Chairman Miller, Ranking Member Filner, and members of the Committee, thank you for allowing Paralyzed Veterans of America (PVA) to testify today on one of the most important health care issues facing America’s veterans and the health care system of the Department of Veterans Affairs (VA). PVA believes that when veterans have timely access to quality mental health care services they in turn have the opportunity to establish productive personal and professional lives. PVA thanks this Committee for their continued oversight and hard work on this important health care issue.
In recent years, the VA has made tremendous strides in the quality of care and variety of services provided to veterans in the area of mental health. These improvements include incorporating mental health into VA’s primary care delivery model, increasing the number of Vet Centers, launching mental health public awareness campaigns, and creating call centers that are available to veterans 24 hours a day, 7 days a week. While these improvements were much needed and have helped many veterans, PVA believes that issues of access to mental health care within the VA continue to exist and more must be done to make certain that all veterans receive mental health care that is timely and effective.
The VA’s Office of Inspector General (OIG) report, entitled, “Veterans Health Administration: Review of Veterans’ Access to Mental Health Care,” identified many weaknesses within VA’s Department of Mental Health that if improved upon will allow VA to continue in its progression of providing high quality mental health services to veterans. Overall, the report concluded that the Veterans Health Administration (VHA) mental health performance data is not “accurate or reliable, and VHA measures do not fully reflect critical dimensions of mental health care access.” More specifically, the report stated that “VHA’s measurement of a first time patient’s access to a full mental health evaluation was not a meaningful measure of wait time; VHA was not providing all first time patients a full mental health evaluation within 14 days as required by VA policy; VHA schedulers did not consistently follow procedures; and VHA overstated its success in providing veterans new and follow-up appointments for treatment within 14 days as required by VA policy.”
While PVA is deeply concerned by these findings, such conclusions were not completely surprising. In fact, this year’s Independent Budget states, “One overreaching concern of the IBVSOs is the lack of clear and unambiguous data to document the rate of change occurring in VA’s mental health programs, as noted in the May 2010 GAO report…VA needs more effective measures to record and validate progress.” Four main recommendations were made by the VA OIG: 1) Revise the current full mental health evaluation measurement to ensure the measurement is calculated to reflect the veteran’s wait time experience upon contact with the mental health clinic; 2) Reevaluate alternative measures or combinations of measures that could effectively and accurately reflect the patient experience of access to mental health appointments; 3) Conduct staffing analysis to determine if mental health staff vacancies represent a systemic issue that impedes VA’s ability to meet mental health timeliness goals; and 4) Align data collection efforts related to mental health access with the operational needs throughout the organization.
PVA supports these recommendations and believes that the recommended actions will allow for VA to better identify and address the issue of access to VA mental health care services. In addition to these recommendations, PVA believes that increased attention to staffing, productivity and performance of providers, and patient demand will further assist VA in providing care that makes a difference in the lives of veterans.
The analysis and results from the VA OIG report on mental health access data shines light on the inconsistencies of policy implementation within VHA, and how such inconsistencies can negatively impact veterans’ access to quality care. For instance, VA requires that all first-time patients receive a treatment planning evaluation no more than 14 days from the initial request or referral for services. As the VA OIG reports states, various mental health offices within VA have been interpreting this policy to have multiple meanings, and the end result is not having reliable data to accurately assess veterans’ access to care or the performance of providers. The VA must not have policies just for the sake of having policies. The VA must ensure that staff adheres to all policies that are put in place to guarantee a high caliber of services for veterans, and must further develop safeguards that ensure such policies are carried out correctly from day to day.
On April 25, 2011, the Senate Veterans Affairs’ Committee held a hearing entitled, “VA Mental Health Care: Evaluating Access and Assessing Care.” During this hearing a veteran and former VA mental health professional testified that too often the VA mental health system places a burdensome emphasis on having staff meet numerical performance goals at the expense of providing veterans with the best care possible. PVA believes that VA leadership must make certain that policies and regulations are developed to provide safe, quality health services for veterans, without compromising the professional integrity of the qualified providers who deliver the care. VA policies must be pragmatic and attainable, and improve the delivery of care by creating benchmarks and measures that help assess strengths and weaknesses of health care services and delivery.
PVA’s Medical Services and Health Policy Department conducts regular site visits to VA Spinal Cord Injury Centers on a monthly basis. PVA’s medical professionals that facilitate these visits, along with VA leadership from the various medical centers, compile staffing and bed capacity data for a monthly report. Included in these reports is the required number of staff that is needed to care for patients within a medical center as determined by VA policy. The reports also include the actual number of staff available for duty during the month of the visit. Staff members counted in the report include nurses, physicians, social workers, psychologists, and therapists.
For the past year there have been consistent deficits in one or more of the mental health positions included in the report. Such deficiencies in mental health staffing directly impact veterans’ access to mental health services. For example, within VA’s Spinal Cord Injury System of Care, veterans receive annual examinations that encompass a mental health screening. This annual mental health screening is extremely important for veterans who have sustained a catastrophic injury as they have a high propensity to face challenges involving self-esteem, independence, and quality of life. The aforementioned mental health staffing shortages have the potential to compromise quality mental health screenings and treatment for veterans within the SCI system of care who are dealing with symptoms of mental health conditions.
Without sufficient staffing, providing care when it is needed is difficult. Timely care is critical to preventing and treating mental health conditions. If VA is going to provide mental health care services in a timely manner, it must be equipped with adequate staffing in the various types of mental health care that it provides. For instance, within VA SCI primary care, our site visit reports indicate that psychologist positions in VA medical centers have extremely high turnover rates due to low compensation scales and high patient panels. This is a systemic issue within VA that involves various departments—human resources, primary care, and mental health. Ultimately, staffing issues such as this impede veterans’ access to mental health care and overall patient wellness.
The VA recently announced increasing the mental health workforce by an additional 1,900 mental health professionals. To ensure that these staff increases are effective, PVA recommends that the VA conduct a comprehensive analysis of the mental health care needs of veterans and hire additional staff based on those needs. The VA cannot accurately assess the performance and productivity of providers if they do not have an understanding of the needs that the providers are expected to meet. As the VA OIG report emphasizes, accurate data on access, as well as trends in demand and provider productivity will help provide care that is timely and meets the health care needs of veterans. PVA also encourages the VA to develop a mental health staffing model that focuses on adequate staffing of mental health professionals throughout the numerous systems of care within the VA. Again, this model should be based on a patient needs assessment of veterans.
Another systemic issue that impedes patient wellness involving VA mental health care is the lack of inpatient mental health services readily available to veterans with catastrophic disabilities. PVA’s Medical Services team has found that inpatient care is not always available to veterans with a spinal cord injury or disorder due to a lack of accessible space, or the VA not being able to provide the necessary physical and medical assistance that is often needed when a veteran has a catastrophic injury or illness. When this is the case, these veterans are referred to alternative methods of treatment that may not always adequately meet their needs. The VA must work to provide all veterans with access to mental health services when they seek help. A physical disability or multiple complex health conditions should not prevent veterans from receiving quality, effective mental health care.
PVA thanks Congress and VA for investing a great deal of resources into improving mental health services in recent years. However, we believe that more must be done to improve access. While PVA does not believe that there is one definite solution to improving veterans’ access to VA mental health services, we do believe that a comprehensive assessment of veterans needs and mental health staffing is a starting point for identifying both strengths and weaknesses within the delivery of mental health care, and improving the delivery of services to veterans. All veterans regardless of generation should have access to timely, quality mental health services.
PVA appreciates the continued oversight from this Committee on this extremely important issue.
PVA would like to once again thank this Committee for the opportunity to testify today, and we look forward to working with you to improve VA mental health services for our veterans. I would be happy to answer any questions that you might have. Thank you.
Information Required by Rule XI 2(g)(4) of the House of Representatives
Pursuant to Rule XI 2(g)(4) of the House of Representatives, the following information is provided regarding federal grants and contracts.
Fiscal Year 2012
No federal grants or contracts received.
Fiscal Year 2011
Court of Appeals for Veterans Claims, administered by the Legal Services Corporation — National Veterans Legal Services Program— $262,787.
Fiscal Year 2010
Court of Appeals for Veterans Claims, administered by the Legal Services Corporation—National Veterans Legal Services Program— $287,992.
Associate Director of Health Legislation
Paralyzed Veterans of America
801 18th Street NW
Washington, D.C. 20006
Alethea joined Paralyzed Veterans of America in 2007 and works in PVA’s National Office in Washington, D.C. As a member of PVA's Government Relations staff, Alethea is responsible for monitoring and analyzing policy within the Department of Veterans Affairs (VA) to determine how such policies impact the health care of disabled veterans, particularly, veterans with Spinal Cord Injury/Dysfunction (SCI). Alethea also covers issues involving women veterans, VA human resources, prosthetics, and mental health. Alethea’s professional experience is in the area of legislative affairs and government policy.
In addition to her policy work, Alethea also manages the production of The Independent Budget, a comprehensive budget and policy document produced by veterans for veterans.
Alethea earned a Master's Degree in Public Policy from George Mason University, and completed her undergraduate studies in Political Science at Spelman College.
 The Department of Veteran Affairs, Office of Inspector General, Offices of Audits and Evaluations and health care Inspections; “Veterans Health Administration, Review of Veterans Access to Mental Health Care.” April 23, 2102, 12-00900-168; http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf
 The Independent Budget, FY 2013, pg. 71; www.independentbudget.org
 United States Government Accountability Office, Report to the Ranking Member, Committee on Veteran Affairs, House of Representatives, “VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access.” GAO-12-12; October 2011; http://www.gao.gov/assets/590/585743.pdf
 Senate Veterans Affairs Committee, “VA Mental Health Care: Evaluating Access and Assessing Care.” April 25, 2012. http://www.veterans.senate.gov/hearings.cfm?action=release.display&release_id=f485cb0d-3ad4-407f-99a8-9f517d9c3af6