Thursday, April 26, 2012

Roeper takes one for Barry



More than 40 years after Richard Nixon said, “Sock it to me!” on “Laugh-In,” some 20 years after a sunglasses-wearing Bill Clinton played the sax on Arsenio Hall’s show, we’re long past the point of being shocked when presidents or candidates play the rodeo clown on TV. They’ll do what they gotta do to get elected or stay in office.




An important hearing took place in DC this morning.  Before it started, Morning Edition (NPR -- link has text and audio) was explaining the problem.  Excerpt.
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.

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