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tv   Key Capitol Hill Hearings  CSPAN  June 10, 2015 8:00pm-10:01pm EDT

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poll was that? caller: guest: i do not think there is a lot of doubt throughout the region or the united states about the existence of a nuclear weapons capability and israel. i also do not think that the question of official u.s. technology meant -- acknowledgment on that issue would make a significant difference to the problems we are talking about. and the long run, i think we would all agree that it would be best if there were no nuclear weapons at all in the middle east. again, i do not know that on the issues we're talking about or frankly on the nuclear issues like the iranian nuclear issue. >> by their insecurity, their
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concern about the military power being used to stop and rest and the drive for germany existed and i am not sure that is an essential variable in this debate. >> host: we hear from bety next in ridge new york independent. >> caller: i agree with a lot of what you are saying. and first of all, we dropped bombs on japan. i don't know what happened with 911 --
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>> host: the house is about to open doors and gavel in so i have to go. i want to ask you quick about the president is set to expand military advisors in iraq. what do you think is the motivation there? >> the best way to do that is having partners on the ground we can work and the iraqi military force is the best choice. phillip gordon now with the senior fellow on council and foreign relation and his piece is in politico. >> coming up tonight, a hearing on veterans' suicide and a link to medications. and then we hear from the tsa nominee and then from david shop
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shapiro, the president's pick to lead the u.s. postal team board of governors. wednesday, a testifying about veterans suicide and heavy rely reliance on medication. this hearing on oversight and investigations is an hour and 40 minutes. >> good morning. this hearing will come to order. i want to welcome everyone to today's hearing titled prescription mismanagement and
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the risk of veteran suicide. before beginning, i would like to ask unanimous consent the statement from the american legion be entered into the hearing record. no objection so ordered. this hearing will examine the relationship between veterans prescribe prescribed medication and the increaset suicide rate among veterans. in a report issued in november of 2014, a hearing on veterans disorders it the extend they were prescribed medicine the extent of proper care and
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whether va monitored that care and the information required to collect on veterans suicides. it is now clear that va is not even aware of the population of veterans with major depressive disorder due to inappropriate coding by va physicians. as a result, va cannot determine if veterans are receiving care consistent with the clinical practice guidelines. these treatments are vital and are designed to provide the maximum relief from the debilitating symptoms associated with mental health. it is imperative our veterans receive the proper care and follow up by receiving mental health care. especially when they are being prescribe
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prescribe prescribed various medications. what is also becoming clear is that va is receiving and reporting inaccurate and inconsistent data regarding veterans suicide. this severely impacts and limits the department's ability to accurate accurately evaluate the efforts and identify trends in veterans' suicide. not only did the committee conduct a hearing in 2010 on this same issue but since then there is countless media stories of veterans being over med medicatted. the proper follow up and monitoring and the all too common result of suicide.
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>> we will hear stories here today highlighting the problems occurring within the va for years and continuing today with regard to treatment of veterans with mental health. with mental health concerns and adequate programs and more importantly the actions taken to insure veterans who are prescribed countless medication receive proper follow-up. va has approximately 10 different programs dealing with prescription medication and suicide prevention issues. but it does not appear that any of these programs interact with one another. no one is talking to anyone
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else. how can we insure that the veterans are getting the proper care, the proper follow-up, and the proper advice if the right hand doesn't know what the left hand is doing. i think it is more appropriate to say based on the statistics from the goa report and in numerous media stories the va is throwing out a bunch of different ideas and programs hoping one of them will stick. and they can claim they have solved the problem. this is unacceptable. we need to know what va is doing to change this pattern and what is it doing to improve protection of veterans. what is a real way forward? who will be held accountable for
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mistakes that have been made and cost veterans their lives? who will stand up and take responsibility for making a change? it is time to answers. it is time for change. with that i yield the ranking member kuster for any opening remarks she may have. >> thank you mr. chairman. good morning to the panel and thank you for being with us. we are addressing an issue affecting veterans and over a hundred million adults. the statistics on veterans experiencing chronic pate is staggering. 50% of all veterans receiving care at av medical facilities experience chronic pain with half a million veterans managing pain with prescribed opioids. as a nation and in my district throughout the northeast we face
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what can be described as an opioid abuse epidemic. the centers for disease control and prevention has termed opioid abuse the worst drug diction in the country's history killing more people than heroin and crock crack cocaine. we must remember veterans experience chronic pain suffer from meant health disorders like pdfs and traumatic brain injuries. it is important to have mechanisms to monitor the safe use of opioids for manage veterans' pain. i am concerned of self medication and addiction being prescribed opioids for pain management. we know the va has struggled to
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monitor the precriptions and the patients. i am concerned a deadly mix of opioid use, mental health disorder and lack of oversight is contributing to the high rate of veteran suicide. the newest drug enforcement regulations that require veterans to see a doctor monthly creates a burden on veterans having issues getting there leaving them in pain and giving them withdraw symptoms. this hearing provides us with the opportunity to begin to seriously examine whether the benefits of managing the veterans pain with opioids is outweighed by the risks and the va's struggling to properly monitor the use.
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i would like to hear from our witnesses how we can better address safe and effective treatment of veterans while insuring care management is not forgotten. i would like to discuss whether a high level of informed consent is needed to insure veterans and their families understand the risk and side effects before choosing to manage passenger with opioids and whether the va is properly coordinating mental health and suicide prevention programs with va clinicians responsible for monitoring the opioid use. i am interested in alternative pain management and whether, as i get to my comments later, i will talk about what is happening at the white river junction da in bringing down the rate of opioid prescriptions and how we can help get ourselves out of this problem, out of this cycle, and address the veterans to serve their needs without
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putting them and their families at risk. and finally, i would like to discuss what is being done to reduce long-term opioid use and treat the underlying conditions causing chronic pain so that veterans are able to live a better quality of life. thank you, mr. chairman and i yield back the balance of my time. >> thank you, ranking member kuster. i will introduce our witnesses in one moment. but i ask that the witnesses stand and raise their right hand. scribed do you swear under a penalty of perjury your testimony you are about to provide is the truth, the whole truth and nothing but the truth? please be seated. i am like to recognize jeff miller chairman of the veteran committee. >> thank you, mr. chairman and
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ranking member and thank you subcommittee all the work you have done over the years. if i might, i want to ask ms. clancy a couple questions. i believe you have been made aware i am going to be asking a couple questions all be it a little out of order. i want to talk specifically about bradley stone. we know he was seen by his va doctor before committed murders and dying of suicide. he was on many, many prescription drugs and had alerted the va as i understand it to mental health and physical difficulties in the weeks leading up to the incident.
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but it appears that the va said he showed no signs of suicidal or homicidal ideations. i would like to know how the va >> people would ask the veterans a series of questions about thoughts of harming themselves and so forth to get assessment of suicide risk. my conclusion if the clinician said would be the veteran gave negative responses to those questions. >> on the 24th of april of this year i asked the department if
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it would confirm whether or not they had provided the full committee with all of the files related to bradley stone. to date i have not received a response. so again i ask you has the va provided this committee with all of the files on bradley stone? >> i had been told that va had provided the committee with the files with some redactions and provided an in-camera review. the redactions were about social security numbers and some information that was about sensitive details about the living family members of bradley stone and offered to discuss that with the committee and camera. >> and again as i have stated in every single letter sent to the department requesting information, an in-camera review
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is not acceptable. that is not at all acceptable. and the staff is informed you and the department, that i would ask a particular question. i ask you, again has all of the information -- and i would go back to -- i sent the secretary a letter on april 24th, where i referred to ms. diana ruben's director of the regional office on april 22nd saying the philadelphia regional office provided everything related to mr. stone's file and her response was unevequivalent and yes. i am taking from your comment today everything that she provided to the central office the central office has now provided to this committee? >> since i am under oath i am going to be very careful. i cannot speak for what diana
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ruben is telling you. i have been informed by our lawyers that we have provided the committee with the records, and the redactions i mentioned, social security numbers and sensitive details about the living family members of ms. stone. >> for the record, mr. chairman and dr. clancy i know va has withhold hundreds of pages related to the bradley stone file. and so with that i would say that we have requested all of the documents every way we know how. so i will ask you one more time. can i expect the department to deliver the complete records by the end of this week? >> i will take that back and i will verify what i have been told. we have given this committee everything except for redactions
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i noted earlier. >> i can assure you it is missing >> i will bring that message back. >> we expect the behavioral health autopsy and an in-camera review is not acceptable and i ask will you commit that all of the documents i have requested will be provided by the end of the week? >> the behavioral health autopsy is a unique feature of watt we do at va health care for veterans. rather than having a private, limited to the people at the facility root cause analysis or deep dive of what happened when a veteran takes his or her own life this is something we centralized so we can learn across the system what factors precipitated the suicide, and what we could have done better
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and it involves a conversation with the family none who have been told we would be sharing their details with members of the committee. we think it will have a chilling affect on family members sharing sensitive details and are uncomfortable sharing that behavioral health autopsy. >> thank you for sharing that. we are the legislative branch and you are the executive branch. we have oversight over the department and unre-redacted information if you chose to withhold he will subpoena it. >> can i expect the documents? >> i will take it back. >> i would like to add on a
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positive note. i was in cincinnati and dayton the day before. i want to thank you for the good job being done at the facilities there. there has been a great change and i enjoyed the opportunity to spend a couple hours with the people in cincinnati. we do focus on a lot of the negative and the press likes to focus on that as well. but i want to commend you on some of the great things. i would hope some of the good things specifically at cincinnati would be shared throughout the dha and the rest of the department. thank you very much. >> if i might for one second first, thank you very much for that. i know how hard those people work. cincinnati is the hub of expertise in intensive care for our system and they provide remote -- >> i had a chance to view it. >> it is great. thank you very much. >> mr. chairman, one point, dr.
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clancy the va has turned over behavioral autopsy to this committee before. so so, ranking member kuster? >> as a health care attorney who worked in this area for a long period of time in the realm of quality asurrance what this is about is it is intends for physicians to grow and learn from the experiences. and i am concerned at the impression that the might be left with the veterans and family members, particularly the family members who have been through the trauma of a suicide this information would be treated private because these hearings are televised.
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i don't want to have a chilling affect on families sharing the most personal aspects. we have a stigma around mental health and people seeking treatment and i would be concerned if we left the impression today that we are in somewhere digging into private affairs. if there is information about living family members that is not relevant it could be extremely personal and i guess i just don't understand why we could not do that in a private setting or in a redacted way? why this committee would be trying to determine -- and i am speaking if you believe there is documents that haven't been provided that is a separate matter -- but under our statutes in the state private information in the quality asurance process
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is private and not to be shared and the purpose of that is so people come forward. >> thank you very much. i appreciated the expertise you bring to the committee and subcommittee. you can rest assured we are trying to hold people accountable. we are not trying to release information that is personally identifible. this is a suicide and a murder. we have gotten this information before from other incidents. this one is particularly
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grevious because of the murders that took place. we are given oversight of the executive branch and we are not bound by hippa laws. this is not political. we are trying to get to the bottom of a very tragic event. we are trying to partner with the va as well. and right now, they are not being as open as they should be. there are documents that are clearly missing from the file. documents that i believe are damning and would put the va in a negative light. i understand that.
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you cannot remove the documents from the file because it makes you look bad and that is what we are trying to get at. i thank every member of the subcommittee for the job you have been doing. i thank you for the good work. >> i ask other members wave the opening remarks. hearing no objection, so ordered. i would like to introduce our panel with that. on the panel, we have dr. carolyn clancy. michael valintino. dr. harlot -- herald cutter and
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randall williamson and the research director for the iraq and afghanistan veterans of america. dr. clancy you are recognized for five minutes. >> good morning, chairman coffman, ranking member and members of the subcommittee. one of the most important priorties is at the va is keeping veterans from harm at all times. i am deeply saddened by the tragic outcome involving a veterans veterans. to families here or watching woo who have lost a loved one i want to appreciate my sorrow. we will honor by learning from
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your cases and improving care. we acknowledge we have more work to do reduce opioid use, meet the increasing demands for mental health and prevent suicides and we have taken significant actions to improve these areas in order to better serve veterans. as ranking member kuster said chronic pain is a national problem affecting a third of the nation's adults population and half of veterans from recent conflicts. as a result a number of veterans and americans rely on opioids for pain control. they can be effective for a while until the side effects become quite worisome and mixed with other drugs they can have additional adverse unintended affects. we have adapted a number of initiatives to enact our goal of pain manages management and
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making the number of opioids visual. starting july 1, we will expand on an approach called academic detailing which consist of one-on-one coaching for every single clinician prescriber in our system. in addition to information about effective use of medications, this approach also works for clinicians to have a difficult conversation with veterans to help them try other alternatives for pain management and so forth. i think it is important to note many of the veterans we serve come to us transitioning from military service on opioids and abrupt discontinuation is not
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possible or appropriate. we have to continue to taper the doses. we have seen some successes and those with the least amount of problems have tended to do better better than those experiencing more severe pain. suicide among veterans is complex and tragic. those of us who have lost a loved one to suicide know the deep and lasting pain. we worked with scientific partners to understand suicide among the veterans receiving va care and all veterans across the nation. we know the treatment works. we have identified many positive outcomes for veterans receiving our care. for example, the rate of repeat attempts at suicide among veterans who have attempted to take their own lives has declined for veterans enrolled in the system. between 1999-2010 the suicide
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rate among middle age males fell by 31% using our system at the time the suicide rate for middle age men who are not veterans or using our system rose. the rate of suicide among women veterans is higher than other women in the general public but women veterans who use our system are less likely to die from suicide when compared to other women veterans. our research allowed us to estimate 22 veterans die by suicide every day. what is less well known is 17 of the 22 do not receive treatment for care within the va system. i worry that some of the 17 are seen in the system and fearful of raising mental health concerns because of stigma or
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privacy. suicide prevention has to extend to veterans that don't seek our help. we have increased targeted outreach efforts to veterans in communities throughout the country and made it easier for anyone to call the veterans crisis line. you will not have to hang up and call a line. you can hit a number on the phone and that will transfer you. i want to express appreciation for the clay hunt act and the passage that will expand our capabilities to help veterans so thank you for that. the importance of mental health treatments, i don't think, can be overstated. about 20 years ago in this country we did not recognize how important a challenge mental health care is for
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all-americans. at va we have embraced the problems that veterans from returning conflict brought to us whether that is various mental health problems post traumatic stress traumatic brain injuries and so forth. we have had to blaze trails doing so. we have had to go ahead in the health where utileization of mental health has been controlled over the years. that meant we have had to work with public and private science partners to build the basic science, the data, and the population health expertise. we have learned a lot made significant gains, and seen the successes of treating mental health problems. but we have so much to do to dispel the stigma of mental health issues. it wasn't that long ago that cancer inspired that whispering
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and people didn't talk about it outloud because of fear and misinformation. we hope with your hope and the help of many partners soon we will be able to eliminate that fear associated with seeking mental health care. we are focused on creating an atmosphere of trust and privacy. we are committed to improving our existing programs, taking every action to create new opportunities and most importantly improving the quality of life for veterans. we are compassioniately committing to serving those who served. we are honored to have this privilege and are prepared to work with you until we get this right. thank you. >> mr. williamson you are recognized for five minutes. >> good morning mr. chairman miller and ranking member kuster. i am pleased to be here to discuss our november 2014 report
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on vha's effort to monitor major depressive disorder who were prescribed one or more anti depressants. this is a mental health associated with severe depression and reduced quality of life. i will focus on certain aspect of the suicide prevention problem. i will discuss the mdd, the rate of anti depressants prescribed, and the data collected. 10% of the veterans receiving hillary clinton were diagnosed with mdd and 94% of them were
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prescribed one or more anti depressants. the estimated of veterans with mdd may be low because we found vamc's didn't always correctly report and record confirmed mdd diagnoses among veterans. we reviewed a sample of veterans with mdd prescribed one or more anti depressants and found they didn't receive care for three important recommendations in the clinical guidelines that was established to guide clinicians in treating mdd. for example, although the cpg recommends a veterans depressive systems be assessed using a standard tool at 4-6 weeks after initiation of anti depressant
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treatment, we found for 26-30 veterans in the sample the va clinician clinicians didn't use this tool or within a specified time frame. not mandatory for clinicians but the recommendations are based on evidence-based data from clinical trials and research and meant to enhance the outcomes for veterans with mdd. and moreover there is not a process to monitor the extent that the clinicians deviate from the recommendations. with little if any, visibility over whether the care provided is consistent with the cpg the va is able to insure that deviations are identified and evaluated and whether appropriate actions are taken to mitigate potential risk to veterans. finally we found demographic and
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clinical data collected on veterans suicide to better inform the suicide prevention program were often incomplete and inaccurate. as part of the behavioral health autopsy program bv is what i will refer to it it creates the number of visit and last va contact. we examined 63 report and found 2/3rds contained inaccurate and incomplete information. this is made worse because the reports are not reviewed at any level within vha for accuracy completeness and consistency. this lack of data doesn't allow us to learn from previous
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suicides and diminishes efforts to develop programs that reduce veteran suicide. the va made good progress in addressing the six recommendations to improve weaknesses we noted in our report. in the six months since the report was issued one recommendation has been fully implemented and several others are very close to being implemented. this work illustrates a continuing pattern of vha's non-compliance of policy and procedure and inaccurate data and poor oversight. this is among the same factors to include vha on the high risk. until a culture is instilled that holds staff and managers accountable for affectively performing their responsibilities and overseeing outcomes and achieving a
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recognized standard of excellence they will continue to fall short of providing the highest quality of care to veterans. this concludes my opening remarks. >> thank you, mr. williamson for your remarks. doctor, you where recognized for five minutes. >> chairman ranking member and the subcommittee on behalf of the veterans for america, thank you for letting us share our views on medicine and potential risk of suicide. iada launched combat suicide prevention and celebrated the clay hunt act into law. this was a first step on a long road to address the challenges of combat and suicide among
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service members and veterans. the issue we are here to talk about is complex because it is two topics. providing care for veterans seeking relief from chronic pain, mental injuries and other conditions and recognizing the potential for misuse and abuse of the powerful drugs. these drugs are powerful, but they can be extremely effective for a veteran. chronic pain affects approximately a hundred million adults and this number is growing. given the physical demands on the troop we have seen a similar trend among service men and veterans. over 60% of the iraq and afghanistan veterans seek care for muscular care element and this is the most common category for disability. nearly 60% seek care for mental injury. the members survey reported
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experiencing chronic pain as a result of their service. 1-5 reported using prescription opioids and 1-3 using anti-anxiety or anti-depression medicine. medical advancements allowed for higher survival rates from injury but increases the impact of nerve and skeletal damage. treatment of pain can be complex because other conditions like depression, anxiety, pdfs or tbi, may limit treatment options. for clinicians assessing pain and devising a strategy to be difficult particularly given knowledge in this field is still growing. primary care physicians who say the bulk of patients report they feel underprepared to treat the patients due to lack of training
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this included va providers surveyed in 2013. untreated pain can put an individual at higher risk of suicide. yet we know that prescription medications are result in strong addictions and provide a means for suicide attempts. half of non-fatal suicide attempts results from overdose or intentional poisoning. this highlights the challenges that clinicians face when treating patients with complex injuries and demonstrates the importance of integrated pain management management. the va published an evidence-based guidelines opioid safety initiative and introducing a pain management system but more remains to be done. with approximately 22 veterans dying by suicide every day and more attempting suicide reducing instances of
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overmedication and limiting access to powerful prescription medications must be included in a comprehensive approach to addressing this issue. a recent study showed patients receiving opioid therapy are at an increased risk of attempting suicide, following the guidelines reduced this. they showed the critical need not only for these guidelines but implementation of the guidelines. va's 2009 director on pain management expired in october of 2013. it expired in date and remains active but updating hasn't been prioritized. we urge the va to prioritize and fully implement this at all facilities. we would like to focus on the risk of men minimizing the risk of overdosing on prescription
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take back. an important change to dea regulation expanded operations for drug drop off sights giving the va the ability to have drug take back programs in the hospital and this is critical to limiting the chance of abuse of powerful drugs but no action has been taken. while the va is working to fully implement its roll in prescription monitoring drug program full implementation remains to be scene and we urge the va to prioritize this as well. too often we hear stories of veterans who are prescribed anti psychotic drugs or opioids with little follow up. and we hear stories in pain and doctors not considering the request for stronger medication to manage the pain. these are tough challenges and
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we are committed to working with the va and congress to address them. again, thank you for the opportunity to offer our views on this important topic we look forward to continuing to work with each of you, your staff and this committee in this critical year ahead. thank you for your time and attention. >> thank you, doctor. i appreciate your testimony. who is next? okay. thanks to the witnesses. dr. clancy according to a jo report va deviated from the guidelines in most of the 30 cases reviewed by not assessing anti depressant treatment properly. is the policy ignored or lack of oversight by leadership in your opinion? >> first, i want to say we
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regard the recommendations, feedback is important, a gift if you will to help us get better. i am not sure that any guidelines written on planet earth should be followed a hundred percent of the time. many doctors think of them as tools not rules because there will be patients with unique circumstances that don't fit perfectly. in terms of the follow-up assessment, i think that is important and we need to do a better job. we will be looking to see whether that is a feature of the fact that we were having access problems and it was hard to get people back in or when we were not on the ball. -- whether -- that is an important feature. >> we found veterans dying from drug toxicity reported hallucinating and reported suicidal thoughts. are these the improved outcomes you are referring to?
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>> no, they are not. >> the va noted it would conduct chart reviews and develop a plan to determine and address the factors contributing to coding variances. this was to be completed -- are you still working on that? >> it is in progress. in addition i have been meeting inspired by the report and other feedback from the mental health leaders in our system to figure out who are the veterans we think are struggling the most with mental health disorders, that we should be targeting two make sure they are getting the best possible care. >> thank you. who do you think that report is -- when -- going to be done? >> i will double check on when we committed to having the recommendations done. >> the va stated it would
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examine associations between treatment practices and indicators of recovery or adverse outcomes for veterans being treated with anti depressants. the target date of completion was march 2015. has this been completed? >> i believe it has. i would have to double check my notes. >> can you get a copy of it? >> absolutely. i will submit that. >> 63% of the behavioral health autopsy reviewed critical data was missing. is this inaccurate reporting based on not being competent or is it to keep the central office in the dark? >> i have no reason whatsoever it is to keep the central office in the dark. i understand the program was
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transitioned from the root cause to a central repostory and training reviewers and people doing the interviews collecting the data to collect the data consistently and accurately took time. and frankly iterations to make sure we were getting it right. do you want to add to that? >> at the time the goa was conducting the study the behavioral health autopsy program was being lunchaunched. it has been refined and the cordinators, 300 of them, who fill them out have been taught more as well. there were questions and they have been addressed through the training and we are reviewing all of these centrally and nationally. we created software to another
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suicide prevention center so we can accurately look at them for perspective. this progressed a great deal since the original report and we will continue to work on it. >> the committee has requested the behavioral autopsy for numerous veterans and in all cases except one holmes, va stated this information is private private, why was the report to ms. holmes released but not others? >> i would have to take that question for the record. i would say in general the behavior health autopsy reports, i think the ranking member kuster described this more clearly than i could, this is
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quality asurasurance and if people think this is going to be disclosed disclosed we will not get information that is forthright. >> we are concerned about the veterans and the committee has oversight responsibility for your operation and we cannot do that oversight operation and making policy that is best for the veterans if you don't fulfill your obligation and submit that information when requested to the congress. >> ranking member kuster? >> thank you. i appreciate you being here and the veterans returning from the
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14 years in conflict. the injuries are complex but the good news is people are surviving but the difficulty is chronic life long issues. i want to focus on how we move forward -- i share concerns about the data and making sure we are getting at the heart of the issue here -- but i am interested, i had a meeting with the team at the white river junction facility and there is cutting-edge research and i am i will talk to the chair about sharing this. but the opioid safety initiative. and a couple different things and whichever is the appropriate witness. one is getting at the heart of what is causing the pain. my husband has various years of backpain and they found out he
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needed a back replacement and lives pain-free with yoga and exercise now. i would like to find out what is being done to get at the crux of what is causing the pain. and secondally setting a goal of reducing the use and worker with practitioners of bringing down the use and emphasizing education, close monitoring, they talked about actual drug testing because in our area, selling the opioids on the market, people will not use the medication themselves and they can determine that through frequent drug testing, which is not poplar with the patients as you can imagine and then alternative medicine -- yoga, massage, exercise -- if you comment on the opioid safety
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initiative. is it in use? what can we do to move that forward? >> those are all terrific questions. i will start and turn to mr. valintino. we have have a clinical practice guidelines on the management of chronic pain and as of september this year it will be updated. we will be having input from the veterans and family members. the guideline does include urine drug testing periodically and we have, as i mentioned too quickly probably in my opening statement, made a series of steps under the umbrella of the opioid safety initiative and made data of the prescription
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patterns available and visible so that clinicians can see what this patient has been on over time, what other drugs they are on, and so forth. getting to the root of the problem, i think is incredibly important and i would be happy to submit and brief anyone any time about the exciting research we have in process. i think it is very important. i think there is a lot we need to learn in two areas. one is what are they predictors of veterans, or anyone who is likely to use opioids for a short time and go down the path of using them on a regular bases? if we knew then that is who we would target a lot of effort. the second is which veterans are most likely to respond to treatment of non-narcotic information and so forth. as i said we have some research going on in that area and a lot more to turn. mike, you want to add to that?
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>> yes, thank you. so the opioid safety program is just shy of two years old. and we have had to build it from the ground up and as dr. clancy mentioned we focused on data to identify outliar problems. the next iteration was to continue to drill down on the va facilities and identified outli outlyers. we are poised at the moment and built the tools and are validating them to accuracy to drill down to the individual provider and patient level. this is very complex.
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someone may show up at as out layer or maybe they treat cancer pain or pain specialist. we have to get it right so there is confidence in the tool. we have had good results. i will go through some of the metrics. since beginning, we have fewer than 11,000 patients receiving opioid. 34,000 using opioid and benzo together. 75,000 patients had a urine drug screen who were on long term opioid use because that is definitely an opportunity for diversion and we want to make sure it patients are taking it. we have 92,000 patients on
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long-term opioid use which is longer than 90 days. we looked at the total opioid burden. there are many opioid drugs but you have to boil them down to a common denominator. morphine equivalent. >> i am sorry, my time is up. i am interested in what you have to say but my colleagues need a chance. >> let's see if we cannot run the clock out on the answers. >> i would like to thank the chairman for bringing this important issue to light. unfortunately, it comes too late for one of my colorado springs families. i would like to tell you the story of noah. a former marine who served in iraq with honor in 2009 and afghanistan in 2011. i am not use his last name but his parents offered the use of his picture. so if i could just show you noah's picture.
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after leaving the marine core miller began work on a business degree at the university of colorado at colorado springs and started his own online business based out of colorado springs. noah comes from a military family. his dad having honorably served for 23 years. noah put off college so he could serve the great nation. his parents are appalled by the care their son didn't receive from the va. they believe their son would be alive had he received better care. noah was diagnosed with ptsd and received a 50 percent dispability. he went to the va carolyin clancy -- clinic and the notes state suicidal ideas. he was prescribed a psycho
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tropic drug and sent on his way. we don't know at the time what the drug did or didn't do. he wasn't referred for suicide prevention he wasn't offered counseling and there was no follow-up from the va. he went missing the evening of may 4th and found dead from an apparent suicide may 12th of this year. a months -- a months ago. his family is devastated. i would like to ask questions on their behalf. why was their son who was document documented with having suicidal thoughts not referred to suicide prevention? why wasn't there a follow-up from the va? and why wasn't he offered counseling? >> i will look into this personally, mr. congressman. that is heart breaking. i cannot even imagine what
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this -- i cannot imagine but i know it is horrendous what his family is going through. the picture was worth many many words. someone who did so much for the country. i will look into this. >> reporter: any other witnesses have response to the family's questions? >> you know as somebody who has treated veterans clinics for 30 years. it is hard to understand the report given and these were the facts available. my first thought is i want to make sure this family was reached out directly and we have a chance to collect this information. we created a system and the system can be cold and inhuman but we need to sit down with them and understand everything that happened from their point of view questions they have
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and we will work with them to do that. >> okay. thank you, both. mr. chairman thank you for having the hearing. i yield back my time. >> mr. o'rourke texas. >> the question i would like a quick direct answer to is we are touting reduced prescriptions of opioids as though perhaps that in itself is success. what i would like to know is the consequences? i have veterans showing up to my town hall meetings saying the precription were cut off without notice and ramping down. how many of those no longer receiving prescription from the va are using heroin or other street drugs? >> we can't know that with the information we have. it is something we worry about constantly. >> let me tell you another problem. this is hopefully helpful feedback from el paso.
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others who have prepscriptions are required to renew them after a month but are unable to get an appointment so can't get it renewed so they go without or something they buy on the street. at a minimum they are suffering and i would connect that suffering to suicides we see in el paso. i would like to give you the follow feedback as well. as i shared with you when i met with you on monday the may 15th access reports shows el paso is ranked 157-158 for mental health access. we have 115 mental health physicians approved for el paso and only 87 are filled leaving 24% vacancy rate. your predecessor, when relaying information i was hearing from veterans told me we are seeing
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everybody in 14 days. we found 1/3 of the veterans couldn't ever get an appointment. that information has not improved in the year we had new leadership there. this should be for you a 5-alarm fire. i have met with the widows and mothers of suicides in el paso far too often. i am continuing to do that. and just did the last time i was hope in el paso. as you know for whatever reason, the va is unable to solve this issue and treat it as a priority it should be. so i am glad to hear good things are happening in other parts of the country but everything i do is through the prism of the veterans i serve in el paso. we have a proposal to address this. i want your commitment we will work with this. the community is coming forward.
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i will do whatever it takes to work with you, your team and the secretary to get this implemented but this is a crisis with deadly reprecussions for the vess veterans. we didn't take it seriously because the statistics and vacancy regarding mental health is worse than last year. i want your commitment to resolve this that is a crisis and we will turn this around. >> you have my full unwavering commitment. we were impressed with you reaching out and bringing in members from the el paso community to work with us. i want to thank you for your support of our employees during what was a different kind of tragedy at the el paso facility several months ago. something that cut to the heart of clinicians across the country bought particularly those
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serving veterans in el paso. you have my full commitment. thank you >> thank you. i yield back. [inaudible talking] >> dr. benishek, michigan. >> i want to associate with the comments of mr. o'rourke. the goal is cutting back on narcotics and the same circumstances happened in my district with people getting their prescription cut off with no alternative treatment to figure it out. there are a couple specifics i
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want to get to and that is something something that was set. there is not that much fallollow up n this. remind me what you said in your testimony, mr. williamson? >> we were talking about oversight oversight, very little oversight, to see if the information is accurate and complete. >> you said you are doing oversight. mr. williamson said you are not. what is going on? >> the difference is the two years passed since the report was written. i am not questions the report and find it helpful. but we are making a difference in this.
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>> can you show me the report? can you get that to me within a reasonable period of time? >> to respond to recommendations on oversight, i don't think the va completed them. it isn't a two or three lag. there has been changes made. there is a box checked on the behavioral autopsy report that oversight has been done. >> that is all there is? >> that is one of the things. they are revising guidelines and making progress. but it hasn't been completed to my understanding. >> i am not give you another chance but dr. clancy you said something in your testimony that was important to me and that is this seems simple but the idea
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that if people want to hurt them several selves have to hang up and call another. you said you are going to fix that and hit a key and make it work. i want to know when so i can get a date and call the number. >> by november or december. one of the things we have been working closely with the veterans crisis line. we don't want to overstretch that system >> i just want a date so if it isn't there by november or december -- because i agree with the guy that stood up in the back -- it is just great to keep hearing you will all do work
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but from where i sit, the actual accomplishment of the job is not happening. so hopefully there is a number we can hit. i have people calling. i will yield back. >> mr. waltz, minnesota. >> thank you to the chairman and thank you for being here. the osi implemented in minneapolis and we have followed this and are getting results. i know this is something knew to you but we saw a dramatic increase to calls to our office after implemented when is probably expected but i think
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the lack of maybe being there or the alternative. this issue of mental health priority and treatment certainly is society wide. i am proud of the work this committee started. a small step on clay hunt. but it is the broader issue. on the opioid issue this issue went back and forth from overprescribing to underpre underprecribing that. and i guess the frustration and you hear it from veterans rather here or all of the time this pain management is tough. i say this is i think it is important because i represent the mayo clinic as well. one of the first bill i moved through was the military care
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act and veterans pain care act and the vha pain's director 2009-053. what it was is we put together through iom the step care pain model which is the gold standard. the best practice. is that correct? okay. and i will not go through all of her, but what i would say is it had a five-year span. i wanted to go further but it expired in 2014 before fully implemented. it did not reauthorized. but dr. clany, you responded we don't need approval and i followed up but the frustration is lying in this.
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seven years ago we were dealing with pain management. we implemented best practices and started but didn't fully implement. eight months ago it expired and three months i asked about it. i hate the exchanges we continue to have. i hate the pattern of communication because it is not boding well for veterans and fitting and it is very irritating. i understand the challenge of this issue. understand the deep positives we are making and the pluses and minuses. the frustration lies more in this may not be the fix but why didn't we do it? >> it has been done. this is an issue highlighted and put us on the high risk list and we have to get better at the
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process of updating our directives. but the pain directive has been updated. >> who knows that? >> would the author of the bill not be somebody who should know? >> we will tell you once we review and make sure we have agreement and not missed details. i have not personal seen your letter but i will before the day is over. >> you have other priorities but this is an issue we struggle with. this very thing. our job is tasked do this. we built a great coalition with companies like boston scientific to working with your talented people in this. we have a good piece of legislation on it. we are trying to communicate to implement it and are left in a no man's land. this is important stuff. there are things and i encourage colleagues to look at this. the thinks i hear the ranking member asking to put in she is
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clicking into this and that is in the pain management. the things you are hearing from dr. benishek are in the plan. if we get it out implemented and make it sop it would be there. i encourage you in many cases to communicate with us and see us in our words. we look forward to the follow-up and i yield back. >> thank you. dr. roe tennessee. >> thank you, mr. chairman. just a couple things. one on data collection and certainly when draw or produce data the results may not be accurate. it is important to get the data
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right because it is conclusions on this many patients did this or that and the outcome is important. when you put bs in you get bs out. and i am being crude but that is what it looks like you have done. and the rank member pooped -- pointed out many alternative theories and dr. murphy continually complains about being at dod and has a patient stable and they are separated from the military and they go to
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the va there is a different formula there so they then stop all of what he has taken forever to get the patient stable on and they are now on something else. i think that is something that needs to be addressed. he was very adamant about that and sees it a lot. and i, too, along with dr. benishek was just frustration from probably a veteran who tried to get in or couldn't. and mr. o'rourke has every right to be frustrated when he has people lined up outside of his office talking about not being able to get in the va. let me share why that is frustrating. i have been on the committee six years and we increased the budget 64%. it is not money. it is management. it is not the amount of money we are spending on the veterans. there is plenty of money out there. i don't understand why the system isn't functioning better. any comments on that? mr. williamson i think you
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pointed out in your testimony, poor oversight, nor accountability, what happens to someone when they are not following the rules? apparently nothing. you mentioned all of the outcomes and things. mr. williamson? >> directed at oversight? >> yes, sir. >> there is a lot of reasons why that doesn't happen. i think a lot of times the va doesn't have the data that is real, accurate and complete to do that kind of thing. i don't think there is willful vote motives. there is not that accountability that a supervisor is holding his or her employee accountable. >> that seems basic to doing your job to me.
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the hold someone accountable for their job. that is not rocket science. you are not doing your job. what happens when you don't do your job? do you lose your job? what happens? >> i am not sure i am the right one to ask that but you know in my perfect world, i would think you would. we are held accountability for the quality of work we do and we get feedback and hopefully corrective action after that. that is business 101. >> so dr. roe, i want to say to you and my colleagues, we share your frustration and i want to absolute my colleagues who are working with others. yes, people do don't do their jobs should be held accountability if they have the resources.
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>> mr. o'rourke pointed out 20-something jobs available right now. we claim we have a job problem. 24 people need a job in el paso texas and there is money to fund fund it. why are the positions not filled? >> we have tried a variety of ways to recruit people. mr. o'rourke came in with a group of partners from the committee, and he has my full commitment to -- >> the va is making it hard for the veterans to leave the system and go to private practitioners with the veterans choice card or non-va. we find it is hard for the rules to get out it takes forever to get an appointment. and one last thing, i know my time is expired, but why does it take six months when you call -- i know how frustrated i get when i call taking two for this and three for that, how hard is that
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to do when someone is thinking about suicide to have a phone changed where they go straight to a person? >> we want to make sure we don't overstress the people who are taking the calls. one of whom recently took their own life. as you can imagine that is a very stressful job. we are testing it first and then rolling it out. >> it may be stressful and i am story for the family but it is stressful on the other end as well. >> we want to make sure when you hit the number that it connects you directly to a counselor. i do have to say that issue of transitions service members over to va they continue on the drugs they were getting in the service. we have done over this with dr. woodson.
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>> talk to dr. murphy on the house floor. he is under a different impression >> i would we happy to follow up with him. >> ms.wright, new york. >> thank you, i hate to say the stress for the poor operators comes from the fact they know they will not have the support from the va in getting the callers the help they need. i would like to recognize the work being done in the my home state and the bronx and manhattan. they reject the diagnose later treatment policy i think is all too often adopted by the va. they have taken what shouldn't be a revolutionary pain approach but it is. they believe the first thing you do is diagnose the patient before developing a path of treatment. instead of prescribing opioids
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from a default, and i understand when a patient comes and presents with real pain you want to take awiay the pain i get that is the doctor's first mode of reaction. but this facility using alternative approaches like acc accupuncture and exercise to relieve pain and they experience relief from pain without the harmful affects of the narcotics. this should be the norm at all va facilities nationwide. my question is to you dr. clancy what is the va opinion on alternative forms of treatment? >> first, let me tell you i share your excitement for what division three is doing. we have many thousands of
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veterans using alternative forms of therapy. there is no aversion. for veterans getting opioids like other americans and some coming to us on active duty the path forward is different. it is not starting from day one. so i love what they are doing in new york. i have spoken with many veterans and have actually begun to thing about using their stories to help those struggling to get off opioids and try alternatives. many of the veterans who take opioids would like not to. but they would like to wake up and it all be okay. the journey there is not so easy. so we actually have -- >> there is a system that we know works. i think one of my colleagues told the story about noah and clearly he was prescribed drugs, no follow-up, no alternative,
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any therapy, anything like that. the doctor who is in charge of visn-3 she stated -- she made a statement i thought was accurate, she said to be on opioid opioids is to be trapped in a cycle of poor function and poor pain control. that is what we need to get away from. it is not rocket science. they get it right there. just export it throughout the rest of the country. another thing i wanted to talk about was a bill i happen to be a proud co-sponsor of put forth from senator kind. it would establish a pain management board within each vis visn to better handle the treatment plans incorporating doctors, patients and family members into decision making process for a veterans' course
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of treatment. has the vha taken the ideas in this bill under advisement? >> representative kind asked for my comments and i told him he had my support which may be different from the department's support. i cannot think of any reason we would not support that fully. i was inspired in updating the practice guidelines i wanted to make sure we had input from veterans and families in doing that. i told him that. because as heart breaking as some of the experiences of the veterans, are the experiences of families who raise their hands saying i am worried about about my son, daughter and spouse. >> this isn't a service person issue even. this is an entire family issue. i don't think we want to be a nation that says to our brave men and women who fight for us and come back so damaged and so
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injured that we are going to do our best to keep you in a catatonic state for the rest of your life as a pain management therapy. this cannot be where we come down on this. so i really i am begging you to do everything you can to look at what they are doing in visn-3 and export it throughout the rest of the country. it is not rocket science. thank you very much mr. chairman. >> i think i am going to sum up the hearing with a veterans health administration would be drugs are a short cut. they are a short cut to doing the right thing. to doing the therepies to treat veterans. in terms of pain management and those suffering from depressive
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disorders and it is concerning and unfair to the men and women who made great sacrifices for the men and women in uniform. one question i have is how many rehabilitation physicians does the veterans administration have? >> i would have to take that for the record. >> i have the number of about 40. so there in lies part of the problem. those are the people central when it comes to pain management and we are short changing that. again the easy thing to do is to drug somebody. drug them not to feel pain. drug them to get them up in the morning. drug them so they can go to sleep at night. ...
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>> >> if so clinician in
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education is so critical to redefine how conditions look at pain management. >> it should be the last course of action. >> absolutely. drugs are one option of many but they should not be the be all and all that part of a comprehensive plan. >> how would you do with the treatment for psychotherapy or pain management? from what we see here, it is the first-ever preferred method of treatment. >> i may not be qualified to answer that but we will look at the operations looking at
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the program later this year. i will be much more educated after that. >> that isn't very comforting. dr. cutler? >> i am glad you asked that question. the bottom line is pain or depression it takes the integrated approach. different patients need to star in different patients -- places some will say i will not talk about this and medication takes me -- makes that possible but with pain people need not to go where they need to go to opiates are to come off of them but they think it will work so start where the veteran is i
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have always said i have a lot of different tools with medication and therapy. what makes sense to you? we can't do both. in most cases we do. >> in the report from 2013 that facilities take action with the post discharge follow-up and in particular those two are identified high risk for suicide. what is being done to make sure the process is followed >> a few years ago we put out as the performance measure that veterans must be seen in person where at least by phone with in the first seven days after leaving a psychiatric hospital based on statistics it is the most vulnerable time faugh for a suicide attempt especially after a
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suicide activity. we are not perfect and we are monitoring it but we are at a point where all across the nation we track this with automatic alerts and teams and i wish i to give you the exact number right now. >> from what we hear on the ground, it is a world apart if it was true we would not be here today having this discussion. >> we're not saying everything is fine. but we are committed to getting it right. it is tough work we have a lot to improve on and we welcome your support. >> it is hard to get a ride if you don't acknowledge the depth of the problem. >> thank you mr. chair.
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and thank you to our committee and panel for coming forward. i just want to follow-up were rigo from sharing best practices with your commentary and expertise i talked about some examples in the junction and how do the best practices get shared with the research under way? had read make sure more veterans and families are served? and the clinician education with the ago to answers that the clinicians have. and how can this committee
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continued to work with the virginia to make sure we are serving these veterans all across the country? obviously one of the challenges is this is the case management intensive approach. the worst cases to cancel the vacation without follow-up because as we know, that is why people return to heroin. how do we get it right across the board and and what is the follow-up? >> and might suggest to invite us back for a briefing. you pick the frequency and i did not get a chance to say before that i do have people monitoring for medications and i am worried if we send
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out a message it is much easier for providers to say no is not acceptable so want to be very clear on this point. some of these challenges are areas where medicine is struggling in general with chronic pain and for mental health we have had to blaze some trails there is no clear-cut blood test to double check on the assessment it depends on standardized questions we are working very hard to change how we schedule appointments so it is much easier to get the man for that assessment but we should be held accountable i look forward to where we
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have been and where we are going and inouye to a want to say we have problems. we do. we own them under stepping up the mud for two your support for you can help to work with us to reduce the stigma it is a huge problem. also the you are supporting for veterans one of the challenges a lot of young people are not choosing to go into these fields which is the ultimate recruitment problem. we have terrific incentives of debt reduction thing to the veterans choice act and those are great tools but someone has to make the decision to go down that path. >> i want to stress again the failure to do to turn
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over those documents makes our job difficult. >> dr. clancy thank you for addressing the al tasso issue to be sure the your monitoring those veterans who will be coming off of opiates but the feedback stands as they hear it directly that apparently that is not happening in el paso. for every veteran who takes the time to come down to the town hall meeting despite what they go through to tell the congress and they're having this problem and is admitting they are receiving opiates and now doing without, there are many others that that person represents to have given up to say why should i bother? we have a problem and perhaps nationally to ramp people down or to find the alternate therapy with their cessation of opiates. i would like you to respond to what we heard the
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secretary say that he has 20,000 positions to fill. it is something that was reiterated four weeks ago then when we read in the command and control center we heard the number is 50,000 positions to be filled could you confirm the number and tell me how you are prioritizing those tires? and if we have a crisis in mental health and treating all buyers the same if you prioritize mental health then this committee and public is at large. >> i did not hear the number 50,000 so i will have to check on that and get back to you directly. with 300,000 employees sorting a normal turnover
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that is about 7 percent across all disciplines with areas that we are trying to fill is challenging. we have identified five areas that are the highest three physicians and nurses mental health professionals, assistance and i block on the surface but mental health professional is on the list. we have been way ahead of the curve with hiring mental-health professionals from multiple disciplines. and is working in mental-health clinics trying to do everything to make it impossible to seek assistance and have a long way to go but i was commenting on the overall pipeline problem but where
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we do have now is with mental health so big screen texas they tried very hard in recent recruit -- recruited one from wisconsin. that individual is providing all virtual care. and to make that process works they find it a bit less confrontational. >> you ask for an additional brief seeing. i hope when you come back it is with the plan to say we pay psychiatrists x dollars then say ex + 20% to get them to el paso began and
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that is the plan that really treats this as the crisis that it is to make this a priority i need dollars on the table or specific offers so i hope to hear specifics next time. thank you for holding this hearing. >> and i want to follow-up few will have a follow-up hearing with the types of paid management but also to talk about mental health to do a short demonstration but
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that it might be in that crisis situation to stay on top of this. thank you. >> our thanks to the witnesses you are now excused. we have a chance to hear about problems that exist in the department of veterans affairs with regard to prescription management this hearing was necessary to accomplish a number of items to demonstrate the lack of care and follow-up the prescribed medications for disorders to demonstrate the accuracy and discrepancy regarding veteran suicide in those diagnosed with mental disorders to allow the virginia to inform the subcommittee to improve the glaring deficiencies to venture veterans are
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receiving the care they deserve for by ask unanimous consent so without objection so ordered so all witnesses and audience members so that the hearing is adjourned. [inaudible conversations]
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[inaudible conversations] >> this hearing will come to order per cry will welcome the admiral and we appreciate your willingness to serve considering your nomination for the position to his vacation security administration we had an interesting hearing yesterday and i thank you come into this position understanding you have significant challenges ahead of you and we are looking forward to the hearing today. we're looking forward to your oral testimony and
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answers to our questions. i will hold off on further comments. also the united states postal service and other agency that will require a lot of the box thinking so i just want to thank both nominees for your willingness to serve in that i turned over to the ranking member. >> thank you for your service you have anybody with your family here today? some brief comments thank you for joining us yesterday also in to take the measure that tsa has been now with the leader since the end of
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last year from press reports from famous briefings guess it faces serious challenges from the senate confirmed leadership with someone that we believe can provide those needs right now. to serve as a commissioned officer in 1982 but vice commandant through may 2014 and the admirable -- general has shown difficult challenges to all -- had on as the commander for the deep water horizon oil spill but has said vhs inspector
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said they need someone that is rolling toward knowledge and confront that will strive for perfection while addressing at the same time the priorities of security and expedited travel. we want to make sure people get where they need to go safely and teetoo expedite to the security checkpoints but oftentimes it is not an easy job and we're grateful for the people who'd do this work and to meet the challenges that we provide that support that they need. i had the opportunity to meet recently with the position for the agency to be the right person for the
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job at this time. and david shapiro sitting in the front row but to serve as governor is the very challenging time at the postal service as albert einstein once said with diversity this opportunity to buy the same token in a lot of opportunity the postal service with the massive logistics' industry and even as lost to other forms of communication it could be any number of ways a of some were discussed yesterday it is still effective option for her thousands that people still like to receive the mail not even the millenials the
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commerce is booming and even the postal service the competitors will rely on that to carry for the last mile they always want to do not want to the last 3 miles or 5 miles but the postal service is happy to do that they go that way anyway. of ford to anything needs to be done in the ongoing challenges with the skills and experience that you will bring to the board as a company with nearly 40,000 employees to bring a unique position - - perspective if confirmed mr. shapiro it
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would double the size and read that a real opportunity here to strengthen the postal service. i want to thank both of the nominees and hopefully we can call him governor shapiro. with the accord to hearing from you. >> thank you senator carter. please rise and raise your right hand to use through the testimony is the truth of whole truth and nothing but the truth so help you god? please be seated. vice admiral, admiral neffenger for us of the coast guard 34 years of service to held key leadership positions and served as the sector
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commander from 2008 through 2010 with the coast guard district for coast guard operations to help secure 1500 miles of u.s.-canada border with the commander through the deep water horizon oil spill in the gulf of mexico. >> thank you mr. chairman i have an opening statement. good morning to members of the committee i am privileged to be here before u.s. the nominee as the head of the tsa i am honored by his call to service his secretary johnson has given strong leadership to the department. with a 30,000 members of the artillery that i have been privileged to serve and i
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have learned important leadership and duty to people and excellence i want you to know i am deeply honored to secure the transportation system that you have a difficult missions that has caused in detail with high level of respect i of confidence in them. to pursue solutions from covert testing the must be in place for the vulnerabilities. to drive a focus on the primary emotion to secure aviation and must be a culture of the evolution of plants am processes with a new concept of operation and new capabilities.
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and turning the confidence of the public with discipline performance their professionalism to bring a perspective to address the immediate challenges to accomplish the most important mission of the tsa that is critical if confirmed it is up the corps in one that has been proven in their real world. the clear and unequivocal peters of performance with the relentless pursuit of accountability after a disservice for leadership positions culminating in my current duties as second in command is the coast guard with there premiere law-enforcement agency.
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with a more complex responsibility of confirmed with my extensive experience of law-enforcement to ensure the nation's transportation system. that the global tariffs that have evolved is more decentralized and more complex of our intent to strike united states and we know that some of these are focused on commercial aviation. the threats are persistent in devolving and work-force training and accountability if confirmed but i will pay close attention to the tsa work force and examine how the academy further improves performance

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