Saturday, December 03, 2011

Their strings are pulled





Starting with veterans issues.
Chair Patty Murray: Dr. Zeiss, I wanted to ask you, when you testified before a hearing for this Committee May 25th, I asked you whether VA had enough resources to meet OEF OIF veterans needs for health care and you said the resources weren't the problem. In light of what you've learned from last May, especially from your own providers do you stand by that statement from me?
Antonette Zeiss: I believe that we have unprecedented resources and that we have gotten them out to the field and that we have hired an enormous amount of staff. And at the time, I believed that they were adequate if used in the most effective ways possible. We continue to have an increasing number of mental health patients. We have looked at the FY'11 data and the numbers have again jumped from FY'10 and we are proactively predicting what kinds of increases there will be in FY 12 and we're working with the Office of Policy and Planning to ensure that those projection are embedded into the actuary model that drives the budget predictions so that I can say that we will be aggressively following all the data that we have available to ensure that we can make effective predictions at the policy level about what level of funding and level of staffing will be essential and we will be partnering very closely with Dr. Schohn's office who are responsible for ensuring that those resources are are used most effectively are used in the field to deliver the kinds of care that we have.
Chair Patty Murray: So you still today do not believe that it's resources that's the issue?
Antonette Zeiss: I believe that we're at a juncture where we need to be looking absolutely at resources because of the greatly increased number of mental health patients that we are serving. And some of that is because of very aggressive efforts we've made to outreach and ensure that people are aware of the care that VA can provide. The more we succeed in getting that word across and serving increasing number of veterans, the more you're absolutely right, we have to look at what's the level of resources to keep -- to be able to sustain the level of care that we believe is essential.
Chair Patty Murray: You're looking at it, we're asking. We need to have this information upfront now if you need more resources. You just look at the stories out there, the thousands of people coming home, the people that aren't getting served, the people are reaching out to. It just feels to me that this is something we should know now. We've been ten years into this.
Anonette Zeiss: We . . . Uhm. We believe that people are receiving an enormous amount of service from VA and we agree -- as Dr. Schohn has said -- that we need to focus on some specific aspects of care, particularly the evidence based therapies. And we are working with Dr.Schohn who will be developing a very specific staffing model so that we can identify what are the levels of staffing that are available at specific sites and how does that --
Chair Patty Murray: Well let me ask a specific question then. Dr. Schohn according to the mental health wait data provided to the Committee by the VA, Veterans at Spokane VA, my own home state, wait an average of 12 days with a psychiatrist, with a maximum wait for a psychiatrist being 87 days. Now I've been told that all of the psychiatrists in VA in Spokane are booked solid for several months and that there are other places in the country that are far worse than that. You mentioned that the VA is working to fill those vacancies but the hiring process is very slow. What can the Dept do now to make sure that we are shortening these wait times?
Mary Schohn: In fact there is efforts already underway in Spokane to improve the hiring. The waiting time has decreased. There is a shortage and there is variability in our system in terms of ability to, for example, hire a psychiatrist in Spokane. One of the efforts that's being made is to use tele-psychiatry. Essentially to use -- to provide service from a site where there's a greater ability to recruit psychiatrists and to use their services at the site where they are at and to then be able to provide resources to Spokane, for example. The chief medical officer in Spokane has worked to ensure that coverage can come from other facilities within VSN 20, to where the needs of the veterans in Spokane are met. Those are the kinds of things that we're working on as we come across evidence that we're short in some areas. We know that in some other areas, there are not shortages and there may be some surpluses that can be used in those sites.
Chair Patty Murray: Well let me ask you another question. There was a provision on using community providers for mental health services in the Caregivers Omnibus that was passed by Congress earlier this year. It included peer-to-peer services and we heard from our first panel how important peer-to-peer services are. I am told that the Department is making very little progress on implementing that. Can you tell me what's holding up that?
Mary Schohn: We have made some progress. I'm going to ask Dr. Kemp to talk specifically on that.
Janet Kemp: As you're aware most of our peer-to-peer services -- Or a lot of our peer-to-peer services are provided by the vet centers which is an exceptional program that you are all very familiar with which we endorse and support. We've grown the number of vet centers. By the end of the year, we will have three hundred vet centers across the country open and running in addition to the 70 mobile vet centers that will be up and traveling across the country. So I think that we have made huge strides in providing those services to combat veterans and their families across the country. We also have a contract which has been let out and is in the process of being filled to provide training to train more peer type support counselors. We're looking forward to that being completed and we will get those people up and going as soon as we're able to get them on board.
Chair Patty Murray: Okay --
Janet Kemp: We agree with the intent of that legislation for lots of good reasons and we will continue to implement those services.
Chair Patty Murray: Okay, well this Committee will be following that very closely. And before I turn it over to Senator Burr, I just want to say that I'm really disturbed by the disconnect between the provider data and your testimony on the wait time issue. And I am going to be asking the Inspector General for a review of that issue. I assume, Senator Burr, you will join me in that. [Senator Burr nods] And I would like all of your [VA witnesses on the panel] commitment to work with them on that.
The three Witnesses replied "Absolutely" in unison, no doubt hoping they came off like the charites when in fact they more closely resembled the beastly cerberus. We'll come back to the beast.
It was Wednesday morning and Committee Chair Senator Patty Murray was calling to order the Senate Veterans Affairs Committee for a hearing, "Today's hearing builds upon our July hearing on the same subject. At that hearing, the Committee heard about two service members who, even after attempting to take their own lives, had their appointments postponed and difficulties getting through red tape in order to access the care that they needed. I know that, like me, many on this Committee were angered and frustrated by their stories and I'm glad that today we are going to have the opportunity to get more information and answers on why these delays persist. [. . .] At our hearing in July, I requested that the VA survey their frontline professionals about whether they have sufficient resources in order to get veterans into treatment. The results that came back to me shortly after that were not good. Of the VA providers surveyed, nearly 40% said they cannot schedule an appointment in their own clinic within the VA mandated 14 day window, 70% said they did not have adequate staff or space to meet the mental health care needs of the veterans they serve, and 46% said the lack of off-hour appointments prevented veterans from accessing care. The survey not only showed that our veterans are being forced to wait for care -- it also captured the tremendous frustration of those who are tasked with healing veterans. It showed wide discrepancies between facilities in different parts of the country -- including the difference between access in urban and rural areas. And it provided a glimpse at a VA system that, 10 years into war, is still not fully equipped for the influx of veterans seeking mental health care."
10 years into war, the VA is still not fully equipped to deal with the influx of veterans seeking mental health care. That's what the hearing was about.
The Committee heard from two panels of witnesses. The first panel was composed of retired Col Charles W. Hoge (who is a medical doctor), Barbara Van Dahlen, Michelle Washington and John Roberts. They shared important experiences within the VA system. We'll skip the panel to focus on the VA's incompentence and we're able to do that because we'll include questioning from Ranking Member Richard Burr which includes him asking about the testimony from the first panel.
The second panel? We're back to the ceberus -- a multi-headed beast in Greeky mythology that guards the entrance to the Underworld: the VA's Mary Schohn, Janet Kemp and, especially, Antonette Zeiss.
Zeiss is a lousy witness. She's such a lousy witness that you doubt she can do her job properly. There's an issue of being professional. This is the fourth or fifth time, I've registered her outfits. When you appear before Congress as a witness, you need to look professional. Now were I to wear my hair a color of gray with garish off-yellow waxy streaks in it and it was down inches below my shoulder, I'd put some color on it or have the yellow waxy streaks removed. [Looking at her hair, one is forever reminded of Mary Hartman (Louise Lasser) discussing yellow waxy build up on kitchen floors.] Were I not to cut it (and I would cut it), I would at the very least pin it up to try to look professional instead of showing up with a rat's nest spilling down my shoulders thereby revealing to the world that I can't afford either a comb or a brush. But,okay, maybe I'm a little too focused on hair. (I don't think so. And, again, she could and should pin it up if she's not going to cut it. She's supposed to be appearing before Congress not chatting with Hugh Hefner on Playboy After Dark.) There is the issue of your professional uniform. And the first time I noticed this with her, I thought, "Well, sure, we can all forget an appointment and then have no time to change. And just have to pull together something to show up in." Either she's always forgetting or no one ever taught her what constitutes professional dress. Here's your first hint, an ugly blazer that needs to be dry cleaned (that sorely needs to be dry cleaned) and pressed to get all the wrinkles out doesn't qualify as professional. Not even when quickly put it on top of a dress that doesn't qualify as professional but might qualify as a house dress. (Did she buy it on her way into DC, from a vendor on the side of the road?) That's before you get to her putting that ratty blazer with every dress regardless of whether they match or not. (Thus far, I haven't seen her match it with anything when testifying before Congress. If she' suffers from color blindness, she should ask for help.)
Then there's her condescending way of answering questions. She speaks slowler and in the tone of a voice that you'd use when speaking to a very young child. It's patronizing and off-putting.
Now let's get to her profession's issues. She's working for the VA. Has been promoted throughout the VA. There are problems in the VA and as Chair Murray noted, things are going to get more hectic with the huge influx of veterans about to be added to the system. So Zeiss might either need to agree to earn that salary or turn in her resignation to continue her on-the-side work on geropsychology.
She's paid a salary by the tax payer and her little sidelines could be justified in the past with the claim (illusion or reality) that the VA was doing just great. It's doing a lousy job and, specifically, her own areas need improvement. So she can earn her salary by devoting her full attention to this issue or she can leave and do her geropscyhology work. Or how about her more recent work on marriage? So let's not pretend she's giving her all to the administrative role she's paid to perform. And, after 29 years with the VA, she really shouldn't need anyone else pointing out that obvious fact. Of that, when you're salary, and not hourly, and things go wrong, you have to put in more than 40 hours.
Meanwhile the VA should be explaining why she and others oversee a psychiatry program. Meaning? That's a medical program. Do you see me calling her "Dr. Zeiss"? No. Nor do I call anyone in these snapshots "doctor" unless they're a medical doctor. (Or unless they're a veterinarian.) Zeiss appears before the Congress and wants to be called "Doctor" and wants to talk about medical issues including psychiatry which is a medical license. I have nothing against psychology (I have many friends who are psychologists including one of my best friends) but why is a psychologist over the VA's pyschiatry program?
Would we put a gastroenterologist over a cardiac ward?
Well, we wouldn't. But the US government might.
And they have. Outside of Lousiana, I don't believe a psychologist can prescribe medicine in the US. (Correct me if I'm wrong on that.) Now when I hear the testimony of Schohn and Zeiss -- neither of whom is a psychiatrist -- that psychiatrist from one VA will be providing medical care to VA patients at another VA via the telephone, my first question is about meds. That's what psyhaiatrists do that draws the line between them and psychologists. So let's pretend I'm a veteran. You're telling me I'm going to get the same level of care from a VA psychiatrist whether I'm on the phone with her or face to face?
Is she able to prescribe for me over the phone?
These are questions that should be asked.
Ranking Member Burr had questions about flexibility and Schohn insisted they had flexible off hours and then tossed to Zeiss who needed a definition from Burr of "flexible." Again, this is someone in charge of oversight? We'll pick up right after that in the exchange.
Antonette Zeiss: Well I believe, as Dr. Schohn has been saying, we do have flexibility in hours of service. What we've discovered, in looking at the data, is that the initial requirement was for evening clinic -- one evening clinic at least once a week and others as needed. And what we're finding is that the data suggests is what works much better for veterans is early morning hours and weekend hours. And so the policy group is looking very carefully at that in terms of changing and creating even more flexibility than the original after hours policy. The Uniform Mental Health Services Handbook that Dr. Schohn referenced also has an incredible array of flexible programs and defines a very broad range and flexible range of mental health services.
Ranking Member Richard Burr: Let me stop you there if I can. Let me just say, I have a tremendous amount of respect for all of you. I mirror what you've heard from other colleagues. I thank all the VA employees for what they do. But the fact that you've got something written in a book or you've put out a guideline and believe that you can still come in front of this Committee and say, "We've got it written! It's right there!" What we hear time and time again, and I heard from Mr. Roberts, in his testimony. There is no evening options in areas. It doesn't exist. Whether your data shows that it's preferred to be in the morning or the afternoon. In his particular case, your guideline shows the evening and he said, testified, it doesn't exist. So I hope you understand our frustration and, Dr. Schohn, I'm going to ask you if you would provide, for the Committee, a detailed audit of how the $5.7 billion has been spent. And I'm not talking about breaking it down in 403 million dollar categories. I'm talking about, for the Committee, a detailed description of how we spent that $5.7 billion in additional mental health money. Now let me just ask you, is Dr. Washington correct when she said a majority of the patients seen in the 14 day window are there for the purpose of information gathering, not necessarily treatment and many are not seen by a health care professional, they are seen by a staffer there to collect data.
Mary Schohn: That was -- That is not how the policy was written. And if that is happening --
Ranking Member RIchard Burr: Well let me ask it again: Is she right or is she wrong?
Mary Schohn: I -- I don't know about Wilmington. I will admit. That is something I would certainly want to follow up on because that is not the expectation of how services are to be measured.
Ranking Member Richard Burr: Let me, let me read you some comments that have been made today, Dr. Schohn, and you just tell me whether these are acceptable. "Veterans have little access to follow up care."
Mary Schohn: That is not acceptable.
Ranking Member Richard Burr: "VA-- VA focuses on medication management."
Mary Schohn: That is not acceptable and we have a huge policy and training program to ensure, in fact, that veterans have access to evidenced-based psycho-therapy.
Ranking Member RIchard Burr: "Can't fill appointments for the proscribed amount of time."
Mary Schohn: That -- I'm not totally clear what that means.
Ranking Member Richard Burr: I would take for granted that an attending has said somebody with PTSD needs to have X amount -- a frequency of consults, a frequency of treatments and it should extend for X amount of time. Would you find it unacceptable if, in fact, the system was not providing what the health care professional prescribed them to have.
Mary Schohn: Absolutely. We do have a system set up in place to actually monitor if in fact this is not happening, we are concerned by reports that it's not happening in places, we have many evidences of places where it is happening, but as we hear these reports, we are as concerned as you are and have developed a plan to go out and visit sites to ensure that these things are happening and to make corrections when they're not.
Ranking Member Richard Burr: The inability to get appointments.
Mary Schohn: Same thing. We -- The VA is available to veterans. We want to assure that any veteran needing medical health care has access to health care in the timeliness standards that we think are important.
Ranking Member Richard Burr: "Mental health treatment is trumped by new entries into the system."
Mary Schohn: Again, not acceptable.
Ranking Member Richard Burr: These are all issues that exist with the current mental health plan at VA.
Again, Burr covers many of the issues raised by the first panel. Now we're going back to the issue I was raising. All three heads of the beastly cerbeus lack a medical degree. And yet they're evaluating mental health care treatment being carried out by doctors with medical degrees. Okay. Well an administrator with a degree in administration can be very effective. But yet again not one of them has that either.
Part of the problem -- a very big part of the problem -- is that they're not qualifed. A large number at the VA shares that quality. They were basically grandfathered in -- often during the eighties -- some were psychologists, some were social workers. It's past time that when this class that's graduated to management repeatedly fails that their qualifications for the position they hold are examined. And when their qualifications are found lacking, they need to be reassigned to an area they are qualified for. And those who would argue experience is a qualification, I don't doubt that it is and can be. Except when there are the same repeat problems. At which point, clearly the experience or alleged experience is not making up for the lack of formal education in the required field.
Further evience of failure can be found in, as Senator Burr noted, the fact that there has been a 136% increase in the VA's mental health services budget since 2006 and yet when the VA's Inspector General surveyed the VA centers, it was discovered "only 16% of the sites they visited met the staffing requirements for mental health care." That's something good adminstrators are aware of and on top of before an IG researches the issue.
In the excerpt of the exchange with Ranking Member Burr, Zeiss brags about flexible hours -- but they clearly aren't flexible or VA centers would have changed them on their own. Mary Schohn talks about how when she hears of a problem it makes her think they should check out a VA center. I'm sorry, I thought their job did require supervision. In fact, it does. They're really not paid the big salaries they are to write manuals every other year. They're paid to be administrators who supervise and ensure a quality of care. This is the Walter Reed Army Medical Center scandal only because the wounds are mental and/or emotional and not solely physical, the press appears little skittish to really sink their teeth into this story.
If a veteran lost a limb would it be acceptable for them to wait 14 days for care? Then why is it acceptable for that time limit to be considered a good time limit for someone with mental or emotional wounds?
It is unacceptable.
And it is unacceptable that Mary Schohn appears to think she never needs to check out the facilities unless there's a complaint to Congress. It would never get to that level if Mary and the other two heads of the cerberus were doing their job.
It was a strong hearing. Senator Jon Tester had a very strong exchange. The first panel had witnesses who were really honest. Senator Daniel Akaka, who used to Chair the Committee, showed up and underscored with Chair Murray and Ranking Member Burr just how important these issues were and how unacceptable the VA's problems are.

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