Thursday, June 04, 2015

She's no bachelor



This afternoon, the Senate Veterans Affairs Committee held a hearing on proposed legislation.  The first panel was made up of the VHA's Dr. Thomas Lynch, Dr. Maureen McCarthy and Susan Blauert.  The second panel was made up of Disabled American Veterans' Adrian Atizado, Medicalodges, Inc's Fred Benjamin, Fleet Reserve Association's Thomas J. Snee and retired SFC Victor Medina.

Senator Patty Murray: To this panel, Dr. Lynch, I wanted to ask you about the Women Veterans Access To Quality Care Act.  I was really pleased to work with Senator [Dean] Heller on this legislation.  As I'm sure you all know the population of women veterans is increasing dramatically.  It's actually doubled since 2001.  This bill will require all VA medical centers to have at least one full time OB-GYN.  And I want to ask you today, how long will it take to meet that standard?  And does the Department usually struggle to recruit OB-GYNs?

Dr. Thomas Lynch: Right now, VA has GYN specialists in 78% of our VA facilities -- about 118.   There are plans to add additional GYN providers, uh, by directive to, I think around 20 more facilities, as part of our operative complexity model.  Uh, the VA has a model of operative complexity that looks at a certain infrastructure required to support surgical services at facilities.  Uh, the mandate would be that all of our complex and intermediate facilities would have a GYN provider.

Senator Patty Murray:  Sure.

Dr. Thomas Lynch:  Some of the smaller facilities -- and, unfortunately, Senator, I don't have the exact count for you --  would have difficult supporting a full time GYN provider and, in some of those case, care is provided through community contract. So I think --

Senator Patty Murray:  So if you do not have an OB-GYN, you do contract out to a community OB-GYN?

Dr. Thomas Lynch:  The expectation would be yes, that we would provide those services in the community if we could not provide them at the VA. 

Senator Patty Murray:  So you can meet the needs of this bill?
Dr. Thomas Lynch: Dr. McCarthy, would you like to?

Dr. Maureen McCarthy:  I-I believe that we could meet the intent.  Uh, which is to do what Dr. Lynch said which is based on the surgical complexity, that there would be a plan to hire for all the facilities, that there would be a certain level of complexity and hire.  But for the facilities, the smaller facilities, there is the expectation that there would be access to care either in the community by contract or by having someone actually come into the facility.

Senator Patty Murray:  Do you have a timeline on how long that would take? 

Dr. Maureen McCarthy:  No, ma'am, I don't.  Some of our facilities are in areas where it may be a challenge to recruit and so I couldn't give you an absolute timeline, I'm sorry. 

Senator Patty Murray:  Okay.  Well if you can give me an estimate, I'd really appreciate it.

Dr. Maureen McCarthy:  Would you be okay if I took that for the record?

Senator Patty Murray:  Yes, you may do it for the record.

Dr. Maureen McCarthy:  Okay.

The VA keeps saying it's aware of the explosion in the number of women veterans but every time they appear before Congress they're offering statements that say otherwise.

At the very least, Lynch should be able to say, "We will have a full time OB-GYN at every VA medical facility who have a need for one or we will have a contract with a private practice provider."

There's a lot of hedging and, honestly, I was bothered that Lynch can't refer to the doctors as OB-GYN and instead goes with GYN.

It's obstetrics and gynaecology -- if you divide it up, you're dividing up what's being practiced.

Just the use of GYN only made me wonder what Lynch sees the practice as.

Murray's long been the leading advocate on women veterans issues as well as on the issue of family planning (highlighting the needs for the VA to cover in vitro fertilization, for example).  Senator Richard Blumenthal is the Ranking Member of the Committee and his addition has allowed one more voice who consistently raises issues that effect women veterans.  Murray is the former Chair of the Committee.  With Republicans in control of the Senate, the Chair is now Johnny Isakson.

Senator Patty Murray: Dr. Lynch, one provision of the Homeless Veterans Prevention Act would allow the grant per diem program to provide payments for dependents who are accompanying homeless veterans.  This is an important change to consider as the number of veterans with dependents -- especially women -- is rising.  Now VA has stated that they support the intent of this part of the legislation but it raised concerns about the need for additional resources to meet the needs of the veterans that would be served.  If this unmet need is still there, why did the VA ask for cuts in the grant per diem program in the budget request?

Dr. Thomas Lynch:  Senator, I'd have to get back to you with the specifics on that. I can't answer it.  I know that we certainly do support the Homeless Veterans Prevention Act.  Uh, we do support, uh, the increase in per diem for veterans participating in the grant per diem program and the transition in place.  Uh, I can't comment specifically on the budget issues that you're speaking to right now.

Senator Patty Murray:  Okay, if you can get an answer back to me?  That's really an important question.

Dr. Thomas Lynch:  We will do that.

Senator Patty Murray:  And finally, Dr. Lynch, it's really essential that we make sure our veterans have seamless transition from DoD to VA's healthcare systems.  But there are still a lot of barriers out there for our service members and veterans.  And one frequent problem for new veterans is having to switch medications when they leave the military and come into the VA because the departments don't carry the same medications.  What are the differences in how the VA and DoD decide which medications to carry?

[Lynch and McCarthy off mike speaking to each other]

Dr. Maureen McCarthy: Senator Murray, the VA formulary is one that is based on published evidence of drug safety and effectiveness.  So there is a process of consideration once a drug is approved by the Food and Drug Administration of whether or not it be included in the pharmacy.  The DoD formulary is one that's statutory -- that anything approved by the FDA is part of the DoD formulary. So the VA formulary is one that has a, uh, a second level review, uhm, for evidence based -- evidence base, efficacy, safety and so forth.  Our formulary process has been reviewed by Inspector General, oh, multiple-multiple Institute of Medicine, multiple people.  And what they say is our-our forumlary is actually a model for the federal government.

Senator Patty Murray: So how come the DoD hasn't done that?  You're probably the wrong people to ask, but you're here.

Dr. Maureen McCarthy: You're probably exactly right about that.  We, uh, we-we feel very strongly that we want to work with DoD and we want to ease those transitions very much but I don't know that the answer is to have exactly the same formulary given that theirs is this statutory  formulary by regulation -- then it's everything that's approved.  Uh, for us, it, uhm, it makes sense.  I believe Senator Blumenthal proposed legislation talks about, uhm, the, uhm, medications related to pyschiatric conditions as well as pain.  And I think that's an important place to start.  And in particular his legislation talks about systemic drugs not topical meds which have-have caused some problems in the past.  So systemi- oral meds that we prescribe for psychiatric conditions and pain would be uh-uh a very, uh, important place to start for blending. 

Dr. Thomas Lynch: If I could, Senator, I would just repeat from my opening statement: Right now 90% of mental health medications and 96% of pain medications dispensed by DoD are also on the VA formulary.  And we also mentioned that there was a specific, uh, directive sent to the field, uh, that veterans will be maintained on their discharge medications from the military, uh, when they transfer to the VA if that is clinically approriate.  I would add that qualification.  But we would not take veterans off of medications that they had been receiving from the military if it was felt to be appropriate to continue those medications. 

Senator Patty Murray:  Okay.

Dr. Thomas Lynch:  I realize there are still -- as you will probably hear in the second panel -- there are still areas where we have failed.  We can do better and we need to do better to make sure that that transition occurs. 

Senator Patty Murray:  Okay, we want to make sure there are no barriers but we also want to make sure people are taking the right medications.  I understand the balance.  But we need -- some attention really needs to be focused on this. 

Chair Johnny Isakson:  I thank Senator Murray for raising that question.  And I'll just make an observation.  I'm not a pharmicist or a physician but it doesn't make a lot of sense to me for the formularies to be different from DoD and the Veterans Administration.  And I know Senator [John] McCain is working on that same issue and we've expressed our desire to see if we can't get that worked out, so I appreciate your focus on that issue today.

 That exchange bothered me first and foremost because of the problem it's creating for veterans -- we'll go more into that in a moment.

But I'm also bothered by the notion that the FDA isn't doing its job.

That's what the VA is arguing.

The FDA is tasked with a responsibility and DoD doesn't question it.

But the VA thinks its their role to do so?

The FDA is tasked with determining what is safe for the American public.

But the VA doesn't accept the FDA's verdict.

RECOMMENDED: "Iraq snapshot"

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