Wednesday, April 25, 2012. Chaos and violence continue, tensions continue to rise between Iraq and Turkey, the US Veterans Affairs Committee has been caught lying about wait time for veterans seeking health care, a witness calls for a cultural change at VA, and more.
Larry Abramson: Over the past five years, the Department of Veterans Affairs says the number of former service members seeking mental health services has climbed by a third. In response, the agency has boosted funding, and tightened standards. Now, any vet asking for help is supposed to be evaluated within 24 hours and start treatment within two weeks. The VA has claimed that happens in the vast majority of cases. But a new investigation by the agency's inspector general says the VA statistics are skewed to make wait times appear shorter. [. . ] The inspector general's report says rather than starting the clock from the moment a vet asks for mental health care, the VA has been counting from whenever the first appointment came available. That could add weeks or months to the wait time. So while the VA has been saying 95 percent of vets were seen as quickly as they were supposed to be, actually, nearly 100,000 patients had to wait much longer.
"Today's hearing builds upon two hearings held last year," declared Senator Patty Murray this morning as she brought the Senate Veterans Affairs Committee hearing to order. "At each of the previous hearings, the Committee heard from the VA how accessible mental health care services were. This was inconsistent with what we heard from veterans and the VA mental health care providers. So last year, following the July hearing, I asked the Department to survey its own health care providers to get a better assessment of the situation. The results as we all now know were less than satisfactory. Among the findings, we learned that nearly 40% of the providers surveyed could not schedule an appointment in their own clinic for a new patient within the 14 days. Over 40% could not schedule an established patient within 14 days of their desired appointment. And 70% reported inadequate staffing or space to meet the mental health care needs. The second hearing, held in November, looked at the discrepancy between what the VA was telling us and what the providers were saying. We heard from a VA provider and other experts about the critical importance of access to the right type of care delivered timely by qualified mental health professionals. At last November's hearing, I announced that I would be asking VA's Office of Inspector General to investigate the true availability of mental health care services at VA facilities. I want to thank the IG for their tremendous efforts in addressing such an enormous request. The findings of this first phase of the investigation are at once substantial and troubling. We have heard frequently about how long it takes for veterans to get into treatment and I'm glad the IG has brought those concerns to light."
There was one panel. William Schoenhard and Mary Schohn were among those present representing the Dept of Veterans Affairs, Iraq War veteran Nick Tolentino was present as a former VA employee who had an understanding of how the VA worked (and didn't work), Outdoor Odyssey's retired Major General Thomas Jones shared his thoughts and observations, and the VA's Office of Inspector General was represented by Linda Halliday and John Daigh.
We'll jump to this exchange where Committee Chair Patty Murray questioned the VA.
Chair Patty Murray: First, let me say that I'm very happy that the VA is finally acknowledging the problem. When the Department is saying there's near perfect compliance but every other indication is that there are major problems, I think it is an incredible failure of leadership that no one was looking into this. In fact, when you sit at that table before this Committee, we expect you to take seriously the issues that are raised here. It should not take multiple hearings and surveys and letters and ultimately an IG investigation to get you to act. I also would like to suggest that if the reality on the ground could be so far off from what central office thought was happening as it relates to mental health, then you better take a very hard look at some of the other areas of care for similar disconnects. Now what we have heard from the IG is very, very troubling. For months now, we have been questioning whether Central Office had a full understanding of the situation out in the field and I believe the IG report has very clearly shown that you do not. So I want to start by asking you today, after hearing from this Committee, from veterans, from providers and from outside experts, why you were not proactive about this problem months ago.
William Schoenhard: Chairman Murray, we have been looking at mental health for, uh, many years, as you know. With the support of the Congress, we increased our capacity and hired about 8,000 new providers between 2007 and 201. We relied primarily on a uniform mental health handbook that would be the source of the way in which we would deliver care to our nation's veterans. That has been the focus of the department to ensure that we're getting evidence-based therapies and a staffing model that is largely based on the handbook put out in 2009. I think what we have learned in this journey -- and we have been wanting to work with our providers -- is a number of things. As I mentioned in my opening statement, the way in which we measure these performance measures is not a good measure of wait time. We want to work very closely with the IG and with, uh, any resources that are available to assist us in ensuring that we provide veteran centered performance measures --
Chair Patty Murray: Mr. Shoenfield, with all due respect, I think back in 2005 the IG said this information was there. So that's a long time with a lot of veterans in between. So my question is how are you going to address that growing gap that we've seen --
William Schoenhard: Well I --
Chair Patty Murray: -- between what Central Office believes and what's actually happening out there.
William Schoenhard: As Dr. Daigh described in our response to the IG report, we have a number of things going on. One is first we have a working group that will report this summer on a new set of performance measures that includes providers on the ground assisting us with ensuring us that we develop measures in conjunction with support from the IG that are really veteran-centered -- that are centered on a veteran's individual condition and one in which we can revamp and go forward. We fully embrace that our performance measurement system needs to be revised and we will be doing that with the work of people on the front lines to assist us. We have the benefit of, uh, these mental health site visits that are assisting us. We're learning as we go on other issues to do with scheduling and all of this effort is assisting us in not just having people at Central Office develop proposed solutions but to engage the field the way that we need to in order to ensure that we're veteran-centered and we're able to support our providers in delivering this care.
Chair Patty Murray: I-I appreciate that but it is very troubling to me that this didn't happen five, ten years ago. That we're just now, after months of this, years of this, that that disconnect is there. But we'll go back to that because I want to ask Mr. Tolentino and I really appreciate your willingness to come forward today and I believe your testimony is going to be very helpful to addressing many of the changes that are needed in a timely fashion. In your testimony, you suggested that VA institute more extensive oversight into how mental health care is actually delivered and funds are spent. Given how adept many of the facility administrators are at getting around the current system without being caught, how do you think the VA can most effectively perform that oversight?
Nick Tolentino: Madam Chairman, to be perfectly honest, I don't have a very good answer for you because of the fact that the gaming is so prevalent. As soon as something is put out, it is torn apart to look to see what the work-around is. I-I feel that the reports -- the reporting is -- It's very redundant reporting that feels like it goes nowhere, there's no feedback loop. It's one way. We're telling you exactly what -- and most of the times you want to hear -- we did at the facilities and even at the network. But there's no coming back and rechecking or coming back with feedback to say, 'Well you said you spent the money on these services but there's no workload to verify it. There's nothing concrete to speak to what you say you've done.' I'm remembering in the short time that I -- that I worked there, many times we got vast amounts of financial monies for different programs but very, very seldomly did we get requests to verify what we've done with work load, with any kind of feedback reports or anything like that. So I think opening the lines of communication and development of feedback loop would be very helpful -- and a very transparent feedback loop at that.
Chair Patty Murray: Mr. Shcoenhard, my time is out and I want to turn it over to Senator Brown. But I do want to address an important issue here. The Department has announced 1600 new mental health care providers and I appreciate that step, I think it's really needed but I am concerned that VA hospitals all across the country are going to run into the same hurdles that Spokane VA has been in not being able to hire health staff and I hope that medical centers are doing everything including using all available hiring incentives to fill those vacancies. And I assure you, that is the next question this Committee is going to look at. But I want to ask you specifically, how are you going to make sure the 1600 new health care providers that you announced don't become 1600 new vacancies?
William Schoenhard: Chairman Murray, that's a very important question. And we have stood up in our human resources group and our VHA workforce two task forces to assist us with this. One is the Recruitment and Retention of mental health providers with particular focus on psychiatry. That's where our greatest need and problem is in retaining and recruiting mental health providers. The second task force is a Hiring Task Force. That is what can we be doing to expedite and make sure that we are having the process of recruitment as speedily as possible. The group has put together a number of good recommendations that we will be implementing. Part of what Dr. Daigh spoke of earlier in terms of our four-part mission, one of our great assests -- having been in the private sector for many years before coming to VA -- is that many mental health providers including hundreds of trainees today get part of their training in VA and have the opportunity to experience us going forward. We need to better link with these trainees and ensure that we have a warm hand-off for employment when they finish this.
Chair Patty Murray: Okay, that's one issue but then how you arrived at your staffing plan is really unclear to me.
William Schoenhard: Oh, I'm sorry.
Chair Patty Murray: The new 1600 mental health providers that you allocated, the information that we got from the department yesterday on where that was going to go isn't supported by any concrete evidence or facts. In fact, the VISN 20 director told Senator [Mark] Begich and I that she learned about the new positions only a couple of days ago, didn't know if it was sufficient and didn't know how the department even reached those numbers. So I want to ask you how did you arrive at that number 1600 and what makes you confident that it's going to be effectively placed across the country? What is the plan -- staffing plan -- that you used to do that?
William Schoenhard: Thank you. Uh, I'm sorry, I misunderstood the question and I'm going to ask Dr. Schohn who may want to embellish on that. We used a model that looks at the volume of services and I wonder if Dr. Schoen might speak to this? We are piloting this in 3 VISINs. I would be happy to answer further.
Mary Schohn: Thank you. Yes, as part of our response to the Committee in November, we planned to develop a staffing model. The staffing model --
Chair Patty Murray: I'm sorry. You planned to -- planned to develop a staffing plan? It's not yet in place?
Mary Schohn: No, no. We did develop the staffing model. But we submitted to you that that was part of our action plan in November. We developed the staffing model. We're in the process of implementing it in VISNs 1, 4 and 22 to -- to understand how to implement it so we don't want to simply say, 'Here's the number of staff,' without actually a plan for how this rolled out. Is this really the right number of staff to really evaluate how well and how effective this methodology is? Our plan, however, also is not to wait until we get a full evaluation of this plan but basically to staff up so that we'll be fully ready to implement this plan throughout the country by the end of the fiscal year. So we will have -- we are planning -- the plan itself is based idnetification of existing staff at facilities, the veteran population, the range of services offered and the demand for services. And our plan is to be able to use this to project the need so that we will have a standard so that we will have a standard model in the future that is empirically validated, that we will all know how many staff is needed.
Murray then passed to Senator Scott Brown who was serving as Ranking Member on the Committee in Senator Richard Burr's absence. Ava will be covering Scott Brown at Trina's site tonight. Kat will offer her impressions on the hearing at her own site tonight and Wally will be reporting on the hearing at Rebecca's site tonight (and probably covering Scott Brown as well -- in terms of money issues). We'll move over to some of Jon Tester's questions. Only four Senators were present for this hearing: Chair Murray, acting Ranking Member Scott Brown, Senator Jon Tester and Senator Jerry Moran. Both Moran and Tester have rural concers due to their states (Moran represents Kansas, Tester represents Montana).
Senator Jon Tester: Just from a rural persepctive, I will tell you that one of the reasons the VA can't contract out in a rural state like Montana is because the private sector doesn't have anymore mental health professionals than the VA has. And I just want to point that out because it's -- it's mental health professionals -- whether it's in the private sector or the VA -- getting these folks is a big problem. And I very much appreciate Mr. Tolentino's statements about nobody's going to go to work for a year or two years in the VA when, in fact, in the private sector, they have much more predictability in their jobs. So we need to take that into consideration when we start allocating dollars for the VA to make sure that they have the advantage to compete. And I very much appreciate that perspective. Along those same lines, I just want to ask -- Senator Brown was right in the area of 1500 positions open and an additional 1900 so there is about 3400 positions. They may not all be psychiatrists, they may not all be clinicians. But how you're going to fill those in an area where the private sector's sucking folks up because this is a big issue there too. And the VA, it's interesting to me. Do you have an allocation by VISN of these 1600 folks? And if you do -- Do you? Could we get a list of those?
William Schoenhard: Yes, sir.
Senator Jon Tester: And how they're going to be allocated?
William Schoenhard: Yes, sir.
Senator Jon Tester: And the metrics. I know you talked about metrics -- number of veterans and that kind of stuff. Could you give me a list of metrics on why the number are there? How many are going to be psychiatrists, how many of them are going to be nurses, clinicians? Are any of them going to be psychologists?
William Schoenhard: Uh, sir, we are leaving to VISN in discussion with the facilities, they could be psychologists --
Senator Jon Tester: Okay.
William Schoenhard: -- they could be family therapists -- a variety of different health care providers.
Senator Jon Tester: Okay, thank you. And when it comes to contracting out, do you guys typically only use psychiatrists? Or can you use psychologists too?
William Schoenhard: No, we can contract with others.
Senator Jon Tester: Super. That's good. Because there are some -- there are some accessibility to those folks in place. I like Montana. I want to put two things that Mr. Tolentino said along with Major General Jones said. Major General Jones, I want to thank you for what you're doing. I very much appreciate it. Mr. Tolentino said when he was there it was fairly common if someone came in with a problem, don't ask if there's another issue. There are all sorts of correlations here that are wrong but I just want to tell you that, okay, if that's done -- and I believe he's probably right because then we can have a problem. But if you combine that with what Maj Jones said, that the folks that he's working with, the major stressor is unknown. We've got a problem in our system here. Because the only way you're going to find out how to get to the real root of the problem when it comes to mental health -- and I'm not a mental health professional -- is that you've got to find out what that stressor is, you've got to find out what created that problem. Does that kind of -- Well let me just ask you. If you had a VA professional in one of the CBOCs [Community-Based Outpatient Clinics] or in one of the hospitals, do you tell their people: Don't ask any questions because we don't want to know? I'm hoping to hell that doesn't come from your end. And why would they do that?
William Schoenhard: Sir, if that is being done, that is totally unacceptable.
If it's being done, it's unacceptable? That's a rather interesting comment. If the VA hadn't lied about wait time, the hearing wouldn't have been called. Had Schoenhard been asked if the VA was lying about wait time a month ago, he most likely would have replied, "If that is being done, that is totally unacceptable." What's totally unacceptable is that the supervision level of the VA doesn't appear able to do their job. They're in supervision for a reason and that is, yes, to supervise. So all these things that are going wrong -- these things they allegedly know nothing about and certainly didn't encourage -- these fall on them. Training apparently needs to be done at extremely high levels of the VA to explain review what job duties are and what these duties entail. There is no oversight at the VA. That's been clear for some time now.
Again, the VA's Office of Inspector General was represented by Linda Halliday and John Daigh. We'll note this exchange near the end of the hearing.
Chair Patty Murray: Dr. Daigh, let me turn to you. As you well know, it's hard enough to get veterans in the VA system to receive mental health care. Once a veteran does take a step to reach out for help, we need to knock down every potential barrier to care. Clearly the report your team produced shows a huge gap between the time that the VA says it takes to get veterans mental health care and the reality of how long it actually takes them to get seen at facilities across our country. Now VA has concurred with all of your recommendations but I think it's clear we all have some real concerns because some of these issues have been problems for years. So can you address a question of what you think it would take the VA to get this right this time?
Dr. John Daigh: I think, uhm, to begin with the veteran population is dispersed across the country and the VA is not evenly dispersed across the country so those veterans that go to fixed facilities to receive their care, the VA -- I'm guessing -- is probably trying to address in this current plan for 1600 people. I haven't come across any details of the plans. So I think the first issue is to realize you have a problem where you have facilities and where you don't have facilities. Then I think the second problem is that, as has been stated here, there simply are not enough mental health providers to hire off the street in a timely fashion, I believe. I mean we looked at it the other day. There's something like 1200 psychiatry graduates a year in this country from our medical schools so there is a limited pool and there's a great deal of demand for mental health providers. In our discussions with private sector, they said that because of the downturn of the economy and other factors that the non-VA, non-military demand had also gone up in their experience, ten and twenty percent in the last couple of years. So I think when I look -- We were asked several years ago to go look at access to mental health care in Montana. And it was a very interesting review for me in that Montana VA had linked up with the community health centers in Montana and I believe -- I may be -- I may be out of date by a couple of years since we did it a couple of years ago but they were, there was an organization of community health centers and by allowing veterans to go to those community health centers which were usually staffed by psychologists and social workers, usually not by physicians, they were able to dramatically improve the access time to get folks to talk to competent people in their neighborhood, in their city, to get some care. I think in order to make that care cohesive, as Mr. Tolentino said, you've got to be able to get medical records back and forth so that there's a coordination of care. So I think the all hands on deck idea is one that I fully endorse and one where if I look at some of the cases -- tragic cases -- we've looked at, in the past it was not infrequent for veterans to show up at a mental health center in their town and because they were veterans, they were sent to the VA and there was not a link, they were not accepted or there was no payment mechanism or there was no authority. So I think that would be a useful step. Secondly, I think you really have to sit down and, as bad as metrics are, you do have to sit down and model what you do and figure out what demand is and try to lay out a business case for what you're doing.
Chair Patty Murray: Is that in place at the VA today?
Dr. John Daigh: Um, I don't believe that they have for mental health the level of business plan that I think they should have. Nor do I think they have it for most specializations.
Daigh's suggestions resulted in a number of people nodding their heads and, as Chair Murray noted, the VA had agreed with the recommendation in the report from Daigh's office. His responses were common sense ones. So why did the brain trust of the VA need someone from the IG office to make these very basic and obvious recommendations for them?
Linda Halliday would note her opinion that the lying about wait time meant that there was a need for "a culture change" at VA. She's right. She also called for holding "the facility directors accountable for how well the data is actually being captured." There needs to be accountability, there needs to be a cultural change. Nothing in today's hearing provided any indication that there would be. Senator Murray was very clear in her closing marks which included, ". . . I want to make it very clear, this is not something we're going to have a hearing on and leave and go do something else tomorrow. This has to be taken care of. We owe it to these men and women." She was very clear. But the VA's attitude didn't seem overly concerned and that was only more true as the hearing concluded and three of them ambled towards the door laughing and joking and clearly not bothered by the warnings, by the reprimands, by anything. Repeating, I don't doubt that Murray means it. I don't doubt that Scott Brown is fed up with it. Tester tries to word things more nicely but it was clear he was irritated. But that hearing had no visible effect on the VA staff that should have walked out of that hearing feeling something other than good humor.
With regards to Iraq, al-Maliki is profoundly at odds with the Sunnis, and wants to imprison his deputy, Tareq al-Hashemi. He has also clashed with the Kurds, as well as the Sadrists loyal to Iran, and even with [Abdulaziz] al-Hakim. He is also got involved in an intense dispute with the Iraqiya bloc, led by Dr. Iyad Allawi. So what left for Mr. al-Maliki after all this? Regionally, and in terms of the Arab world, al-Maliki does not have any normal relations with the influential Arab countries of the region, or any countries in the region for that matter, with the exception of Iran. Al-Maliki has launched attacks on Saudi Arabia in language not worthy of a diplomat, let alone a Prime Minister, and he has done the same with Qatar, and now with Turkey! This is not all of course, as al-Maliki is also the one who said: "the [al-Assad] regime did not fall, and it will not fall, and why should it fall?", despite all that the Baathist tyrant of Damascus has done to the Syrian people. Iraq is now creating passageways to help the al-Assad regime by transferring weapons and money and smuggling oil. So what left after all this? How can al-Maliki say that Turkey is a hostile country, inciting sectarianism in Iraq, while Tehran launches an attack on [Massoud] Barzani, on the eve of al-Maliki's visit to Iran, and also accuses al-Hashemi of wanting to restore Sunni rule in Iraq with the support of Saudi Arabia?
And Nouri's stepped in it again prompting State of Law (his political slate) surrogates to rush to the media to play another round of When Nouri Said ____, He Meant ___. Nouri's called for a federation of Iraq and Iran. No surprise, that call has alarmed many Iraqis. Al Rafidayn quotes a State of Law-er insisting Nouri was using a metaphor. (Ask Nouri to define "metaphor" and, if he can do that, I might believe it.) Iraq has good relations with Iran, insists Nouri's surrogates, but they do not want to jeopardize their relationship with others. Alsumaria also carries the we-don't-really-want-a-federation-despite-what-Nouri-said story. Nouri just wrapped up a visit to Tehran, one would assume he could speak plainly. To listen to State of Law, that's not the case.
The World Bulletin notes Ahmet Davutoglu, Foreign Minister of Turkey, has rejected Nouri al-Maliki's accusations that Turkey is interfering in Iraq's internal affairs and quotes Davutoglu stating, "Turkey's Iraq policy is quite clear and we have been a direct part of any controversy in Iraq. We want that all our Iraqi brothers, Shiites, Sunnis, Turkmens, Arabs and Kurds live in peace and in prosperity." Turkey's one of Iraq's largest regional trading partners. Joe Parkinson (Wall St. Journal) observes, "The two countries have in recent years enjoyed a fast-expanding trade relationship. Iraq is now Turkey's second-largest trading partner after Germany, with trade swelling 40% to reach $12 billion last year, according to Turkey's government. However, more than half of that volume is between Turkey and Iraq's semiautonomous Kurdish region." This war he's declared on Turkey really doesn't help Iraq nor does it improve relations with the Arabic states (Saudi Arabia, Qatar, etc) that Nouri's already on shaky ground with. Tony Karon (Time) notes:
And these days, it's not only Iraqi politicians that are courting the Kurds. Turkey last week feted Barzani in Ankara, rolling out the red carpet and affording him a meeting with Turkey's President Abdullah Gul and Foreign Minister Ahmet Davutoglu, and he recently returned from a visit to Washington D.C. where he met with senior Administration officials. Those visits seemed to amplify Barzani's defiance of Baghdad in a dispute over oil revenues, with the KRG prime minister accusing Maliki of paving the way for a return to dictatorship, and warning that absent "radical solutions and a specific time-frame to resolve the present crisis … we will resort to other decisions" -- a not-so-veiled threat to declare independence from Iraq. Independence, of course, remains the historical goal of Kurdish Iraqis, and a referendum on the issue staged in 2005 saw some 98% vote to break away from Iraq. Geopolitical realities, however, has required a curbing of that popular sentiment. Iraqi Kurdistan is small and landlocked, and while it possesses significant oil reserves, it would require the cooperation of one of its powerful neighbors --Turkey, Iran or Iraq -- to pipe that oil to market. Also, the KRG was carved out in large part because the U.S., which had just overthrown Saddam Hussein, helped ensure its emergence, but made clear it was not ready to support a breakup of Iraq.
Al Rafidayn reports that it's been decided to open up 50% of Baghdad's main streets over the next 45 days due to traffic congestion and other issues. Dar Addustour notes there is some concern that barriers that have protected various political party offices may also be lifted. Their fears may be justified and AFP reports that today saw "the offices of two of Iraq's top four Shiite clerics in the central city of Najaf [attacked] with sound bombs".