA would have to identify the services available under each program at each VA medical center and the projected resource and staffing requirements needed to meet the projected workload demands. 

Section 103 would also require VA to submit, not later than one year after the bill’s enactment, a report to the Congress on the conduct of this assessment.  The Comptroller General of the United States would then be required to review VA’s report and to submit to Congress its own report on the Department’s findings, together with any recommendations for administrative or legislative action.  

Mr. Chairman, we do not believe section 101 is needed because a longitudinal study is already underway.  Therefore, VA does not support this provision.  For several years veterans, VA, and Congress have been concerned with identifying possible war-related illnesses among returning women veterans, including adverse effects on reproductive health.  To that end, in 2007, VA initiated its own 10-year study, the “Longitudinal Epidemiologic Surveillance on the Mortality and Morbidity of OIF/OEF Veterans including Women Veterans.”  Several portions of the study mandated by section 101 are already incorporated into this project; however, to comply fully, we will need to increase the number of women veterans in the original longitudinal study.  We already have a proposal before the Under Secretary for Health to adjust the number of study participants accordingly. 

Mr. Chairman, section 101(c) of H.R. 4107 would be objectionable because it requires the DoD to provide health data on active-duty women, as well as "access to the cohort of such women while serving in the Armed Forces. This provision could require active-duty women to participate in a VA survey while still in the military.   It also could require the DoD to provide private medical information before separation.

Similarly we do not believe section 102 is necessary because a similar comprehensive study is already underway.  VA contracted for a “National Survey of Women veterans in FY 2007-2008,” which is a structured survey based on a pilot survey conducted in VISN 21.  This study is examining barriers to care (including access) and includes women veterans of all eras of service.  Additionally, it includes women veterans who never used VA for their care and those who no longer continue to use VA for their health care needs. 

Section 103 would require a very complex and costly study.  While we maintain data on veteran populations receiving VA health care services that account for the types of clinical services offered by gender, we lack current resources to carry out such a comprehensive study within a one-year time-frame.  We would therefore have to contract for such a study with an entity having, among other things, significant expertise in evaluating large health care systems.  This is not to say that such a comprehensive assessment is not needed and we recognize there may well be gaps in services for women veterans, especially given that VA designed its clinics and services based on data when women comprised a much smaller percentage of those serving in the Armed Forces.  (Since the 1950s, the number of women veterans using VA services has averaged between 3-5% of all veterans.  With women now representing 5 % of all veterans using VA, and 38.9% of OEF/OIF returning women veterans using VA for their health care needs, it is incumbent on us to identify gaps in services and in availability of gender-related services.)  VA’s Strategic Health Care Group for Women Veterans already studies and uses available data and analyses to assess and project the needs of women veterans for the Under Secretary for Health.  The study required by section 103 would unacceptablydivert significant funding from direct medical care. 

We estimate the costs of section 101 to be $2,327,503 in fiscal year 2008 and $10,857,000 over a ten-year period.  We estimate no costs for section 102 because VA’s own comparable study is underway, with $975,000 in funding committed for fiscal years 2007 and 2008.  Section 103 would have a cost of $4,354,000 in fiscal year 2008.

Title II. Improvement and Expansion of VA Health Care Programs for Women Veterans

Section 201, titled “Improvement of Sexual Trauma Care Programs of the Department of Veterans Affairs,” would require VA to train all mental health professionals who provide services to veterans under that program and to ensure such training is done in a consistent manner that includes principles of evidenced-based treatment.  Section 201 would also require VA to train primary care providers in screening and recognizing the symptoms of Military Sexual Trauma (MST) and to ensure procedures exist for prompt referral of these veterans to appropriate mental health professionals.  The provision recommends that VA’s care and services for MST include the services of therapists who are qualified to provide counseling and who demonstrate an understanding of the burden experienced by former service members who experience both combat and MST. 

Section 201 would also require VA to establish staffing standards used at VA health care facilities for full-time equivalent employees trained to provide treatment for conditions related to MST.  These standards would need to ensure availability of services, and access to MST treatment, for all veterans seeking this care.  This provision would also establish detailed reporting requirements for the Department.

We do not support the training-related requirements of section 201 because they are not necessary.  In Fiscal Year 2007, VA funded a Military Sexual Trauma Support Team, whose mission is, in part, to enhance and expand MST-related training and education opportunities nationwide.  VA also hosts an annual four-day long training session for 30 clinicians in conjunction with the National Center for PTSD, which focuses on treatment of the after-effects of MST.  VA also conducts training through monthly teleconferences that attract 130 to 170 attendees each month.  Recent topics included overviews of several commonly used evidence-based treatment protocols (e.g., protocols for CP Therapy, PE Therapy, and Acceptance and Commitment Therapy).  VA has also recently unveiled the MST Resource Homepage, a webpage that services as a clearinghouse for MST-related resources such as patient education materials, sample power point trainings, provider educational opportunities, reports of MST screening rates by facility, and descriptions of VA policies and benefits related to MST. It also hosts discussion forums for providers.  In addition, VA primary care providers screen their veteran-patients, particularly recently returning veterans, for MST, using a screening tool developed by the Department.  We are currently revising our training program to further underscore the importance of effective screening by primary care providers who provide clinical care for MST within primary care settings. 

We object strongly to the provision in section 201 that would require VA to establish staffing standards for this program.  Staffing-related determinations must be made at the local level based on the identified needs of the facility’s patient population for MST treatment and services, workload, staffing, and other capacity issues.  Imposition of national staffing standards would be an utterly inefficient and ineffective way to manage a health care system that is dynamic and experiences continual changes in workload, utilization rates, etc. 

Section 202 would require VA, through its National Center for PTSD, to develop and implement a plan for developing and disseminating information regarding effective treatments, including evidence-based treatments, for women veterans with PTSD and other co-morbid conditions.  The plan would need to include a proposed timetable for the dissemination to all VA facilities, but in no case could dissemination occur later than one year after the bill’s enactment.  Section 202 would also require the plan to include any proposed additional resources needed to provide MST training and MST counseling and treatment.  The measure would establish detailed reporting requirements, as well. 

VA does not support section 202 because it is duplicative of activities already underway by the Department.  VA is strongly committed to making state-of-the-art, evidence-based psychological treatments widely available to veterans and this is a key component of VA’s Mental Health Strategic Plan.  We are currently working to disseminate evidence-based psychotherapies for a variety of mental health conditions throughout our health care system.  There are also two programs underway to provide clinical training to VA mental health staff in the delivery of certain therapies shown to be effective for PTSD, which are also recommended in the VA/DoD Clinical Practice Guidelines for PTSD.  Each training program includes a component to train the professional who will train others in this area, to promote wider dissemination and sustainability over time.

Section 203 would require VA to conduct a study of the Vet Centers’ capacity to provide services for women veterans and to determine their capacity to provide a sufficient scope and intensity of services.  Once completed, the Secretary would have to develop a plan to ensure that adequate counseling and mental health services for women veterans are available at each Vet Center, taking into account their specialized needs. 

We do not support section 203 because it is not necessary and is duplicative of VA’s on-going activities in this area.  VA’s Vet Center program is one of VA’s best-received programs as it currently exists, and it already provides the services sought by this subsection.  We would be glad to brief the Committee on all of our activities, particularly our extensive outreach efforts and the significant expansion now underway to increase capacity (both in terms of staff and new facilities).

Section 204 would require VA, not later than six months after the bill’s enactment, to carry out a two-year pilot program to furnish child-care services (directly or indirectly) to eligible women veterans receiving certain services through the Department.  Sites for the pilot program must include at least three VISNs.  Child care could only be provided for the period of time that the eligible veteran receives covered services at a Department facility and is required to travel to and from the facility for those services.  Eligible veterans would include women veterans who are the primary caretaker of a child (or children) and who are receiving one or more of the following health care services: regular or intensive mental health care services, or such other types of intensive health care services for which the Secretary determines the provision of child care would improve access to those services.  Moreover, under section 204, VA could provide the covered child care services through a variety of means, i.e.,  stipends offered by child care centers (directly or by voucher system), the development of partnerships with private agencies, collaboration with other Federal facilities or program, or the arrangement of after school care.  Section 204 would authorize $1.5 million to be appropriated for each year of the pilot and establish Congressional reporting requirements. 

VA does not support section 204.  Although we understand that the lack of available child care services can pose a barrier to access to care for some of our veterans, providing child care services –either in house or through other arrangements--would divert funds and resources from our primary mission of providing direct patient care.  We note that private health care facilities do not generally provide these services.  Section 204 also unjustifiably discriminates against male veterans who, but for their sex, would otherwise meet the eligibility criteria.  We estimate the cost of section 204 to be $500,000 in fiscal year 2008 and $2,500,000 in fiscal year 2009.

Section 205 would require VA to establish a two-year pilot program to evaluate the feasibility and advisability of providing counseling and transition adjustment assistance for newly separated women veterans that is conducted in a group retreat setting for as long as the Secretary deems is needed to be effective.  Participation in the program would be voluntary and would not require a referral from any provider.  Section 205 provides that the counseling services would be individually tailored to the participants’ specific needs, and they could include some or all of the following types of counseling:   mental health, family and marital, role and relationship, substance use disorder, or other counseling services determined to be necessary to assist the veteran before final repatriation with her family.  Section 205 would also authorizes $2 million for each year of the pilot, and require VA to submit a detailed report to Congress within six months of the pilot’s completion. 

VA does not support section 205.  We find the intent of the legislation confusing in that it would require that counseling be at the same time provided in a group setting but specifically tailored to the individual needs of each participating veteran.  We know that counseling services provided in group therapy sessions are not appropriate or effective for all veterans and/or certain mental health conditions.  Determination of the appropriate treatment milieu for each veteran should be based on the clinical judgment of a trained VA professional and should not be mandated—even as a pilot program.  Likewise, we object to the precedent of permitting patients to self-refer for medical care.  The need for these services should be made by the appropriate VA professional who can ensure they are medically appropriate and necessary.  Moreover, the veterans participating in the pilot may assume in error that their medical and counseling problems can be completely resolved through this program with no need for future VA services.  We note that VA has a number of counseling and transition adjustment programs underway to meet the needs of newly discharged/separated women veterans.

Finally, section 206 would require the Department’s Advisory Committee on Women Veterans, created by statute, to include women veterans who are recently separated veterans.  It would also require the Department’s Advisory Committee on Minority Veterans to include recently separated veterans who are minority group members.  (It is noted that section 206 contains a typographical error, as the Advisory Committee on Minority Veterans was established by section 544 of title 38, United States Code, not section 542.)  These requirements would apply to committee appointments made on or after the bill’s enactment. 

We support section 206.  Given the expanded role of women and minority veterans serving in the Armed Forces, the Committees should address the needs of these cohorts in carrying out their reviews and making their recommendations to the Secretary.  Having the perspective of those who have recently separated would enable the Committees to, among other things, project the future needs of these veteran-groups. 

This concludes my prepared statement.  I would be pleased to answer any questions you or any of the members of the Subcommittee may have.