Joint Hearing of the Committee on Homeland Security and Governmental Affairs of the U.S. Senate and the Committee on Veterans’ Affairs of the U.S. House of Representatives at 1:00 p.m. CDT.
Witness Testimony of RADM Thomas Carrato, USPHS (Ret.) President, Health Net Federal Services
Biography of RADM Thomas Carrato, USPHS (Ret)
Thomas Carrato is President of Health Net Federal Services, responsible for the daily leadership and management of Health Net’s Government Services Division. His responsibilities include the management and oversight of Health Net’s Department of Defense and Department of Veterans Affairs lines of business to include the DoD’s TRICARE program for the North Region and the worldwide Military & Family Life Counseling contract.
Mr. Carrato has over 30 years of experience, success and accomplishments in both the public and private health care sector as senior executive, chief operating officer and clinician. He served as Assistant Surgeon General of the United States, Regional Health Administrator for the U.S. Department of Health and Human Services, Deputy Assistant Secretary of Defense for Health Plan Administration, and Group Vice President for a publicly traded government services company. Mr. Carrato joined Health Net in March 2006 as Vice President and DoD Program Executive.
Previously, Mr. Carrato served as Deputy Assistant Secretary of Defense for Health Plan Administration and Executive Director of the TRICARE Management Activity where he directed and managed worldwide operations and performance of the TRICARE health plan. In an earlier role as the Department of Health and Human Services’ Regional Health Administrator for Region IV, Mr. Carrato was the Department’s principal representative, providing advice and participating in policy development and implementation of key health care initiatives in the southeastern United States. He managed regionally based programs of the Office of Public Health and Science including the Offices of Emergency Preparedness, Minority Health, Women’s Health, and Population Affairs.
Mr. Carrato holds a Master of Science in Accounting from Georgetown University and is a licensed Certified Public Accountant. In addition, he holds a Master of Social Work from the University of South Carolina and is a licensed clinical social worker.
Mr. Carrato, retired as a Rear Admiral in the Commissioned Corps of United States Public Health Service. His decorations include the Defense Distinguished Service Medal and the Public Health Service Distinguished Service Medal.
A Partnership History
Chairman Miller, Ranking Member Filner and Members of the Committee, I appreciate the opportunity to testify on Veterans’ access to mental health care services.
Health Net is proud to be one of the largest and longest serving health care administrators of government and military health care programs for the Departments of Defense (DoD) and Department of Veterans Affairs (VA).
In partnership with DoD, Health Net serves as the Managed Care Support Contractor in the TRICARE North Region, providing health care and administrative support services for three million active duty family members, military retirees and their dependents in 23 states. We also deliver a broad range of customized behavioral health and wellness services to military services members and their families, including Guardsmen and reservists. These services include the Military Family Life Counseling (MFLC) Program providing non-medical, short-term problem solving counseling, financial counseling, rapid response counseling to deploying units, victim advocacy services, and reintegration counseling.
In collaboration with VA, Health Net supports Veterans’ physical and behavioral health care needs through Community Based Outpatient Clinics and the Rural Mental Health Program. The Rural Mental Health Program was launched by VA in 2010 to provide access to community mental health services in select rural counties in three Veterans Integrated Service Networks (VISNs). Health Net delivers these services for VA in VISNs 19 and 20.
While helping VA meet the needs of Veterans, Health Net also has collaborated with VA in its efforts to ensure efficiency in the non-VA care (Fee) program, helping VA save and recover millions of dollars since 1998. The monies recovered through these programs (less program expenses) are available to provide or enhance services for our nation’s Veterans.
Health Net also is proud to support a number of VA’s national sports and rehabilitation programs, such as the Disabled Veterans Winter Sports Clinic and the National Veterans Summer Sports Clinic. At the summer clinic, we provide behavioral health coaches who conduct education sessions designed to help Veterans take what they learn at the summer clinic home with them and apply it to their everyday lives.
It is from this long-standing commitment to serving service members, Veterans and their families that we offer our thoughts on addressing Veteran access to mental health services.
Call to Action
According to the Department of Veterans Affairs, the number of Veterans seeking mental health services has climbed by a third. VA faces a significant challenge with respect to providing access to care with more and more service members returning from Iraq and Afghanistan with mental health issues stemming from their military service. It is imperative that Veterans receive care in a timely manner. With the rising tide of suicides, access to timely care can mean the difference between life and death. Untreated mental illness impacts overall health and reintegration into the community, as well as the long term security, productivity, and well-being of this generation of Veterans, their families, and their communities. Chairman Miller, as you stated in a recent news release, “These are wounds that cannot wait.”
As this committee knows, the VA Office of Inspector General (OIG) recently released a report that was critical of VA’s methods for recording patient wait times for both initial and follow up mental health visits, as well as its ability to provide access to these services in a timely manner. VA has been quick to respond to the April 2012 OIG report. Likewise, we understand the urgency of the situation identified in the OIG report and the need for a prompt response.
Addressing the dramatic increase in the demand for VA mental health services is challenging. Clearly, the demand has stretched VA’s capacity to its limits. We appreciate VA’s efforts to enhance capacity for the unique care needs of today’s Veterans and respect its leadership in developing comprehensive guidelines for ensuring clinical quality, particularly in the area of Post Traumatic Stress Disorder (PTSD).
VA has led in the validation of evidence-based treatment and, in collaboration with the DoD, in the development of clinical practice guidelines and provider educational materials addressing PTSD. VA also has taken steps to address access and to reduce the stigma associated with seeking these services. The DoD and VA are both actively training behavioral health providers in the delivery of these treatment modalities, and the VA has endeavored to make evidence-based mental health services available to Veterans across the range of treatment settings.
Based on current services we provide to VA, as well as the DoD, we believe there are ready approaches to address this urgent need quickly and effectively. Moreover, these proven solutions for addressing both short-term and ongoing access issues can be performed without sacrificing clinical excellence which is so appropriately a priority for VA.
Access Pressure Points
The demographics of the Veteran population are changing. There are more Veterans living in rural areas and a growing number of female Veterans. For example, of the over 8.3 million Veterans currently enrolled in the VA Health System, about 41 percent live in rural or highly rural areas, and approximately 30 percent of rural enrolled Veterans have served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Currently, women Veterans comprise over eight percent of the total United States Veteran population, and their numbers have grown by 31 percent since 2006. It is expected that the proportion of women Veterans will continue to grow -- VHA projects that women will represent ten percent of the total Veteran population in 2020, increasing to nearly 14 percent by 2030. Women comprise nearly 12 percent of OEF/OIF Veterans.
From Surge to Rural Access
Building upon over 20 years of experience serving active duty military service members, their families, and Veterans, Health Net has developed a full continuum of programs to meet the behavioral health needs of this population. Throughout the design and implementation of these various programs, Health Net has collaborated with VA and DoD in delivering high quality, accessible programs which augment existing capacity and capability, both within VA and DoD.
Overview of Programs Offered by Health Net
(please refer to Attachment 1 for detailed description)
Military & Family Life Counseling Program (MFLC) Program:Provides short-term, problem-solving situational counseling; program includes a network of more than 5,000 credentialed, trained, and experienced counselors supporting 320 military installations in 50 states, 4 territories, and 13 countries
TRICARE North Region:Provides managed care support services to 3 million activity duty service members, military retirees, and their families in 23 states and the District of Columbia, provider network includes 22,500 licensed, credentialed behavioral health providers and 392 facilities, have offered web-enabled, video short-tem counseling
Community Based Outpatient Clinics:Provides primary care, mental health and preventive health services to Veterans
Rural Mental Health Program: Provides care to Veterans close to home, behavioral health services provided by a network of clinicians and peer support specialists
These programs are very flexible in meeting demand, from supporting a “surge” of returning service members to reaching out to Veterans living in remote geographic areas located many hours away from a VA Medical Center. We are able to deliver a full spectrum of services from preclinical to clinical, using a combination of face-to-face, telephonic, and video counseling with licensed clinicians to help service members and their families and Veterans to address the unique issues of the military lifestyle and the challenges of transitioning from active duty to Veteran status. In addition, these programs are further enhanced through educational training and workshop presentations led by clinicians for patients and community providers.
The success of these various programs has been noted by military leaders and beneficiaries. For example, the Military Family Life Counseling Program was the subject of a recent independent study performed on behalf of the Deputy Assistant Secretary of Defense (Military Community and Family Policy) by Virginia Tech University. In this study, recipients of MFLC support were asked to complete a brief survey, which indicated that 96 percent were mostly or completely satisfied with MFLC services. 
Established Best Practices
The Department of Defense has engaged private sector firms like Health Net as partners in addressing the needs of service members and their families up to the point of discharge from the service. Many of the services developed for service members and their families as a result of this partnership are innovative, proven effective, and now considered “best practices” throughout the military. Among the “best practices” developed through this partnership are the following:
- The development and deployment of a standby capacity that is delivered when and where it is needed on a temporary basis. This “surge” capability can provide brief, non-medical, problem-oriented counseling to address issues that arise in connection with deployment-demobilization-re-deployment cycles of the troops and their families. This standby capacity is comprised of a network of highly trained, credentialed mental health professionals who are willing to serve in this standby force.
- The engagement of civilian and community-based networks of trained, credentialed, mental health professionals to reach the service members and their families who are not in the vicinity of a Military Treatment Facility. This is often the case for the National Guard and Reserve components. The networks also meet the clinical behavioral health needs of military beneficiaries assigned to a Military Treatment Facility when the demand for behavioral health services exceed the capacity or the scope of care which can be provided within the military facility.
- The use of telephonic and web-based tools to provide fast access to resources that can assist with identifying serious cases early, before anything dramatic can occur.
The Department of Veterans Affairs, likewise, has developed a number of innovations and “best practices” to deliver quality clinical services to Veterans.
- Through the Rural Mental Health Program, Veterans may access mental health or peer support services through a network of licensed behavioral health specialists and peer support specialists. All providers are trained on VA benefits and are able to address specific Veteran issues and conditions which occur among the Veteran population, including traumatic brain injury (TBI) and PTSD. VA specific training covers the mission of VA, describes the patient population, explains VA customer service, instructs providers on VA documentation of health records and outlines VA patient rights.
- Through the Claims Repricing Program, Health Net has helped VA reduce Fee Program claims costs by identifying more than $650 million in discounts since the program’s inception in August 1999. These discounts are the result of applying claims pricing available with Health Net’s nationwide provider networks.
- Through a national recovery audit program, Health Net has helped VA in identifying over $113 million in overpayments for inpatient and outpatient care.
Access to Care Solutions
Recruitment and training of clinical staff is paramount to the effective delivery of behavioral health services. Overall, Health Net has a national network of over 50,000 behavioral health providers. For the Military Family Life Counseling Program, we have a network of over 5,200 licensed counselors who have been carefully selected, are fully trained, and ready to deploy on short notice as needed. These networks are further supported by 22,500 behavioral health providers in the TRICARE provider network.
In this program, Military Family Life Counselors provide brief, problem-oriented non-clinical counseling services. They are required to assess risk in the context of non-medical interactions and to make referral into clinical behavioral health services when indicated. They have particular expertise in engaging service members and their families in ways that minimize or mitigate stigma.
Military Family Life Counselors are deployed on an as needed basis. When they are not deployed in support of the MFLC program, many of these masters-level behavioral health providers maintain clinical behavioral health practices in their home communities.
As part of our program, MFLC counselors receive extensive core training and orientation. To ensure clinical approaches are current, we have established an independent Expert Curriculum Review Panel composed of an expert panel of retired military and academic researchers who specialize in deployment related psychology and military family resiliency.
Health Net also has recognized the need to educate and train community providers about the unique needs of the military and Veteran population. Health Net, along with the American Red Cross and the Penn State Hershey College of Medicine, sponsored 1-day conferences targeting primary care and behavioral health providers. The conference was designed for primary care and behavioral health-care professionals to improve understanding, assessment, and treatment of the invisible wounds of war: PSTD and TBI.
Providers expressed satisfaction with the content, based on a survey performed 6-12 months following participation: 84 percent of respondents expressed increased confidence in caring for returning service members; 41 percent had implemented new strategies of asking about military service in their clinical practice. Additional programs are planned for 2012 in New York, Washington, D.C., and Ohio.
As an industry leader in behavioral health, Health Net has committed extensive resources to developing effective programs to support the military and Veteran populations. Our highly trained and credentialed provider network is the foundation for health care delivery, whether on a military installation, in nearby population centers, or in rural, hard –to-reach locations.
A Path Forward
We believe that these same clinical resources—a highly trained, credentialed mental health surge capacity, along with community-based, specially trained mental health providers—could effectively supplement VA’s capacity to quickly and effectively address the access issues identified by the OIG without sacrificing VA’s clinical excellence.
In addition, enhanced use of telephonic and web-based tools, many of which VA has pioneered, offer Veterans with easy access to ongoing support, helping to de-stigmatize the care, as well as facilitating access for harder to reach Veterans.
Specifically, we believe the urgent need created by today’s environment – increased demand, strained resources, stressed facility capacity – requires a comprehensive approach, one that is designed to augment and enhance VA, based on the specific needs of each VA Medical Center. The components of this approach should include:
- A standby capacity to address urgent, short-term demand, similar to models used by the Department of Defense. Such an approach would be an effective and efficient model to provide rapid deployment of resources to alleviate short-term demand requirements at a VA Medical Center (VAMC) or a Community Based Outpatient Clinic (CBOC). In short, it would be an effective means to address the urgent mental health needs of today’s Veterans, “wounds that cannot wait.”
These rapid-response or surge providers would work alongside VA providers, using the same clinical guidelines. In addition, this standby capacity would enable the early identification of Veterans who might be at risk for suicide or have other serious mental health issues. Such Veterans could then be triaged into a high priority process to gain access to VA providers and facilities as soon as possible.
- Telephonic and web-based tools that would offer the possibility of reaching deeper into the Veteran population to identify and serve those in need.
- A network of community-based mental health providers that would augment VA’s capacity and reach, enabling VA to meet the needs of Veterans who do not live near a VA Medical Center or a Community Based Outpatient Clinic. Since this capacity already exists, it could be brought to bear almost instantaneously. An added benefit of using community-based provider networks similar to the ones we use for the Military Family Life Counseling Program and TRICARE is that they include a number of female clinicians to support treating the special needs of women Veterans.
Specific considerations for VA to consider in developing this approach include:
- Deploy only a cadre of supplemental providers who are professionally competent and credentialed, as well as specifically trained in military culture.
- Exploit existing network and standby capacity to implement the solution very quickly. Time is critical here.
- Utilize surge techniques to concentrate the mobilization of the supplemental capacity in areas where the demand arises quickly as a consequence of force downsizing.
- Use of a single VA medical record system to record all services provided to ensure that care is delivered in close coordination with other VA providers.
Taken together, the components of this model could transform the experience of Veterans in gaining access to their earned benefits in a timely fashion.
We commend the VA for promptly responding to the VA OIG report on Veterans’ access to mental health care. As VA seeks to address this urgent issue, we strongly encourage consideration of a comprehensive approach that builds upon VA’s strengths in clinical quality excellence; one that draws upon best practices of not only the Department of Veterans Affairs, but also other federal agencies and the private sector. Doing so provides VA with the fastest means for providing more immediate results for this nation’s well-deserving Veterans.
Chairman Miller and Ranking Member Filner, thank you again for the opportunity to testify before this committee today. More importantly, thank you for your strong leadership over this critical issue for our nation’s Veterans. I am happy to answer any questions you may have of me.
Background on Health Net, Inc.
Health Net, Inc. is one of the nation’s largest publicly traded managed health care companies and is currently ranked #179 on the 2011 Fortune 500. Health Net’s government services division is one of the largest and longest performing administrators of government and military health care programs. Our health plans and government contracts subsidiaries provide health benefits to approximately six million individuals across the country through DoD, VA, as well as group, individual, Medicare, and Medicaid programs. As a leader in behavioral health, Health Net provides behavioral health benefits to approximately five million individuals across the U.S. and internationally through its subsidiaries, MHN, Inc. and MHN Government Services.
Health Net Federal Services manages several large contracts for the government operations’ division of Health Net, Inc. and is proud to be one of the largest and longest serving health care administrators of government and military health care programs for the DoD and VA.
In partnership with DoD, Health Net serves as the Managed Care Support Contractor in the TRICARE North Region, providing managed care services for three million active duty family members, military retirees and their dependents in 23 states. In collaboration with VA, Health Net supports Veteran health care to meet the physical and behavioral health needs of Veterans through CBOCs and the Rural Mental Program. Additionally, Health Net also supports VA by applying sound business practices to achieve greater efficiency in claims auditing, recovery and re-pricing.
MHNGS delivers a broad range of customized behavioral health and wellness services to the military services’ members and their families and to Veterans. These services include military family counseling, financial counseling, rapid response counseling to deploying units, victim advocacy services, and reintegration counseling.
Military & Family Life Counseling (MFLC) Program
§ Develop and manage a network of more than 5,000 credentialed, trained, and experienced licensed counselors, including 1000 qualified personal financial counselors, who serve 320 installations in 50 states, 4 territories, and 13 countries
§ Deploy on average 1,400 consultants world-wide in any given month to provide private and confidential, non-medical and financial short-term, situational, problem-solving counseling assistance and support services to Service Members (including the National Guard) and their families
§ An additional 280 MFLCs [on average, per month] travel throughout geographically dispersed areas to ensure access to care for National Guard families; these MFLCs provide support at Pre-Deployment training events, welcome home ceremonies, departure ceremonies, and Yellow Ribbon events on weekends through the On Demand component of the MFLC Program
§ Provide problem-solving, situational counseling in support of active duty service, guard, and reserve members and their families, during reunion/reintegration and mobilization/de-mobilization; non-medical problem-solving counseling support is intended to augment existing military and civilian support services
§ Develop and support other components: the Marine Individual Ready Reserve (IRR) Outreach program and Joint Family Support Assistance Program (JFSAP), Child and Youth Services, Personal Financial Counseling, DoDEA Summer Enrichment Program, Victim Advocacy Support, Purple Camps, Recruiting Command, Victory Resilience, and the U.S. Army Recruiting Command effort
- Marine IRR Outreach – Provide support to Marine Reservists who often live far from their command structure and other Reservists, with limited support network to address the experiences of combat and the inevitable changes that have occurred while at war; provide telephone outreach to homecoming IRR citizen warriors; Address administrative issues associated with activation/deactivation, as well as life issues typical for returning service members, such as readjusting to family life, reestablishing sleep habits, and rebuilding relationships at work; Placed over 22,000 outreach calls to Marine Reservists
- JFSAP – Provide services at geographically dispersed and rural locations; Bring behavioral health and financial support services to active duty service members, Guardsmen, and Reservists and their family members who might otherwise be unable to access such support through MFLCs personal financial counselors; Help reduce deployment and reintegration stress, teach coping skills, build resiliency, develop community resources, and support mobilization and reintegration activities
TRICARE North Region
§ Serve over 3 million active duty service members, military retirees, and family members in 23 states and the District of Columbia
§ Provide behavioral health services contracting and credentialing
§ Established network of 22,500 licensed, credentialed, behavioral health providers, and contracts with 392 behavioral health facilities
§ Awarded original TRICARE North Region contract in 2004 (post DoD consolidating 12 regions into three: North, South, and West); re-awarded contract in May 2010
§ Provided health care and associated services in California and Hawaii through CHAMPUS Reform Initiative (CRI), first contract awarded in 1988 and became the foundation for future TRICARE contracts
§ Awarded three contracts for five regions in 11 states to provide managed health care services to over 2.5 million beneficiaries following CRI
§ Provided expert short-term services available on demand to help beneficiaries cope with normal reactions to abnormal/adverse situations
§ Delivered short-term, solution-focused counseling for situations resulting from deployment stress, relationships, personal loss, and parent-child communications
§ Tested the use of web-based technologies to quickly provide information and short-term services to beneficiaries, and determined if services and platform increase DoD’s ability to:
- Identify beneficiaries in need of medical mental health care at an early stage
- Refer beneficiaries quickly or facilitate access to appropriate level of mental health care
VetAdvisor Support Program (subcontractor to a SDVOSB)
§ Provided behavioral health counseling, military family counseling, and rapid response counseling to deploying units, victim advocacy services, and reintegration counseling programs for this pilot program
§ Provided telephonic outreach offering benefits and behavioral-health risk assessments for returning Veterans
Rural Mental Health (VISNs 19 and 20)
§ Delivers care to Veterans at locations closer to the Veteran’s home than the nearest VA Medical Center or Community Based Outpatient Clinic
§ Veterans are eligible to receive therapy services as well as peer support services
§ All providers are trained on VA benefits, and on addressing specific Veteran issues (i.e., Military sensitivity, women Veteran issues, TBI, and PTSD)
§ Peer support specialists are certified through a nationally accredited organization; network providers are licensed psychiatrists, psychologists, and master’s level therapists
§ Available to OEF/OIF Veterans within certain counties
Rural Mental Health (VISN 6)
§ Used excess funds to establish a Rural Mental Health program that mirrored many of the pilot program’s requirements (the VISN 19/20 Rural Mental Health program is a pilot program)
§ Veterans were eligible to receive therapy services (peer support was not included).
§ All providers were trained on VA benefits, and on addressing specific Veteran issues (i.e., Military sensitivity, women Veteran issues, TBI, and PTSD)
§ Program was available to all Veterans (not just OEF/OIF Veterans) within certain counties
§ Program ended in December 2011 due to lack of funding
Warrior Care Support
§ Provide complete health care planning and coordination services for warriors severely injured or with combat-related behavioral health diagnoses, and support for their families through TRICARE Program
§ Assist Veterans transition from military to VA care
§ Provide warrior with a “Health Care Coordinator” – acts as single point of contact for health care services and works with military and VA to achieve a seamless transition
 GAO VA Mental Health Report to Ranking Member, HVAC: Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access; 10/14/11.
 Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using VA Health Care: Facts and Figures; Congressional Research Service; 8/16/11.
 Presentation for National Rural Health Day: Caring for Rural Veterans; Dr. Mary Beth Skupien, Director of VHA Office of Rural Health; 11/17/11.
 Women Veterans by the Numbers, Lisa Foster and Scott Vince; California Research Bureau; 9/09/09.
DoD Counseling Program Evaluation, Partner: Virginia Tech; Examining the Perceived Effectiveness of Two Innovative Models of Mental Health Service Provision to Service Members and Their Families: Military One Source (MOS) and the Military Family Life Consultants (MFLC); January, 2001.